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Bohr NL, Brown G, Rakel B, Babrowski T, Dorsey C, Skelly C. Predictive Modeling for One-Year Lower Extremity Endovascular Revascularization Failure in Black Persons. J Surg Res 2024; 300:117-126. [PMID: 38805844 DOI: 10.1016/j.jss.2024.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 04/04/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
INTRODUCTION Black persons bear a disproportionate burden of peripheral artery disease (PAD) and experience higher rates of endovascular revascularization failure (ERF) when compared with non-Hispanic White persons. We aimed to identify predictors of ERF in Black persons using predictive modeling. METHODS This retrospective study included all persons identifying as Black who underwent an initial endovascular revascularization procedure for PAD between 2011 and 2018 at a midwestern tertiary care center. Three predictive models were developed using (1) logistic regression, (2) penalized logistic regression (least absolute shrinkage and selection operator [LASSO]), and (3) random forest (RF). Predictive performance was evaluated under repeated cross-validation. RESULTS Of the 163 individuals included in the study, 113 (63.1%) experienced ERF at 1 y. Those with ERF had significant differences in symptom status (P < 0.001), lesion location (P < 0.001), diabetes status (P = 0.037), and annual procedural volume of the attending surgeon (P < 0.001). Logistic regression and LASSO models identified tissue loss, smoking, femoro-popliteal lesion location, and diabetes control as risk factors for ERF. The RF model identified annual procedural volume, age, PAD symptoms, number of comorbidities, and lesion location as most predictive variables. LASSO and RF models were more sensitive than logistic regression but less specific, although all three methods had an overall accuracy of ≥75%. CONCLUSIONS Black persons undergoing endovascular revascularization for PAD are at high risk of ERF, necessitating need for targeted intervention. Predictive models may be clinically useful for identifying high-risk patients, although individual predictors of ERF varied by model. Further exploration into these models may improve limb salvage for this population.
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Affiliation(s)
- Nicole L Bohr
- Department of Nursing Research, UChicago Medicine, Chicago, Illinois; Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago, Chicago, Illinois.
| | - Grant Brown
- Department of Biostatistics, University of Iowa, Iowa City, Iowa
| | - Barbara Rakel
- College of Nursing, University of Iowa, Iowa City, Iowa
| | - Trissa Babrowski
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago, Chicago, Illinois
| | - Chelsea Dorsey
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago, Chicago, Illinois
| | - Christopher Skelly
- Department of Surgery, Section of Vascular and Endovascular Surgery, University of Chicago, Chicago, Illinois
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:2497-2604. [PMID: 38752899 DOI: 10.1016/j.jacc.2024.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Bates KJ, Moore MM, Cibotti-Sun M. 2024 Lower Extremity Peripheral Artery Disease Guideline-at-a-Glance. J Am Coll Cardiol 2024; 83:2605-2609. [PMID: 38752900 DOI: 10.1016/j.jacc.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
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Gornik HL, Aronow HD, Goodney PP, Arya S, Brewster LP, Byrd L, Chandra V, Drachman DE, Eaves JM, Ehrman JK, Evans JN, Getchius TSD, Gutiérrez JA, Hawkins BM, Hess CN, Ho KJ, Jones WS, Kim ESH, Kinlay S, Kirksey L, Kohlman-Trigoboff D, Long CA, Pollak AW, Sabri SS, Sadwin LB, Secemsky EA, Serhal M, Shishehbor MH, Treat-Jacobson D, Wilkins LR. 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1313-e1410. [PMID: 38743805 DOI: 10.1161/cir.0000000000001251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
AIM The "2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease" provides recommendations to guide clinicians in the treatment of patients with lower extremity peripheral artery disease across its multiple clinical presentation subsets (ie, asymptomatic, chronic symptomatic, chronic limb-threatening ischemia, and acute limb ischemia). METHODS A comprehensive literature search was conducted from October 2020 to June 2022, encompassing studies, reviews, and other evidence conducted on human subjects that was published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through May 2023 during the peer review process, were also considered by the writing committee and added to the evidence tables where appropriate. STRUCTURE Recommendations from the "2016 AHA/ACC Guideline on the Management of Patients With Lower Extremity Peripheral Artery Disease" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with peripheral artery disease have been developed.
