Studies show Medicaid expansion benefits minorities with diabetes, telehealth improves rural patients’ lives
A new study released at ADA shows the Affordable Care Act’s Medicaid expansion appears to have substantial positive effects on the care of racial and ethnic minorities with diabetic foot ulcerations (DFUs). The study found a 17% decrease in the risks of amputation among patients who lived in states that adopted Medicaid Expansion in 2014.
Existing research shows more than half of people with a diabetes-related lower extremity amputation will die within 5 years. It is estimated up to one-third of people with diabetes will develop a foot ulcer — the most common reason for foot infection and leg amputation. Loss of sensation in the feet (peripheral neuropathy) and blockage in the artery (peripheral artery disease) are major risk factors for leg amputation. Racial and ethnic minorities have significantly higher risks of DFUs and leg amputation than non-Hispanic Whites. Lack of health insurance is known to be a significant factor in patients with diabetes and peripheral artery disease.
Researchers analyzed 19 state inpatient databases from 2013 to 2015 to identify people with DFUs who were either uninsured or who had Medicaid coverage. Patients were then categorized into early-adopter states and non-adopter states. The study included 25,493 non-white Medicaid beneficiaries and 9,863 uninsured minority patients, aged 20 to 64, all of whom had DFUs.
The data analysis revealed:
- In early-adopter states, the number of inpatient admissions to treat DFU for Medicaid beneficiaries increased by 180.7%, while the number of admissions for uninsured patients decreased by 21.5%.
- In non-adopter states, the number of admissions of uninsured patients increased by 78.2%
- The odds of major amputation among non-white Medicaid beneficiaries decreased by 17.3% in early-adopter states and increased 1% in non-adopter states.
- The odds of minor amputation increased 14% in early adopter states and decreased 8% in non-adopter states.
“These results might suggest patients with DFUs living in states that chose to expand Medicaid coverage might be seeking care earlier and were able to prevent major leg amputation,” said study lead author Tze-Woei Tan, assistant professor of surgery at the University of Arizona, in a news release. “African Americans, Hispanics and those without health insurance have disproportionately higher risks of lower extremity amputation, so access to care for patients with foot ulcers is vital. The broadening of the ACA may reduce disparities in diabetes-related amputations.”
A separate study found that the use of intensive telehealth intervention for rural patients with uncontrolled diabetes revealed improved HbA1c levels. The study found a 1.36% reduction in HbA1c levels after 6 months of care, and indicated patients maintained the improvement up to 18 months after beginning the program.
Current information shows managing diabetes in rural areas is difficult due to limited access to specialty care and self-management programs. Using an award from the U.S. Department of Veterans Affairs Office of Rural Health in Iowa City, the researchers built the Advanced Comprehensive Diabetes Care (ACDC) program for delivery using the existing Veterans Health Administration’s home telehealth (VHA HT) infrastructure and clinical staff.
An earlier randomized trial, researchers found that ACDC improved HbA1c, blood pressure and diabetes self-care in the initial 50 veterans who participated. Since 2017, ACDC has been implemented in clinical practice at seven VHA sites around the country that serve rural veterans.
The most recent analysis examined 125 patients receiving ACDC at five sites. Across all locations, the patients’ average HbA1c levels improved from 9.25% at baseline to 7.89% at 6 months, a benefit that largely persisted 18 months after the start of the study. On qualitative analyses, ACDC enhanced patient engagement and awareness of diabetes control.
“We are pleased to see that the intervention was well-suited for delivery in clinical practice and that it remained effective in real-world settings,” said study investigator Elizabeth Kobe, an MD candidate at Duke University Medical School, in a news release. “When telehealth interventions are designed to leverage existing resources, they can greatly improve diabetes care in underserved rural populations. We also believe this design-minded approach can extend to other chronic diseases.”