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Akinyemi O, Weldeslase T, Fasokun M, Odusanya E, Tsion A, Cornwell E, Hughes K. Impact of the Affordable Care Act on Revascularization Versus Amputation in Patients Presenting With Chronic Limb-Threatening Ischemia in Maryland. Am Surg 2024:31348241259046. [PMID: 38822765 DOI: 10.1177/00031348241259046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2024]
Abstract
INTRODUCTION The Affordable Care Act (ACA) aimed to expand Medicaid, enhance health care quality and efficiency, and address health disparities. These goals have potentially influenced medical care, notably revascularization rates in patients presenting with chronic limb-threatening ischemia (CLTI). This study examines the effect of the ACA on revascularization vs amputation rates in patients presenting with CTLI in Maryland. METHODS This was a retrospective analysis of the Maryland State Inpatient Database comparing the rate of revascularization to rate of major amputation in patients presenting with CLTI over 2 periods: pre-ACA (2007-2009) and post-ACA (2018-2020). In this study, we included patients presenting with CLTI and underwent a major amputation or revascularization during that same admission. Using regression analysis, we estimated the odds of revascularization vs amputation pre- and post-ACA implementation, adjusting for pertinent variables. RESULT During the study period, 12,131 CLTI patients were treated. Post-ACA, revascularization rate increased from 43.9% to 77.4% among patients presenting with CLTI. This was associated with a concomitant decrease in the proportion of CLTI patients undergoing major amputation from 56.1% to 22.6%. In the multivariate analysis, there was a 4-fold odds of revascularization among patients with CLTI compared to amputation (OR = 4.73, 95% CI 4.34-5.16) post-ACA. This pattern was seen across all insurance groups. CONCLUSION The post-ACA period in Maryland was associated with an increased revascularization rate for patients presenting with CLTI with overall benefits across all insurance types.
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Affiliation(s)
- Oluwasegun Akinyemi
- Department of Surgery Outcomes Research Center, Howard University School of Medicine, Washington, DC, USA
| | | | - Mojisola Fasokun
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Eunice Odusanya
- Department of Surgery Outcomes Research Center, Howard University School of Medicine, Washington, DC, USA
| | - Andine Tsion
- Department of Surgery Outcomes Research Center, Howard University School of Medicine, Washington, DC, USA
| | | | - Kakra Hughes
- Howard University College of Medicine, Washington DC, USA
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Henkin S, Kearing SA, Martinez-Camblor P, Zacharias N, Creager MA, Young MN, Goodney PP, Columbo JA. The impact of the Affordable Care Act Medicaid Expansion in Medicare beneficiaries with peripheral artery disease. Vasc Med 2024:1358863X241237776. [PMID: 38607558 DOI: 10.1177/1358863x241237776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
Background: In 2014, the Affordable Care Act Medicaid Expansion (ME) increased Medicaid eligibility for adults with an income level up to 138% of the federal poverty level. In this study, we examined the impact of ME on mortality and amputation in patients with peripheral artery disease (PAD). Methods: The 100% MedPAR and Part-B Carrier files from 2011 to 2018 were queried to identify all fee-for-service Medicare beneficiaries with PAD using International Classification of Diseases codes. Our primary exposure was whether a state had adopted the ME on January 1, 2014. Our primary outcomes were the change in all-cause 1-year mortality and leg amputation. We used a state-level difference-in-differences (DID) analysis to compare the rates of the primary outcomes among patients who were in states (including the District of Columbia) who adopted ME (n = 25) versus those who were in states that did not (n = 26). We performed a subanalysis stratifying by sex, race, region, and dual-eligibility status. Results: Over the 8-year period, we studied 37,743,929 patients. The average unadjusted 1-year mortality decreased from 2011 to 2018 in both non-ME (9.5% to 8.7%, p < 0.001) and ME (9.1% to 8.3%, p < 0.001) states. The average unadjusted 1-year amputation rate did not improve in either the non-ME (0.86% to 0.87%, p = 0.17) or ME (0.69% to 0.69%, p = 0.65) states. Across the entire cohort, the DID model revealed that ME did not lead to a significant change in mortality (p = 0.15) or amputation (p = 0.34). Conclusion: Medicaid Expansion was not associated with reduced mortality or leg amputation in Medicare beneficiaries with PAD.