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Kalbaugh CA, Witrick B, Howard KA, Sivaraj LB, McGinigle KL, Robinson WP, Cykert S, Hicks CW, Lesko CR. Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation. Vasc Med 2024; 29:17-25. [PMID: 37737127 PMCID: PMC10922837 DOI: 10.1177/1358863x231196139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). METHODS We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. RESULTS Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). CONCLUSION Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.
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Affiliation(s)
- Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN, USA
| | - Brian Witrick
- West Virginia Clinical and Translational Sciences Institute, Morgantown, WV, USA
| | - Kerry A Howard
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
- Center for Public Health Modeling and Response, Clemson University, Clemson, SC, USA
| | | | - Katharine L McGinigle
- Department of Surgery, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Samuel Cykert
- Division of General Medicine and Clinical Epidemiology, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Catherine R Lesko
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Martinez OP, Storo K, Provenzano Z, Murphy E, Tomita TM, Cox S. A systematic review and meta-analysis on the influence of sociodemographic factors on amputation in patients with peripheral arterial disease. J Vasc Surg 2024; 79:169-178.e1. [PMID: 37722513 DOI: 10.1016/j.jvs.2023.08.130] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 09/20/2023]
Abstract
OBJECTIVE To identify disparities in sociodemographic factors that are associated with major lower limb amputation in patients with peripheral arterial disease (PAD). METHODS A systematic review of the literature was performed to identify studies that reported major lower limb amputation rates in patients with PAD among different sociodemographic groups. Data that compared amputation rates on the basis of sex, race, ethnicity, income, insurance, geography, and hospital type were collected and described. Outcomes were then aggregated and standardized, and a meta-analysis was performed to synthesis data into single odds ratios (ORs). RESULTS Forty-one studies were included in the review. There was no association found between males and females (OR, 0.95; 95% confidence interval [CI], 0.90-1.00). Compared with Whites, higher rates of amputation were seen among Blacks/African Americans (OR, 2.02; 95% CI, 1.81-2.26) and Native Americans (OR, 1.22; 95% CI, 1.04-1.45). No significant association was found between Whites and Asians, Native Hawaiians, or Pacific Islanders (OR, 1.15; 95% CI, 1.00-1.33). Hispanics had higher rates of amputation compared with non-Hispanics (OR, 1.36; 95% CI, 1.22-1.52). Compared with private insurance, higher rates of amputation were seen among Medicare patients (OR, 1.38; 95% CI, 1.27-1.50), Medicaid patients (OR, 1.59; 95% CI, 1.44-1.76), and noninsured patients (OR, 1.41; 95% CI, 1.02-1.95). Compared with the richest income quartile, higher rates of amputation were seen among the second income quartile (OR, 1.10; 95% CI, 1.05-1.15), third income quartile (OR, 1.20; 95% CI, 1.07-1.35), and bottom income quartile (OR, 1.36; 95% CI, 1.24-1.49). There was no association found between rural and urban populations (OR, 1.35; 95% CI, 0.92-1.97) or between teaching and nonteaching hospitals (OR, 1.01; 95% CI, 0.91-1.12). CONCLUSIONS Our study has identified a number of disparities and quantified the influence of sociodemographic factors on major lower limb amputation rates owing to PAD between groups. We believe these findings can be used to better target interventions aimed at decreasing amputation rates, although further research is needed to better understand the mechanisms behind our findings.
