Factors in Hand Surgery Access for Rheumatoid Arthritis Before vs After the Patient Protection and Affordable Care Act
Authors: Shashank Dwivedi, Meghan N. Cichocki, Hao Wu, Celeste A. Kettaneh, Lu Wang, Kevin C. Chung
Journal: JAMA Surgery (2024)

Importance Rheumatoid arthritis (RA) has severe functional and economic consequences. The implications of the Patient Protection and Affordable Care Act (ACA) and demographic factors for access to surgical treatment are unclear. Objective To investigate factors associated with time to RA hand surgery, surgical incidence, and cost after implementation of the ACA. Design, Setting, and Participants This cross-sectional study used insurance data from the IBM MarketScan Research Databases from 2009 through 2020 to compare time to surgery, surgical incidence, and treatment cost for RA of the hand before and after ACA implementations. Included patients were 18 years or older with a new diagnosis for RA of the hand and at least 1 procedural code for arthroplasty, arthrodesis, tenolysis, tendon repair, or tendon transfer. Patients with coexisting inflammatory arthritis diagnoses were excluded. Demographic variables analyzed included patient sex, age at index date, residence within or outside a metropolitan statistical area (MSA; hereafter urban or nonurban), insurance and health plan type, Social Deprivation Index, Elixhauser Comorbidity Index score, and Rheumatic Disease Comorbidity Index. Data analysis occurred from October 2022 to April 2023. Exposures Surgery for RA of the hand during the pre-ACA (before 2014) vs post-ACA (2014 or later) periods. Main Outcomes and Measures Time to surgery, surgical incidence, and cost of treating RA in patients undergoing hand surgery for RA. Results Among 3643 patients (mean [SD] age, 57.6 [12.3] years) who underwent hand surgery for RA, 3046 (83.6%) were women. Post-ACA passage, 595 (86.2%) patients who resided in urban areas had a significantly lower time to surgery than those who did not (−70.5 [95% CI, −112.6 to −28.3] days; P &amp;amp;lt; .001). Among urban patients, the least socially disadvantaged patients experienced the greatest decrease in time to surgery after ACA but the change was not statistically significant. For all patients, greater social disadvantage (ie, a higher SDI score) was associated with a longer time to surgery in the post-ACA period; for example, compared with the least socially disadvantaged group (SDI decile, 0-10), patients in SDI decile 10 to 20 waited an additional 254.0 days (95% CI, 65.2 to 442.9 days; P = .009) before undergoing surgery. Compared with the pre-ACA period, the mean surgical incidence in the post-ACA period was 83.4% lower (162.3 vs 26.9 surgeries per 1000 person-years; P &amp;amp;lt; .001), and surgical incidence was 86.3% lower in nonurban populations (27.2 vs 3.7 surgeries per 1000 person-years; P &amp;amp;lt; .001) but only 82.8% lower in urban populations (135.1 vs 23.2 surgeries per 1000 person-years; P &amp;amp;lt; .001). Per capita total costs of all treatment related to RA of the hand decreased in the post-ACA period but the change was not statistically significant. Insurer-paid costs were lower in the post-ACA period but the change was not statistically significant. Out-of-pocket expenses did not change. Conclusions and Relevance Findings of this cross-sectional study suggest that after ACA passage, disparities exist in access to timely, cost-effective hand surgery for RA. Increased access to surgical hand specialists is needed for nonurban residents and those with greater social deprivation, along with insurance policy reforms to further decrease out-of-pocket spending for RA hand surgery.