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Affiliation(s)
- Stanislav Henkin
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
- Gonda Vascular Center, Mayo Clinic, Rochester, MN, USA
| | - Stephen A Kearing
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
| | | | - Nikolaos Zacharias
- Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mark A Creager
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Michael N Young
- Cardiovascular Medicine, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Philip P Goodney
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Jesse A Columbo
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Section of Vascular Surgery, Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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White M, McDermott KM, Bose S, Wang C, Srinivas T, Kalbaugh C, Hicks CW. Risks and Benefits of the Proposed Amputation Reduction and Compassion Act for Disadvantaged Patients. Ann Vasc Surg 2024; 101:179-185. [PMID: 38142961 PMCID: PMC10957305 DOI: 10.1016/j.avsg.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/26/2023]
Abstract
Racial, ethnic, and socioeconomic disparities in the major risk factors for vascular disease and access to vascular specialist care are well-documented.1-3 The higher incidence of diabetes, peripheral artery disease (PAD), and related nontraumatic lower extremity amputation among racial and ethnic minority groups, those of low socioeconomic status, and those with poor access to care based on geography (together, referred to below as disadvantaged groups) are particularly pervasive.1,4-9 Practitioners of vascular surgery and endovascular therapy are uniquely positioned to address health inequities in lower extremity screening, medical management, intervention, and limb preservation among the population of adults at the highest risk for limb loss.
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Affiliation(s)
- Midori White
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Sanuja Bose
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Caroline Wang
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Tara Srinivas
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Corey Kalbaugh
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University, Baltimore, MD.
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4
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Semaan DB, Abdul-Malak OM, Avgerinos ED, Chaer RA, Madigan MC, Siracuse JJ, Eslami MH. Racial Disparities in Treatment Indications and Outcomes for Limb Ischemia. Ann Vasc Surg 2023; 96:89-97. [PMID: 37737257 DOI: 10.1016/j.avsg.2023.04.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/15/2023] [Accepted: 04/19/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Studies suggest that the Affordable Care Act (ACA) of 2014 has improved access to vascular care and vascular outcomes among patients suffering from peripheral arterial disease (PAD). We sought to examine the racial disparities that exist in patients with PAD who have undergone lower extremity bypass (LEB) or a peripheral vascular intervention (PVI) using the Vascular Quality initiative (VQI) database. METHODS The VQI infrainguinal and PVI datasets were queried for patients receiving elective and urgent LEB or PVI between 2016, 2 years after ACA implementation, and in 2021. Patients undergoing interventions urgently/emergently or for aneurysm were excluded. The primary outcome was major adverse limb event (MALE-defined as any vascular reintervention or above-ankle amputation) free survival at 1 year. Standard statistical methods were utilized as appropriate. RESULTS A total of 17,455 LEB and 87,475 PVIs were included in this analysis. Black persons present at a younger age when compared to non-Hispanic White persons (NHW) and are more likely to have diabetes, hypertension, end-stage renal disease (ESRD), and higher rates of prior amputation. Black persons are more likely to present with chronic limb-threatening ischemia (CLTI) rather than claudication, and in a more urgent setting. Postoperative outcomes show higher rates of major amputations among racial minorities, specifically Black persons for both LEB (1.8% vs. 0.8% P < 0.001) and PVI (20.8% vs. 16.8% P < 0.001). Black persons are at higher risk of 1-year MALE for LEB (36.7% vs. 29.9% P < 0.001) and PVI (31.0% vs. 21.7%; P < 0.001). Even after adjusting for confounding variables, Black persons have a higher risk of 1-year MALE for LEB, with an adjusted hazard ratio (aHR) of 1.15 (95% CI [1.05-1.26], P = 0.003) and PVI (aHR 1.18 95% CI [1.12-1.24], P < 0.001). Other major determinates of 1-year MALE on multivariate Cox regression included CLTI (LEB aHR 1.57 95% CI [1.43-1.72], P < 0.001; PVI aHR 2.29 95% CI [2.20-2.39], P < 0.001) and history of prior amputation (LEB aHR 1.35 95% CI [1.17-1.56], P < 0.001; PVI aHR 1.5 95% CI [1.4-1.6], P < 0.001). CONCLUSIONS Compared to NHW persons, Black persons present with more advanced vascular disease regardless of the operative indication. Black persons are also at significantly higher risk of 1-year MALE. Despite some advances in more accessible care through the ACA of 2014, our observations suggest that Black persons still have significantly worse outcomes due to variety of variables that need further investigation.