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Affiliation(s)
- O Parker Martinez
- University of South Carolina School of Medicine Columbia, Columbia, SC.
| | - Katharine Storo
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | | | - Eric Murphy
- University of South Carolina School of Medicine Columbia, Columbia, SC
| | - Tadaki M Tomita
- Department of Surgery, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
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Bazikian S, Urbina D, Hsu CH, Gonzalez KA, Rosario ER, Chu DI, Tsui J, Tan TW. Examining health care access disparities in Hispanic populations with peripheral artery disease and diabetes. Vasc Med 2023; 28:547-553. [PMID: 37642640 PMCID: PMC10712238 DOI: 10.1177/1358863x231191546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
INTRODUCTION This study investigated disparities in health care access for Hispanic adults with diabetes and peripheral artery disease (PAD) who are at risk of lower-extremity amputation and other cardiovascular morbidities and mortalities. METHODS We utilized the health care access survey data from the All of Us research program to examine adults (⩾ 18 years) with either diabetes and/or PAD. The primary associations evaluated were: could not afford medical care and delayed getting medical care in the past 12 months. Multivariable logistic regression models were used to assess the association of Hispanic ethnicity and survey responses, adjusting for age, sex, income, health insurance, and employment status. RESULTS Among 24,104 participants, the mean age was 54.9 years and 67% were women. Of these, 8.2% were Hispanic adults. In multivariable analysis, Hispanic adults were more likely to be unable to afford seeing a health care provider, and receiving emergency care, follow-up care, and prescription medications (p < 0.05) than non-Hispanic adults. Furthermore, Hispanic adults were more likely to report being unable to afford medical care due to cost (odds ratios [OR] 1.72, 95% CI 1.50-1.99), more likely to purchase prescription drugs from another country (OR 2.20, 95% CI 1.69-2.86), and more likely to delay getting medical care due to work (OR 1.46, 95% CI 1.22-1.74) and child care (OR 1.80, 95% CI 1.35-2.39) issues than non-Hispanic White adults. CONCLUSION The Hispanic population with diabetes and PAD faces substantial barriers in health care access, including a higher likelihood of delaying medical care and being unable to afford it.
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Affiliation(s)
- Sebouh Bazikian
- Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | | | | | | | - Emily R. Rosario
- Research Institute at Case Colina Hospital and Centers for Healthcare, Pamona, CA, USA
| | - Dan I. Chu
- Heershink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer Tsui
- Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
| | - Tze-Woei Tan
- Keck School of Medicine at University of Southern California, Los Angeles, CA, USA
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Divakaran S, Krawisz AK, Secemsky EA, Kant S. Sex and Racial Disparities in Peripheral Artery Disease. Arterioscler Thromb Vasc Biol 2023; 43:2099-2114. [PMID: 37706319 PMCID: PMC10615869 DOI: 10.1161/atvbaha.123.319399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Abstract
Several studies have shown that women and racial and ethnic minority patients are at increased risk of developing lower extremity peripheral artery disease and suffering adverse outcomes from it, but a knowledge gap remains regarding the underlying causes of these increased risks. Both groups are more likely to be underdiagnosed, have poorly managed contributory comorbidities, and incur disparities in treatment and management postdiagnosis. Opportunities for improvement in the care of women and racial and ethnic minorities with peripheral artery disease include increased rates of screening, higher rates of clinical suspicion (particularly in the absence of typical symptoms of intermittent claudication), and more aggressive risk factor management before and after the diagnosis of peripheral artery disease.
