TY - JOUR
T1 - Rates of Diabetes-Related Major Amputations among Racial and Ethnic Minority Adults Following Medicaid Expansion under the Patient Protection and Affordable Care Act
AU - Tan, Tze Woei
AU - Calhoun, Elizabeth A.
AU - Knapp, Shannon M.
AU - Lane, Adelina I.
AU - Marrero, David G.
AU - Kwoh, C. Kent
AU - Zhou, Wei
AU - Armstrong, David G.
N1 - Funding Information:
Conflict of Interest Disclosures: Dr Kwoh reported receiving grants from Abbvie, EMD Serono, Eli Lilly and Co, Pfizer, GlaxoSmithKline, Cumberland Pharmaceuticals; receiving personal fees from EMD Serono, Thusane, Express Scripts, Regeneron, Taiwan Liposome Company, Amzell, LG Chem, Novartis, Focus Communications, PRIME Education, and Kolon Tissue Gene; and contributing voluntary service on the International Chinese Osteoarthritis Research Society board outside the submitted work. No other disclosures were reported.
Funding Information:
Funding/Support: This work is partially supported by grants 1K23DK122126 and 1R011124789 from the National Institute of Diabetes and Kidney Disease. Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. Meeting Presentation: This study was presented as an American Diabetes Association Presidents’ Select Abstract at the 80th Scientific Sessions of the American Diabetes Association; June 14, 2020; virtual.
Publisher Copyright:
© 2022 American Medical Association. All rights reserved.
PY - 2022/3/24
Y1 - 2022/3/24
N2 - 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 100000 population. Results: Among the 115071 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 36829 hospitalizations (32%) for Medicaid beneficiaries and 10500 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 (P 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..
AB - 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 100000 population. Results: Among the 115071 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 36829 hospitalizations (32%) for Medicaid beneficiaries and 10500 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 (P 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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U2 - 10.1001/jamanetworkopen.2022.3991
DO - 10.1001/jamanetworkopen.2022.3991
M3 - Article
C2 - 35323948
AN - SCOPUS:85127018407
SN - 2574-3805
VL - 5
JO - JAMA network open
JF - JAMA network open
IS - 3
M1 - e223991
ER -