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Affiliation(s)
- Dana B Semaan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | | | | | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Michael C Madigan
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh, Pittsburgh, PA.
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Ramadan OI, Kelz RR, Sharpe JE, Wirtalla CJ, Keele LJ, Harhay MO, Roberts SE, Wang GJ. Impact of Medicaid expansion on outcomes after abdominal aortic aneurysm repair. J Vasc Surg 2023; 78:648-656.e6. [PMID: 37116595 DOI: 10.1016/j.jvs.2023.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 04/04/2023] [Accepted: 04/17/2023] [Indexed: 04/30/2023]
Abstract
OBJECTIVE Lack of insurance has been independently associated with an increased risk of in-hospital mortality after abdominal aortic aneurysm repair, possibly due to worse control of comorbidities and delays in diagnosis and treatment. Medicaid expansion has improved insurance rates and access to care, potentially benefiting these patients. We sought to assess the association between Medicaid expansion and outcomes after abdominal aortic aneurysm repair. METHODS A retrospective analysis of Healthcare Cost and Utilization Project State Inpatient Databases data from 14 states between 2012 and 2018 was conducted. The sample was restricted to first-record abdominal aortic aneurysm repairs in adults under age 65 in states that expanded Medicaid on January 1, 2014 (Medicaid expansion group) or had not expanded before December 31, 2018 (non-expansion group). The Medicaid expansion and non-expansion groups were compared between pre-expansion (2012-2013) and post-expansion (2014-2018) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors, open vs endovascular repair, and standard errors clustered by state. Our primary outcome was in-hospital mortality. Outcomes were stratified by insurance type. RESULTS We examined 8995 patients undergoing abdominal aortic aneurysm repair, including 3789 (42.1%) in non-expansion states and 5206 (57.9%) in Medicaid expansion states. Rates of Medicaid insurance were unchanged in non-expansion states but increased in Medicaid expansion states post-expansion (non-expansion: 10.9% to 9.8%; P = .346; expansion: 9.7% to 19.7%; P < .001). One in 10 patients from both non-expansion and Medicaid expansion states presented with ruptured aneurysms, which did not change over time. Rates of open repair decreased in both non-expansion and Medicaid expansion states over time (non-expansion: 25.1% to 19.2%; P < .001; expansion: 25.2% to 18.4%; P < .001). On adjusted difference-in-differences analysis between expansion and non-expansion states pre-to post-expansion, Medicaid expansion was associated with a 1.02% absolute reduction in in-hospital mortality among all patients (95% confidence interval, -1.87% to -0.17%; P = .019). Additionally, among patients who were either on Medicaid or were uninsured (ie, the patients most likely to be impacted by Medicaid expansion), a larger 4.17% decrease in in-hospital mortality was observed (95% confidence interval, -6.47% to -1.87%; P < .001). In contrast, no significant difference-in-difference in mortality was observed for privately insured patients. CONCLUSIONS Medicaid expansion was associated with decreased in-hospital mortality after abdominal aortic aneurysm repair among all patients and particularly among patients who were either on Medicaid or were uninsured. Our results provide support for improved access to care for patients undergoing abdominal aortic aneurysm repair through Medicaid expansion.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Rachel R Kelz
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - James E Sharpe
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | | | - Luke J Keele
- Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Michael O Harhay
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Palliative and Advanced Illness Research Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sanford E Roberts
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Center for Surgery and Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Huepenbecker SP, Fu S, Sun CC, Zhao H, Primm KM, Giordano SH, Meyer LA. Medicaid Expansion and Postoperative Mortality in Women with Gynecologic Cancer: A Difference-in-Difference Analysis. Ann Surg Oncol 2023; 30:1508-1519. [PMID: 36310311 PMCID: PMC10466211 DOI: 10.1245/s10434-022-12663-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/28/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND The association between Medicaid expansion and postoperative mortality after surgery for gynecologic cancer is unknown. Our objective was to compare 30- and 90-day postoperative mortality after gynecologic cancer surgery before and after 2014 in states that did and did not expand Medicaid. METHODS We searched the National Cancer Database for women aged 40-64 years old