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Affiliation(s)
- Sanjay Divakaran
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna K Krawisz
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Eric A Secemsky
- Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Shashi Kant
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Powell CA, Albright J, Culver J, Osborne NH, Corriere MA, Sukul D, Gurm H, Henke PK. Direct and Indirect Effects of Race and Socioeconomic Deprivation on Outcomes After Lower Extremity Bypass. Ann Surg 2023; 278:e1128-e1134. [PMID: 37051921 DOI: 10.1097/sla.0000000000005857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVE To evaluate the potential pathway, through which race and socioeconomic status, as measured by the social deprivation index (SDI), affect outcomes after lower extremity bypass chronic limb-threatening ischemia (CLTI), a marker for delayed presentation. BACKGROUND Racial and socioeconomic disparities persist in outcomes after lower extremity bypass; however, limited studies have evaluated the role of disease severity as a mediator to potentially explain these outcomes using clinical registry data. METHODS We captured patients who underwent lower extremity bypass using a statewide quality registry from 2015 to 2021. We used mediation analysis to assess the direct effects of race and high values of SDI (fifth quintile) on our outcome measures: 30-day major adverse cardiac event defined by new myocardial infarction, transient ischemic attack/stroke, or death, and 30-day and 1-year surgical site infection (SSI), amputation and bypass graft occlusion. RESULTS A total of 7077 patients underwent a lower extremity bypass procedure. Black patients had a higher prevalence of CLTI (80.63% vs 66.37%, P < 0.001). In mediation analysis, there were significant indirect effects where Black patients were more likely to present with CLTI, and thus had increased odds of 30-day amputation [odds ratio (OR): 1.11, 95% CI: 1.068-1.153], 1-year amputation (OR: 1.083, 95% CI: 1.045-1.123) and SSI (OR: 1.052, 95% CI: 1.016-1.089). There were significant indirect effects where patients in the fifth quintile for SDI were more likely to present with CLTI and thus had increased odds of 30-day amputation (OR: 1.065, 95% CI: 1.034-1.098) and SSI (OR: 1.026, 95% CI: 1.006-1.046), and 1-year amputation (OR: 1.068, 95% CI: 1.036-1.101) and SSI (OR: 1.026, 95% CI: 1.006-1.046). CONCLUSIONS Black patients and socioeconomically disadvantaged patients tended to present with a more advanced disease, CLTI, which in mediation analysis was associated with increased odds of amputation and other complications after lower extremity bypass compared with White patients and those that were not socioeconomically disadvantaged.
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Affiliation(s)
- Chloé A Powell
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Jeremy Albright
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor MI
| | - Jacob Culver
- Blue Cross Blue Shield of Michigan Cardiovascular Consortium, Ann Arbor, MI
| | - Nicholas H Osborne
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Matthew A Corriere
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Devraj Sukul
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor MI
| | - Hitinder Gurm
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor MI
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
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Alhuneafat L, Omar YA, Naser A, Jagdish B, Alameh A, Al-Ahmad M, Abdouh AA, Mhanna M, Hammad N, Khalid U, Yousaf A, Madanat L, Al-Amer M, Gharaibeh A, Siraj A, Nasser F, Jabri A. Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample. Am J Cardiol 2023; 202:74-80. [PMID: 37421733 DOI: 10.1016/j.amjcard.2023.06.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 06/05/2023] [Accepted: 06/11/2023] [Indexed: 07/10/2023]
Abstract
Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.
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Affiliation(s)
- Laith Alhuneafat
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Yazan Abu Omar
- Department of Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Abdallah Naser
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Balaji Jagdish
- Department of Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Anas Alameh
- Department of Cardiology, MetroHealth Medical Center, Cleveland, Ohio
| | - Majd Al-Ahmad
- Department of Geriatrics Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ahmad Al Abdouh
- Division of Hospital Medicine, University of Kentucky, Lexington, Kentucky
| | - Mohammed Mhanna
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Nour Hammad
- Department of Nephrology, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Umar Khalid
- Department of Vascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Adnan Yousaf
- Department of Cardiology, MetroHealth Medical Center, Cleveland, Ohio
| | - Luai Madanat
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan
| | | | | | - Aisha Siraj
- Department of Cardiology, MetroHealth Medical Center, Cleveland, Ohio
| | - Farhan Nasser
- Department of Cardiology, MetroHealth Medical Center, Cleveland, Ohio
| | - Ahmad Jabri
- Department of Cardiovascular Disease, Henry Ford, Detroit, Michigan.
