Abstract
INTRODUCTION: The coronavirus 2019 pandemic disrupted medical care delivery for cerebrovascular disease. Little is known about the long-term changes in healthcare utilization and mortality among people who suffered cerebrovascular events. METHODS: We used 2018-2022 data to identify all Medicare fee-for-service and Medicare Advantage beneficiaries with a diagnosis code for an acute cerebrovascular event (stroke, transient ischemic attack, hemorrhage). We used Poisson-lognormal regression models with an offset term (beneficiary years) to model incident rate ratios (IRR) for late COVID (2021-2022) versus pre-COVID (2018-2019) for outpatient visits, emergency department (ED) visits, hospitalizations, and mortality in the year following the index event, adjusting for age, sex, and race. We examined patterns overall and by rurality (urban, micropolitan, rural) and quartile (q) of social vulnerability index. RESULTS: We identified 7,071,072 and 7,065,171 unique beneficiaries in the pre-COVID and late-COVID periods, respectively, with an acute cerebrovascular event. Our cohort was predominantly non-Hispanic white (73%), female (54%), and urban (83%). Compared to pre-COVID, outpatient care utilization in the year following the acute event was higher in 2021-2022 (IRR = 1.14, 95% confidence interval [CI]: 1.13-1.14), while ED visits (IRR = 0.92, 95% CI: 0.91-0.92) and inpatient hospitalizations (IRR = 0.94, 95% CI: 0.94-0.95) were lower. Mortality was higher during the late-COVID versus pre-COVID period (IRR = 1.24, 95% CI: 1.23-1.25). The mortality differences were similar across rural strata but higher in more socially disadvantaged areas (IRR 1.20, 1.22, 1.24, 1.27 for q1 [reference], p interaction = q2 = 0.12, q3 = 0.01, and q4 < 0.001). CONCLUSIONS: Medicare beneficiaries who sustained acute cerebrovascular events had marked differences over the subsequent year in healthcare utilization patterns and increased mortality in the late-COVID period compared with their utilization and outcomes pre-COVID. The differences in mortality were the most pronounced for beneficiaries in socially disadvantaged areas.