between 2010 and 2016 who underwent surgery for a primary gynecologic malignancy. We used pre/post and quasi-experimental difference-in-difference (DID) multivariable logistic regressions to evaluate mortality pre-2014 (2010-2013) and post-2014 (2014-2016) for states that did and did not expand Medicaid in January 2014. We completed univariable logistic regressions for covariates of interest. RESULTS Among 169,731 women, 30-day postoperative mortality in expansion states after 2014 significantly decreased for endometrial cancer (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.26-0.67) and ovarian cancer (OR 0.67, 95% CI 0.46-0.99) and increased for cervical cancer (OR 3.82, 95% CI 1.12-13.01). Compared with non-expansion states, expansion states had improved 30-day postoperative mortality for endometrial cancer after 2014 (DID OR 0.54, 95% CI 0.31-0.96). Univariable analysis demonstrated improved 30-day postoperative mortality for Black women with endometrial cancer in expansion states (DID OR 0.22, 95% CI 0.05-0.95). There was improved 90-day postoperative mortality for endometrial cancer in expansion states (OR 0.66, 95% CI 0.50-0.85), and improved 90-day postoperative mortality for Midwestern women with ovarian cancer in expansion states on univariable analysis (DID OR 0.48, 95% CI 0.26-0.91). CONCLUSIONS State Medicaid legislation was associated with improved postoperative survival in women with endometrial cancer and subgroups of women with endometrial and ovarian cancer.
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Affiliation(s)
- Sarah P Huepenbecker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Shuangshuang Fu
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Becton, Dickinson and Company, Franklin Lakes, NJ, USA
| | - Charlotte C Sun
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA
| | - Hui Zhao
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kristin M Primm
- Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sharon H Giordano
- Department of Health Services Research, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1362, Houston, TX, 77030, USA.
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Eslami MH, Semaan DB. Increased Medicaid eligibility of Affordable Care Act: Evidence of improved outcomes for patients with peripheral artery disease. Semin Vasc Surg 2023; 36:58-63. [PMID: 36958898 DOI: 10.1053/j.semvascsurg.2023.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 01/19/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023]
Abstract
Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularization and worse outcomes, including higher rates of major amputation. In 2010, the Affordable Care Act (ACA) was signed into law, providing better opportunities for health care access to millions of uninsured Americans, although the implementation of different components started at a later date. Political issues led to uneven adaptation by states of the different ACA components. In states that adopted Medicaid expansion under the ACA, similar to that under the Massachusetts Health Care Reform Law of 2006, patients of low socioeconomic status and racial minority patients gained better access to health care. This review article will examine the disparities that exist in peripheral artery disease outcomes, as well as the effects of the ACA and Medicaid expansion on revascularization, limb salvage, and major amputation rates.
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Affiliation(s)
- Mohammad H Eslami
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213.
| | - Dana B Semaan
- Division of Vascular Surgery, UPMC, Heart and Vascular Institute, South Tower, 200 Lothrop Street, Pittsburgh, PA 15213
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Ramadan OI, Santos T, Stoecker JB, Belkin N, Jackson BM, Schneider DB, Rice J, Wang GJ. The Differential Impact of Medicaid Expansion on Disparities in Outcomes Following Peripheral Vascular Intervention. Ann Vasc Surg 2022; 86:135-143. [PMID: 35460861 DOI: 10.1016/j.avsg.2022.04.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/06/2022] [Accepted: 04/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Peripheral artery disease (PAD) disproportionately affects nonwhite, Hispanic/Latino, and low socioeconomic status patients, who are less likely to have insurance and routine healthcare visits. Medicaid expansion (ME) has improved insurance rates and access to care, potentially benefitting these patients. We sought to assess the impact of ME on disparities in outcomes after peripheral vascular intervention (PVI) for PAD. METHODS A retrospective analysis of prospectively-collected Vascular Quality Initiative PVI procedures between 2011 and 2019 was conducted. The sample was restricted to first-record procedures in adults under the age 65 in states that expanded Medicaid on January 1, 2014 (ME group) or had not expanded before January 1, 2019 (non-expansion [NE] group). ME and NE groups were compared between pre-expansion (2011-2013) and post-expansion (2014- 2019) time periods to assess baseline demographic and operative differences. We used difference-in-differences multivariable logistic regression adjusted for patient factors and clinical center and year fixed effects. Our primary outcome was 1-year major amputation. Secondary outcomes included trends in presentation, 30-day mortality, 1-year mortality, and 1-year primary and secondary patency. Outcomes were stratified by race and ethnicity. RESULTS We examined 34,313 PVI procedures, including 20,378 with follow-up data. Rates of Medicaid insurance increased post-expansion in ME and NE states (ME 16.7% to 23.0%, P < 0.001; NE 10.0% to 11.9%, P = 0.013) while rates of self-pay decreased in ME states only (ME 4.6% to 1.8%, P < 0.001; NE 8.1% to 8.4%, P = 0.620). Adjusted difference-in-differences analysis revealed lower odds of urgent/emergent PVI among all patients and all nonwhite patients in ME states post-expansion compared to NE states (all: odds ratio [OR] 0.53 [95% confidence interval 0.33-0.87], P = 0.011; nonwhite: OR 0.41 [0.19-0.88], P = 0.023). No differences were observed for 1-year major amputation (OR 0.70 [0.43-1.14], P = 0.152), primary patency (OR 0.93 [0.63-1.38], P = 0.726), or secondary patency (OR 1.29 [0.69-2.41], P = 0.431). Odds of 1-year mortality were higher in ME states post-expansion compared to NE states (OR 2.50 [1.07-5.87], P = 0.035), although 30-day mortality was not different (OR 2.04 [0.60-6.90], P = 0.253). Notably, odds of 1-year major amputation among Hispanic/Latino patients decreased in ME states post-expansion compared to NE states (OR 0.11 [0.01-0.86], P = 0.036). CONCLUSIONS ME was associated with lower odds of 1-year major amputation among Hispanic/Latino patients who underwent PVI for PAD. ME was also associated with lower odds of urgent/emergent procedures among patients overall and nonwhite patients specifically. However, 1-year mortality increased in the overall cohort. Further study is needed to corroborate our findings that ME may have benefits for certain underserved populations with PAD.
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Affiliation(s)
- Omar I Ramadan
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Tatiane Santos
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; The Wharton School at the University of Pennsylvania, Philadelphia, PA
| | - Jordan B Stoecker
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Nathan Belkin
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Benjamin M Jackson
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Darren B Schneider
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Jayne Rice
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Grace J Wang
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Cohen BD, Zeymo A, Bouchard M, McDermott J, Shara NM, Sellke FW, Sodha N, Al-Refaie WB, Ehsan A. Increased Access to Cardiac Surgery Did Not Improve Outcomes: Early Look into Medicaid Expansion. Ann Thorac Surg 2021; 114:1637-1644. [PMID: 34678282 DOI: 10.1016/j.athoracsur.2021.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 08/02/2021] [Accepted: 09/04/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac surgery utilization has increased after passage of the Affordable Care Act. This multi-state study examined whether changes in access after Medicaid Expansion (ME) have led to improved outcomes, overall and particularly among ethno-racial minorities. METHODS State Inpatient Databases were used to identify non-elderly adults (ages 18-64) who underwent coronary artery bypass grafting, aortic valve replacement, mitral valve replacement, or mitral valve repair in three expansion (Kentucky, New Jersey, Maryland) vs two non-expansion states (North Carolina, Florida) from 2012 to 2015. Linear and logistic Interrupted Time Series (ITS) were used with two-way interactions and adjusted for patient, hospital, and county-level factors to compare trends and instantaneous changes at the point of ME implementation (Q1 2014) for mortality, length of stay (LOS), and elective status. ITS models estimated expansion effect, overall and by race-ethnicity. RESULTS Analysis included 22,038 cardiac surgery patients from expansion states and 33,190 from non-expansion states. In expansion states, no significant trend changes were observed for mortality (OR 1.01, p=0.83) or LOS (β= -0.05, p=0.20), or elective surgery (OR 1.00, p=0.91). There were similar changes seen in non-expansion states. Among ethno-racial minorities, ME did not impact outcomes or elective status. CONCLUSIONS Despite an increase in cardiac surgery utilization following ME, outcomes remained unchanged in the early period after implementation, overall and among ethno-racial minorities. Future research is needed to confirm long-term trends and examine reasons behind this lack of improved outcomes.