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11
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Alabi O, Beriwal S, Gallini JW, Cui X, Jasien C, Brewster L, Hunt KJ, Massarweh NN. Association of Health Care Utilization and Access to Care With Vascular Assessment Before Major Lower Extremity Amputation Among US Veterans. JAMA Surg 2023; 158:e230479. [PMID: 37074700 PMCID: PMC10116382 DOI: 10.1001/jamasurg.2023.0479] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 12/10/2022] [Indexed: 04/20/2023]
Abstract
Importance Patient-level characteristics alone do not account for variation in care among US veterans with peripheral artery disease (PAD). Presently, the extent to which health care utilization and regional practice variation are associated with veterans receiving vascular assessment prior to major lower extremity amputation (LEA) is unknown. Objective To assess whether demographics, comorbidities, distance to primary care, the number of ambulatory clinic visits (primary and medical specialty care), and geographic region are associated with receipt of vascular assessment prior to LEA. Design, Setting, and Participants This national cohort study used US Department of Veterans Affairs' Corporate Data Warehouse data from March 1, 2010, to February 28, 2020, for veterans aged 18 or older who underwent major LEA and who received care at Veterans Affairs facilities. Exposures The number of ambulatory clinic visits (primary and medical specialty care) in the year prior to LEA, geographic region of residence, and distance to primary care. Main Outcomes and Measures The main outcome was receipt of a vascular assessment (vascular imaging study or revascularization procedure) in the year prior to LEA. Results Among 19 396 veterans, the mean (SD) age was 66.78 (10.20) years and 98.5% were male. In the year prior to LEA, 8.0% had no primary care visits and 30.1% did not have a vascular assessment. Compared with veterans with 4 to 11 primary care clinic visits, those with fewer visits were less likely to receive vascular assessment in the year prior to LEA (1-3 visits: adjusted odds ratio [aOR], 0.90; 95% CI, 0.82-0.99). Compared with veterans who lived less than 13 miles from the closest primary care facility, those who lived 13 miles or more from the facility were less likely to receive vascular assessment (aOR, 0.88; 95% CI, 0.80-0.95). Veterans who resided in the Midwest were most likely to undergo vascular assessment in the year prior to LEA than were those living in other regions. Conclusions and Relevance In this cohort study, health care utilization, distance to primary care, and geographic region were associated with intensity of PAD treatment before LEA, suggesting that some veterans may be at greater risk of suboptimal PAD care practices. Development of clinical programs, such as remote patient monitoring and management, may represent potential opportunities to improve limb preservation rates and the overall quality of vascular care for veterans.
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Affiliation(s)
- Olamide Alabi
- Surgical and Perioperative Care, Atlanta VA Healthcare System, Decatur, Georgia
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | | | - Julia W. Gallini
- Foundation for Atlanta Veterans Education and Research, Decatur, Georgia
| | - Xiangqin Cui
- Atlanta VA Healthcare System, Decatur, Georgia
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | - Luke Brewster
- Surgical and Perioperative Care, Atlanta VA Healthcare System, Decatur, Georgia
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Kelly J. Hunt
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Healthcare System, Decatur, Georgia
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia
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Alabi O, Hunt KJ, Patzer RE, Henry Akintobi T, Massarweh NN. Racial Differences in Vascular Assessment Prior to Amputation in the Veterans Health Administration. Health Equity 2023; 7:346-350. [PMID: 37284536 PMCID: PMC10240309 DOI: 10.1089/heq.2023.0004] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 06/08/2023] Open
Abstract
Purpose It is unclear whether disparities in the care provided before lower extremity amputation (LEA) is driven by differences in receipt of diagnostic work-up versus revascularization attempts. Methods We performed a national cohort study of Veterans who underwent LEA between March 2010 and February 2020 to assess receipt of vascular assessment with arterial imaging and/or revascularization in the year prior to LEA. Results Among 19,396 veterans (mean age 66.8 years; 26.6% Black), Black veterans had diagnostic procedures more often than White veterans (47.5% vs. 44.5%) and revascularization as often (25.8% vs. 24.5%). Conclusion We must identify patient and facility-level factors associated with LEA as disparities do not appear related to differences in attempted revascularization.
