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Effects of Medicaid Expansion of Affordable Care Act on the Operative Care and Outcomes of Abdominal Aorta Aneurysm (AAA) Repair
Hanaa D. Aridi, MD1, Mahmoud Malas, MD, MHS2, Alik Farber, MD3, Efthymios D. Avgerinos, MD4, Nathan Liang, MD4, Mohammad H. Eslami, MD, MPH4.
1Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA, 2Division of Vascular and Endovascular Surgery, University of San Diego, San Diego, CA, USA, 3Boston University School of Medicine, Boston, MA, USA, 4University of Pittsburgh Medical School, Pittsburgh, PA, USA.

OBJECTIVES:
Multiple studies have suggested that Medicaid expansion (ME) will lead to improved surgical outcomes and higher utilization of care. This study aims to assess whether ME has affected care and outcomes for patients undergoing elective AAA repair. Methods:We retrospectively reviewed the VQI database between 2010 and 2017. Centers not available before and after 2014 were excluded. Interrupted time series (ITS) was utilized to evaluate changes in annual trends of postoperative outcomes after elective AAA repair before and after ME(Intragroup analysis) and assess if these trend changes were significant by comparing the changes in ME States (MES) vs. Non-ME States (NME) (Intergroup analysis). Primary outcomes included in-hospital mortality and adverse events. One-year outcomes such as mortality, follow-up rates and medication compliance were also studied.Results:A total of 24,907 procedures were included (EVAR: 84.5% and OAR: 15.5%), of which 54.6% were in MES. Compared to pre-expansion trends, there was a 2% annual increase in the use of EVAR for AAA repair in MES (CI=-0.13,4.1, P=0.06), compared to a 3% decrease in NME (CI=-5.8, -0.6, P=0.03). ME did not seem to influence in-hospital and one-year mortality, follow-up rates in the states which expanded Medicaid .Nonetheless, it was associated with a significant decrease in trends of in-hospital complications relative to the pre-expansion period (MES: -1.4% (-2.1,-0.8) vs. NME: 0.2% (-0.2,0.8), P<0.01). One year postoperative follow up was available for 32% of patients (n=7,948). Compliance trend analyses showed an increase in statin compliance (MES:4.3%(1.9-6.6) vs. NME:0.01(-4.7,4.7), P=0.05) and smoking cessation (MES: 2.9%(-12.5,18.2) vs. NME:-8.1% (-19.4,3.3), p=0.15) but a decrease in compliance with aspirin (MES: -3.1% (-7.6,1.4) vs. NME: 1.6% (0.3,3.0),P=0.02) and beta blockers (MES:-2.8% (-7.9, 2.3) vs. NME: 2.9% (-5.5,11.4), p=0.15) within the first postoperative year. Conclusion:This trend analysis of the effect of ME shows a significant reduction of postoperative complication rates as well as an increase in utilization of EVAR in states that expanded Medicaid. Compliance with medication was not uniformly improved by Medicaid expansion, despite a trend towards improved statin compliance and smoking cessation in MES. The long-term beneficial effects of healthcare reform policies on AAA repair will require further studies.


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