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Affiliation(s)
- Brian D Cohen
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Alexander Zeymo
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Megan Bouchard
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - James McDermott
- MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC
| | - Nawar M Shara
- MedStar Health Research Institute, Washington, DC; Georgetown-Howard Universities, Center for Clinical and Translational Science, Washington, DC
| | - Frank W Sellke
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Neel Sodha
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
| | - Waddah B Al-Refaie
- MedStar-Georgetown University Medical Center, Department of Surgery, Washington, DC; MedStar Health Research Institute, Washington, DC; MedStar-Georgetown Surgical Outcomes Research Center, Washington, DC.
| | - Afshin Ehsan
- Brown University Medical School/Rhode Island Hospital, Division of Cardiothoracic Surgery, Providence, RI
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Association of Medicaid Expansion with In-Hospital Outcomes After Abdominal Aortic Aneurysm Repair. J Surg Res 2021; 266:201-212. [PMID: 34022654 DOI: 10.1016/j.jss.2021.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 02/08/2021] [Accepted: 02/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Multiple studies have shown improved outcomes and higher utilization of care with the increase of insurance coverage. This study aims to assess whether Medicaid expansion (ME) has changed the utilization and outcomes of abdominal aortic aneurysm (AAA) repair in the United States. DESIGN Retrospective observational study. MATERIALS Data of patients undergoing AAA repair in the Vascular Quality Initiative (2010-2017). METHODS Interrupted time-series (ITS) analysis was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after 2014. We also assessed if these trend changes were significant by comparing the changes in states which adopted ME in 2014 versus nonexpansion states (NME), and conducting a difference-in-difference analysis. Primary outcomes included in-hospital mortality and adverse events (bowel and leg ischemia, cardiac, renal, respiratory, stroke and return to the OR). RESULTS A total of 19,143 procedures were included (Endovascular: 85.8% and open: 14.2%), of which 40.9% were performed in ME States. Compared to preexpansion trends (P1), there was a 2% annual increase in elective AAA repair in ME states (P1: -1.8% versus P2: +0.2%, P< 0.01) with no significant change in NME (P1: +0.3% versus P2: +0.2%, P = 0.97). Among elective cases, annual trends in the use of EVAR increased by 2% in ME states (95% confidence interval (CI) = -0.1, 4.1, P = 0.06), compared to a 3% decrease in NME States [95%CI = -5.8, -0.6, P = 0.01) (PMEversusNME < 0.01]. There was no association between ME and in-hospital mortality. Nonetheless, it was associated with a decrease in the annual trends of in-hospital complications (ME: -1.4% (-2.1,-0.8) versus NME: +0.2% (-0.2, +0.8), P < 0.01). CONCLUSIONS While no association between ME and increased survival was noted in states which adopted ME, there was a significant increase of elective AAA cases and EVAR utilization and a decrease in in-hospital complications in ME States.
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Neiman PU, Tsai TC, Bergmark RW, Ibrahim A, Nathan H, Scott JW. The Affordable Care Act at 10 Years: Evaluating the Evidence and Navigating an Uncertain Future. J Surg Res 2021; 263:102-109. [PMID: 33640844 DOI: 10.1016/j.jss.2020.12.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 12/06/2020] [Accepted: 12/16/2020] [Indexed: 10/22/2022]
Abstract
The year 2020 marks the 10th anniversary of the signing of the Affordable Care Act (ACA). Perhaps the greatest overhaul of the US health care system in the past 50 y, the ACA sought to expand access to care, improve quality, and reduce health care costs. Over the past decade, there have been a number of challenges and changes to the law, which remains in evolution. While the ACA's policies were not intended to specifically target surgical care, surgical patients, surgeons, and the health systems within which they function have all been greatly affected. This article aims to provide a brief overview of the impact of the ACA on surgical patients in reference to its tripartite aim of improving access, improving quality, and reducing costs.
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Affiliation(s)
- Pooja U Neiman
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Thomas C Tsai
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Regan W Bergmark
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts; Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Ibrahim
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hari Nathan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | - John W Scott
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan; Department of Surgery, University of Michigan, Ann Arbor, Michigan.
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