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Affiliation(s)
- Olamide Alabi
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Kelly J. Hunt
- Charleston Health Equity and Rural Outreach Innovation Center (HEROIC), Ralph H. Johnson VA Medical Center, Charleston, South Carolina, USA
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rachel E. Patzer
- Health Services Research Center, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Tabia Henry Akintobi
- Department of Community Health and Preventive Medicine, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Nader N. Massarweh
- Surgical and Perioperative Care, Atlanta VA Health Care System, Decatur, Georgia, USA
- Division of Surgical Oncology, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Surgery, Morehouse School of Medicine, Atlanta, Georgia, USA
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13
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Fereydooni A, Patel J, Dossabhoy SS, George EL, Arya S. Racial, ethnic, and socioeconomic inequities in amputation risk for patients with peripheral artery disease and diabetes. Semin Vasc Surg 2023; 36:9-18. [PMID: 36958903 DOI: 10.1053/j.semvascsurg.2023.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/26/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Abstract
Peripheral artery disease and diabetes are highly prevalent diseases and the leading cause of limb loss. Despite advances in medical and surgical techniques, there are stark differences in delivery and outcomes of lower extremity amputation among populations when stratified by race, ethnicity, and socioeconomic status. We reviewed studies from the last 2 decades (1999-2022) to provide a comprehensive assessment of the current impact of disparities on the risk for, and management of, lower extremity amputation and offer action items that can optimize health outcomes.
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Affiliation(s)
- Arash Fereydooni
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304
| | - Janhavi Patel
- Michael G. DeGroote School of Medicine, Michael G. DeGroote Centre for Learning and Discovery, Hamilton, Ontario, Canada
| | - Shernaz S Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304
| | - Elizabeth L George
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304; Surgery Service Line, Veterans Affairs Palo Alto Healthcare System, 3801 Miranda Avenue, Palo Alto, CA 94304
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304; Surgery Service Line, Veterans Affairs Palo Alto Healthcare System, 3801 Miranda Avenue, Palo Alto, CA 94304.
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14
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McDermott KM, Bose S, Keegan A, Hicks CW. Disparities in limb preservation and associated socioeconomic burden among patients with diabetes and/or peripheral artery disease in the United States. Semin Vasc Surg 2023; 36:39-48. [PMID: 36958896 PMCID: PMC10039285 DOI: 10.1053/j.semvascsurg.2023.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 01/27/2023] [Accepted: 01/27/2023] [Indexed: 02/05/2023]
Abstract
Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (PAD). Higher rates of major LEA in disadvantaged groups are associated with increased health care utilization and higher costs of care. Functional decline that often follows major LEA confers substantial risk of disability and premature mortality, and the burden of these outcomes is more prevalent in racial and ethnic minority groups, people with low socioeconomic status, and people in geographic regions where limited resources or distance from specialty care are barriers to access. We present a narrative review of the existing literature on estimated costs of diabetic foot disease and PAD, inequalities in care that contribute to excess costs, and disparities in outcomes that lead to a disproportionate burden of diabetes- and PAD-related LEA on systematically disadvantaged populations.
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Affiliation(s)
- Katherine M McDermott
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287
| | - Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287
| | - Alana Keegan
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287; Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Baltimore, MD, 21287.
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15
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Conte MS. Vascular health and the health of vascular surgery-2021 Western Vascular Society Presidential Address. Semin Vasc Surg 2023; 36:1-8. [PMID: 36958890 DOI: 10.1053/j.semvascsurg.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/26/2023] [Indexed: 02/04/2023]
Affiliation(s)
- Michael S Conte
- Division of Vascular and Endovascular Surgery, University of California, San Francisco, 400 Parnassus Avenue, A-501, San Francisco, CA 94143-0957.
