Effects of the Affordable Care Act on Vascular Patient Amputation Rates in Arkansas.

BACKGROUND: The Patient Protection and Affordable Care Act was signed into law in 2010 and enacted in 2013 which improved insurance coverage across America due to increasing Medicaid eligibility as well as changes to individual insurance markets. In Arkansas, this was implemented by a Medicaid expansion waiver which allowed patients to purchase insurance with funds provided by the government to subsidize premiums through the marketplace. The goal of this study was to determine the effects of the Affordable Care Act (ACA) on Arkansas patients with peripheral arterial disease. METHODS: A pre-post research design using the Arkansas Hospital Discharge Dataset was used to study the impact of the ACA on limb amputation, distal bypass, discharge disposition, and total costs for patients diagnosed with peripheral arterial disease/atherosclerosis. The data were obtained for the years 2007 through 2009 (pre-ACA), 2011 through 2013 (post-ACA), and 2014 through 2015 (post-Arkansas expansion). Bivariate analysis, analysis of variance, and regression analyses were performed to analyze the data. RESULTS: A total of 10,923 patients were identified. Uninsured patients ("self-pay") decreased from 7% pre-ACA to 3.4% post-Arkansas expansion (P < 0.0001). There was a decrease in adjusted health-care costs after the Arkansas expansion (P < 0.0001). There was no change in mortality or transfer to rehabilitation facilities, but there was an increase in discharge to skilled nursing facilities along with a decrease in patients being discharged home (P < 0.0001). Regression analysis showed private insurance to be associated with a 49% reduction in the odds of an amputation (P < 0.0001). The Arkansas expansion was associated with a 26% reduction in the odds of an amputation when compared with that before the ACA implementation (P < 0.005). Having private insurance was associated with a 26% increase in the odds of having a bypass when compared with uninsured patients (P < 0.05). CONCLUSIONS: Patients with private insurance have a decreased chance of amputation and increased odds of having a bypass when compared with patients who were of the self-pay category. The increase in private insurance coverage in our patient population could improve the rate of amputation in the vascular population in Arkansas by increasing early interventions for peripheral vascular disease.

[The interdisciplinary approach in reconstructive surgery of the extremities]. / Operative Interdisziplinarität-Extremitäten. Aus der Sicht des plastischen Chirurgen.

In cases of extended post-traumatic soft-tissue and bone loss as well as with mutilating infection or radical tumor resection, multidisciplinary options are required to salvage extremities and functional rehabilitation. A surgical team approach allows for reduction of amputation rates, wound healing complications, and secondary procedures in limb oncology and trauma. The goals and limitations of cooperative surgical concepts are described. In the future, continuing medical education will focus not only on indications and techniques but also on complication management, medicolegal problems, and economic deficits due to maladapted legal structures. Provided clear clinical pathways are introduced to guide indications, surgical procedures, and postoperative treatment, marked financial deficits may be avoided. While, in the past, responsibility for the patient and ethical considerations resulted in the development of voluntary interdisciplinary treatment programs, economic strategies and an increasing number of malpractice suits will inevitably produce new imperatives for interdisciplinary cooperation in the future.