Some forms of preventive CV screening increased after ACA; gender gap remains

Physicians have increased preventive screening for some cardiovascular risk factors since the Affordable Care Act (ACA) took effect, a new study found, but women remain less likely than men to receive aspirin therapy to guard against heart attack and stroke.

“There has been a lot of concern about women receiving poorer quality cardiovascular care, and our study reinforces this concern,” co-author Joseph A. Ladapo, MD, PhD, said in a press release. He added the disparity could be due to a lingering perception among physicians that heart disease is more of a “man’s disease.”

Ladapo and Dave A. Chokshi, MD, MSc, studied data from the National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2006 to 2013. Beginning Sept. 23, 2010, the ACA required certain screenings to be covered at no cost to insured customers under criteria established by the U.S. Preventive Services Task Force (USPSTF).

Yet, physicians are the “gatekeepers” to these services, so “directly assessing their patterns of preventive care provision in response to the ACA is critical to informing the design of future policies for clinical prevention,” Ladapo and Chokshi wrote in the American Journal of Managed Care.

“To our knowledge, this study is the first to analyze changes in use of cardiovascular preventive care after the ACA using physician visit-level data,” they added.

Both before and after the ACA was enacted, aspirin was listed as a medication in about 9.5 percent of office visits by women ages 55 to 79, even though it is recommended for most patients in that range due to their increased risks of MI and stroke. On the other hand, aspirin was listed as a medication for men in 13.5 percent of office visits after the ACA was enacted compared to 11.1 percent before the legislation took effect.

Ladapo and Chokshi also found increases in the number of visits in which diabetes screening was performed (7.6 percent after the ACA versus 3.9 percent before the ACA), in which patients discussed smoking (74.5 percent vs. 64.4 percent) and in which they were screened for high blood pressure (76.4 percent vs. 73.2 percent). Rates of preventive care for seven other risk factors didn’t change significantly over the study period.

“Our study supports the argument that the ACA’s cost-sharing provisions are an effective way to increase uptake of clinical preventive services, although overall levels of service provision were still lower than those recommended by the USPSTF and these gaps increase the population risk of CVD,” the authors wrote. “However, the absolute effects of the ACA’s preventive cardiovascular care provisions were often modest. Physician decision making may be more sensitive to more proximal factors such as educational interventions, enhanced reimbursement for preventive services, or ease of operational processes, such as referrals for smoking cessation advice or point-of-care A1C testing.”

The researchers said practice-level strategies could boost screening services for hypertension and tobacco use to near-universal levels. For less-ubiquitous preventive measures, such as screening for diabetes or prescribing aspirin therapy, they suggested electronic health record defaults could remind physicians of those options.

Ladapo and Chokshi noted they weren’t able to account for grandfathered insurance plans that were exempt from some ACA provisions. They were also unable to determine whether physicians or patients were aware of the provisions.