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16
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Luna P, Harris K, Castro-Dominguez Y, Algara M, Severiche-Mena C, Smolderen KG, Mena-Hurtado C. Risk profiles, access to care, and outcomes in Hispanics hospitalized for lower extremity peripheral artery disease. J Vasc Surg 2023; 77:216-224.e15. [PMID: 36037965 DOI: 10.1016/j.jvs.2022.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous studies have shown that Hispanics have worse clinical outcomes for lower extremity peripheral artery disease (PAD) than non-Hispanic White (NHWs). Using a national database, this study aimed to document the contemporary burden of PAD in Hispanics by evaluating their risk profiles, access to care, and outcomes compared with NHWs. METHODS Hospitalizations of Hispanics and NHWs with a primary diagnosis of PAD were identified using 2011-2017 National Inpatient Sample data. Patient sociodemographic characteristics, comorbidities, whether the admission was through the emergency department (ED) or elective, length of stay, and costs accrued were compared by ethnicity. Temporal trends in revascularizations, amputations, and ED admissions by year were evaluated with the Cochran-Mantel-Haenszel test and stratified by ethnicity. Data were combined across years and multivariable logistic regression was used to evaluate the association of ethnicity with inpatient revascularization, amputation, and mortality, adjusting for sociodemographic and cardiovascular risk factors. RESULTS From 2011 to 2017, there were a total of 1,018,220 PAD hospitalizations among Hispanics (13.9%) and NHWs (86.1%) between 2011 and 2017. Hispanics were more often low income and uninsured and presented with higher burden of comorbidities including diabetes, renal failure, prior amputations, and chronic limb-threatening ischemia compared with NHWs. Most Hispanics were admitted via the ED compared with NHWs (58.0% vs 36.7%; d = 0.48), and median length of stay was almost a day longer (4.5 days vs 3.7 days). Hispanic ethnicity was associated with lower odds of surgical (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.57-0.67) and endovascular revascularization (OR, 0.94; 95% CI, 0.89-0.996) and mortality (OR, 0.83; 95% CI, 0.75-0.93), but higher odds of minor (OR, 1.25; 95% CI, 1.20-1.31) and major (OR, 1.08; 95% CI, 1.03-1.14) amputation. CONCLUSIONS Two tiers of health care consumption for inpatient PAD care and outcomes manifested among Hispanics and NHWs. First, Hispanics with PAD had a more vulnerable socioeconomic profile and presented with more severe PAD than NHWs. Second, they sought care more disproportionately through the ED and underwent more amputations than NHWs. To eradicate these inequities in PAD care and risk, strategies that improve access to outpatient care and expand health care coverage, as well as targeted management of risk factors in these vulnerable minority groups are needed.
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Affiliation(s)
- Paulina Luna
- Yale University School of Medicine, New Haven, CT; Weill Cornell Medicine, New York, NY
| | | | - Yulanka Castro-Dominguez
- Yale University School of Medicine, New Haven, CT; Case Western Reserve University, Cleveland, OH
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17
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Raja A, Wadhera RK, Choi E, Chen S, Shen C, Figueroa JF, Yeh RW, Secemsky EA. Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States. Circ Cardiovasc Qual Outcomes 2023; 16:e009199. [PMID: 36472193 PMCID: PMC9851941 DOI: 10.1161/circoutcomes.122.009199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 09/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers. METHODS In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up. RESULTS Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings. CONCLUSIONS In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.
