By Monica Smith
Certain aspects of the Affordable Care Act (ACA) may have significantly benefited patients with chronic limb-threatening ischemia (CLTI), according to new research that found a much higher proportion of Maryland patients undergoing limb-salvaging revascularization instead of amputation after the state implemented the ACA.
Since passage of the ACA in 2010, more than 20 million previously uninsured residents in the United States have gained access to healthcare coverage. To study the impact of the ACA on patients in Maryland with CLTI, researchers from Howard University, in Washington, D.C., compared time periods before and after implementation of the act, analyzing rates of revascularization and amputation.
Using data from the Maryland State Inpatient Database, the researchers identified 12,126 patients who presented with CLTI during the two time periods, 2007-2009 and 2018-2020. (Maryland implemented the ACA in 2014.)
“There was no significant difference in baseline characteristics in the study population from both periods, but we noticed a significant drop in patients presenting to the hospital in the post-implementation period: 4,537 compared with 7,589 in the pre-implementation period,” said Oluwasegun Akinyemi, MD, MS, a senior research fellow at the Clive O. Callender Outcomes Research Center at Howard University College of Medicine, who presented the study at the 2024 Southeastern Surgical Congress. “This reduction was due to the increased management of CLTI in ambulatory care settings, which led to more patients being treated outside the hospital.”
Not surprisingly, there was a significant increase in the proportion of patients with Medicaid benefits, with a concomitant reduction in the proportion of patients with private insurance and those paying out of pocket. The difference in the management of CLTI patients between the two time periods was striking, according to the researchers.
“In the pre-implementation period, 56% of patients underwent amputation. In the post-implementation period, an impressive 77.4% of those patients had revascularization,” Dr. Akinyemi said, noting that this shift in treatment was seen across all races and ethnicities. After adjusting for patient baseline characteristics, preexisting comorbidities, lifestyle and hospital characteristics, the researchers found the post-ACA implementation period was associated with a fourfold increase in limb-salvaging revascularization. They also found a reduction in in-hospital mortality and prolonged hospital stay in the post-implementation period, irrespective of the treatment received.
“Whether amputation or revascularization, the post-implementation period was associated with a significant drop in both,” Dr. Akinyemi said. He also acknowledged the study’s limitations. The data were obtained from administrative databases, which may contain coding errors, and the investigators did not assess for long-term complications and other outcomes beyond the immediate postoperative period.
Despite these limitations, the post-implementation period was associated with a substantial increase in revascularization in CLTI patients, Dr. Akinyemi said. “Also, procedures became safer as indicated by a significant drop in postoperative mortality rates.”
Khanjan Nagarsheth, MD, MBA, an associate professor of surgery at the University of Maryland School of Medicine, in Baltimore, the program director of the vascular surgery residency and medical director of the Limb Preservation Program, said the temporal findings were interesting, but questioned whether other factors may be responsible for these changes.
“For example, vascular care has advanced dramatically in recent years, opening it up to patients who wouldn’t have been candidates even five years ago,” Dr. Nagarsheth said. “Could it be these advances rather than implementation of the ACA?”
Dr. Akinyemi noted that advances in technology could play a role, “but also, because of the expansion of insurance coverage, patients are likely to present with earlier stages of disease and more likely to be candidates for revascularization.” He and his colleagues plan to further study these shifts in treatment by comparing Maryland with another state that has not implemented ACA policies to see if these findings still prove to be accurate.
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