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.

Causes of successful medico-legal claims following amputation.

INTRODUCTION: The causes of successful medico-legal claims following amputation were reviewed. METHODS: A retrospective analysis of claims handled by the National Health Service Litigation Authority, from 2005 to August 2010, was performed. Under the Freedom of Information Act, the National Health Service Litigation Authority provided limited details on closed claims, settled with damages, following a search of their database with the term "amputation." No demographic data were provided. RESULTS: During this period, 174 claims were settled by the National Health Service Litigation Authority, who paid out more than £36.3 million. The causes of the claims were the need for a lower limb amputation due to a delay in the diagnosis and or treatment of arterial ischaemia (56), an iatrogenic injury (15), the development of preventable pressure sores (15), the delay and or failure to diagnose a limb malignancy (6) and the delay in the management of an infected pseudo-aneurysm (1). Complications following orthopaedic surgery resulted in 25 successful claims as did the delayed diagnosis or mismanagement of 10 lower limb fractures. Additional claims followed the amputation of the wrong toe (1), a retained foreign body (2), an unnecessary amputation (4), inadequate consent (4), failure to provide thrombo-prophylaxis following amputation resulting in death (2) and a diathermy burn injury during an amputation (1). Delay in the diagnosis of and/or failure to manage an injury or infection resulted in 21 upper limb amputations. There was insufficient information provided in the remaining 11 claims to determine how the claim related to an amputation procedure. The largest single payout for damages (£1.9 million) resulted from the failure to diagnose and treat a femoral artery injury following a road traffic accident leading to an eventual below knee amputation. CONCLUSION: Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons for a settled claim. Lessons can be learnt from potentially preventable cases that can be incorporated in medical education and training programs with the aim of reducing both amputation rates and litigation costs.

Non-normative bodies, rationality, and legal personhood.

This article questions how legal personhood is constructed by law. Elective amputation is used as a way of interrogating the institutional, material, and discursive relations that combine in order to suspend legal personhood. Elective amputation is introduced in terms of medical and psychological explanations. Additionally, the perspective of self-identified elective amputees who choose to share their stories through online blogs is utilised to gain a narrative sense of how these individuals understand and engage with law. In particular, the areas of disability, sexuality, and rationality are used to exemplify law's continuing commitment to normative embodiment as grounds for ascribing legal personhood.

Medico-legal claims following amputations in the UK and Ireland.

The causes and outcomes of medico-legal claims following amputation were evaluated. A retrospective analysis of the experience of a consultant surgeon acting as an expert witness within the United Kingdom and Ireland (1990-2010). There were 154 claims referred for an opinion of which 53 related to female patients. The median age was 67 (range, 20-101) years. Forty nine (32%) of the patients were known diabetics. Seventy-eight (51%) of the claims actually arose following a medically expected amputation, i.e. an amputation that was not preventable or due to negligence. The other common causes of claims were a delay in the diagnosis and or treatment of arterial ischaemia (34%), and following iatrogenic injuries (5%). Eleven of the claims are still ongoing, 3 went to trial, 52 (34%) were settled out of court and 83 (54%) were discontinued after the claimants were advised that they were unlikely to win their case. Disclosed settlement amounts are reported. Delays in the diagnosis and or treatment of arterial ischaemia were the commonest reasons that a claimant was successful. Half of claims did not proceed but were not without financial and psychological costs.

[Who does my leg belong to after amputation?; informed consent on amputation of body parts]. / Van wie is mijn geamputeerde been?

In the Netherlands, when body parts are amputated as part of a medical procedure the patient's consent is required if this body part is used for, or subjected to, medical tests. The patient's consent is, however, rarely obtained, when body parts are discarded as 'pathological waste'. This can raise concerns, as patients have good reasons and distinct rights to demand a different fate, such as a burial or cremation, for their amputated limb. This article analyses the legal status of an amputated body part. We conclude that, legally, the amputated part does not belong to the hospital or doctor and can therefore not be disposed of at whim, in accordance with the hospital's wishes. Doctors have an obligation to actively inform their patients of their property rights over the amputated limbs and of the alternatives to disposal that are available. Doctors might find themselves exposed to tortuous liability procedures if they dispose of amputated body parts without proper consent.

Consent for Surgery in View of an Ambigious Court Decision - Case Report.

Guardianship courts seem to issue decisions in case of the need to obtain consent for surgery, amongst other things, when the patient is unable to consciously express written consent, and at the same time does not have a legal representative or a statutory representative does exist, but settlement with him is impossible. The presented study case demonstrated the abnormalities of applying court procedures, as well as the responsibilities and dilemmas posed in front of a surgeon. A specialist surgeon wanted to help the patient and he was able to accomplish his mission.

Healthy limb amputation: ethical and legal aspects.

A surgeon in Scotland has amputated the legs of two consenting, physically healthy patients. Although a handful of medical professionals believe that the desire for healthy limb amputation is symptomatic of a mental disorder that can be treated only by amputation, there is currently no consensus on what causes a person to desire such a disabling intervention. As long as there is no established body of medical opinion as to the diagnosis and treatment of such a condition, performing the surgery may be a criminal act. Given the ethically problematic history of surgery for psychiatric conditions, as well as the absence of sound medical data on this condition, surgeons should exercise great caution before complying with a request to amputate a healthy limb.

[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.

[Amputation of the hand as last resort in severe complex regional pain syndrome]. / Amputation der Hand als Ultima ratio bei schwerstem komplexen regionalen Schmerzsyndrom.

In very rare cases, a complex regional pain syndrome type I (CRPS I) of the hand can take a serious, chronic, incurable course. We describe the case of a 36-year-old patient who after reconstruction of a scaphoid fracture developed such a condition. 9 years after the operation an amputation of the hand was performed at the request of the patient after various expert opinions had been obtained and legal action against the insurance provider was successfully concluded. Amputation of the hand can be discussed as a last resort for relief of suffering in cases of severe CRPS I.