33% Reduction in Major Amputations in Non-White Patients with Diabetes In States Adopting Medicaid Expansion vs. No Change in Non-Adopters #ActAgainstAmputation @UArizona @USC @ALPSLimb @apma

This manuscript from our combined team led by Tze Woei Tan was just published in JAMA Network Open.

Further coverage of this manuscript can be found in Close Concerns here.

Rates of Diabetes-Related Major Amputations Among Racial and Ethnic Minority Adults Following Medicaid Expansion Under the Patient Protection and Affordable Care Act

Tze-Woei Tan, MD1,2Elizabeth A. Calhoun, PhD3Shannon M. Knapp, PhD4Adelina I. Lane, BS1David G. Marrero, PhD5C. Kent Kwoh, MD6Wei Zhou, MD1David G. Armstrong, PhD2,7

Key Points

Question  Has the amputation rate among African American, Hispanic, and other racial and ethnic minority adults with diabetic foot ulcerations (DFUs) changed during the early implementation of the Patient Protection and Affordable Care Act (ACA)?

Findings  In a cohort study of 115 071 hospitalizations for DFUs among racial and ethnic minority adults, early Medicaid expansion was associated with decreased major amputation and hospitalization rates in early-adoption states compared with nonadoption states.

Meaning  These findings suggest that early ACA implementation was associated with decreased lower extremity amputation among underserved racial and ethnic minority adults with DFUs.Abstract

Importance  It is not known whether implementation of Medicaid expansion under the Patient Protection and Affordable Care Act (ACA) was associated with improvements in the outcomes among racial and ethnic minority adults at risk of diabetes-related major amputations.

Objective  To explore the association of early Medicaid expansion with outcomes of diabetic foot ulcerations (DFUs).

Design, Setting, and Participants  This cohort study included hospitalizations for DFUs among African American, Asian and Pacific Islander, American Indian or Alaska Native, and Hispanic adults as well as adults with another minority racial or ethnic identification aged 20 to 64 years. Data were collected from the State Inpatient Databases for 19 states and the District of Columbia for 2013 to the third quarter of 2015. The analysis was performed on December 4, 2019, and updated on November 9, 2021.

Exposures  States were categorized into early-adopter states (expansion by January 2014) and nonadopter states.

Main Outcomes and Measures  Poisson regression was performed to examine the associations of state type, time, and their combined association with the proportional changes of major amputation rate per year per 100 000 population.

Results  Among the 115 071 hospitalizations among racial and ethnic minority adults with DFUs (64% of sample aged 50 to 64 years; 35%, female; 61%, African American; 25%, Hispanic; 14%, other racial and ethnic minority group), there were 36 829 hospitalizations (32%) for Medicaid beneficiaries and 10 500 hospitalizations (9%) for uninsured patients. Hospitalizations increased 3% (95% CI, 1% to 5%) in early-adopter states and increased 8% (95% CI, 6% to 10%) in nonadopter states after expansion, a significant difference (for interaction < .001). Although there was no change in the amputation rate (0.08%; 95% CI, −6% to 7%) in early-adopter states after expansion, there was a 9% (95% CI, 3% to 16%) increase in nonadopter states, a significant change (P = .04). For uninsured adults, the amputation rate decreased 33% (95% CI, 10% to 50%) in early-adopter states and did not change (12%; 95% CI, −10% to 38%) in nonadopter states after expansion, a significant difference (P = .006). There was no difference in the change of amputation rate among Medicaid beneficiaries between state types after expansion.

Conclusions and Relevance  This study found a relative improvement in the major amputation rate among African American, Hispanic, and other racial and ethnic minority adults in early-expansion states compared with nonexpansion states, which could be because of the recruitment of at-risk uninsured adults into the Medicaid program during the first 2 years of ACA implementation. Future study is required to evaluate the long-term association of Medicaid expansion and the rates of amputation.

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