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Affiliation(s)
- Aishwarya Raja
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rishi K. Wadhera
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eunhee Choi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Siyan Chen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Changyu Shen
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Robert W. Yeh
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Department of Medicine; Beth Israel Deaconess Medical Center, Boston, MA, USA
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18
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Scierka LE, Mena-Hurtado C, Ahmed ZV, Yousef S, Arham A, Grimshaw AA, Harris KM, Burg M, Vriens PW, Heyligers J, Lee M, Yazgan I, Smolderen KG. The association of depression with mortality and major adverse limb event outcomes in patients with peripheral artery disease: A systematic review and meta-analysis. J Affect Disord 2023; 320:169-177. [PMID: 36179780 DOI: 10.1016/j.jad.2022.09.098] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peripheral artery disease (PAD) is highly prevalent and associated with poor outcomes. Depression is a risk factor for adverse outcomes in patients with coronary artery disease. Despite evidence showing that depression is common in patients with PAD, less is known about its association with adverse prognostic outcomes. To address this, we conducted a systematic review and meta-analysis to summarize the association between depression and outcomes in patients with PAD. METHODS We performed a systematic search of eight databases to January 2022 including studies that reported a risk estimate for the association of depression or depressive symptoms with all-cause mortality or major adverse limb events (MALE) in patients with PAD and pooled results in a meta-analysis. Risk of bias was assessed using ROBINS-I. RESULTS Of the 7048 articles screened, 5 observational studies with 119,123 patients were included. A total of 16.2 % had depression or depressive symptoms. Depression was associated with a statistically significant increased risk of all-cause mortality (HR 1.24, confidence interval 1.07-1.25, p = .005). The association between depression and MALE was not significant but trended toward a positive association. LIMITATIONS Due to lack of data, results were limited by a single study with a large sample size, overrepresentation of men, and lack of information of depression severity or treatment status. CONCLUSION Depression or depressive symptoms are associated with a 24 % increased risk of all-cause mortality in patients with PAD. Future work should explore the mechanisms and directionality of this association and identify depression as an important comorbidity to address for patients with PAD. REGISTRATION PROSPERO CRD 42021223694.
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Affiliation(s)
- Lindsey E Scierka
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Zain V Ahmed
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sameh Yousef
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ahmad Arham
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Alyssa A Grimshaw
- Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, CT, USA
| | - Kristie M Harris
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Burg
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Patrick W Vriens
- Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Jan Heyligers
- Department of Surgery, St. Elisabeth Hospital, Tilburg, the Netherlands
| | - Megan Lee
- Yale School of Medicine, New Haven, CT, USA
| | | | - Kim G Smolderen
- Vascular Medicine Outcomes (VAMOS) Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA; Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA.
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19
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Salhi RA, Dupati A, Burkhardt JC. Interest in Serving the Underserved: Role of Race, Gender, and Medical Specialty Plans. Health Equity 2022; 6:933-941. [PMID: 36636113 PMCID: PMC9811834 DOI: 10.1089/heq.2022.0064] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/29/2022] Open
Abstract
Introduction Medical students often express their plans to care for medically underserved populations, but little is known about how this interest remains during medical school (MS). This study examined how self-reported interest in working with medically underserved communities may change during MS training based on several student characteristics. Methods A secondary data analysis of all student records in the Electronic Residency Application Service (ERAS) from 2005 to 2010 is presented. Predictors included gender, under-represented in medicine (URiM) status, age, academic metrics, career interest, and medical specialty choice. Outcomes included interest in caring for medically underserved populations when entering MS, graduating MS, and graduating MS controlling for entering interest. Results The total population included 6890 student records (49.5% women and 18.2% URiM). Women had a higher likelihood of being interested in practicing in underserved communities when entering and graduating MS (odds ratio [OR] 1.55, 95% confidence interval [CI] 1.37-1.77; OR 1.24, 95% CI 1.09-1.40). For all outcomes, URiM students had a higher likelihood of planning on a career with underserved populations compared with their non-URiM peers. Compared with Emergency Medicine, Internal Medicine/Pediatrics and Family Medicine had a higher likelihood of plans to work with underserved populations upon entering, graduating, and at graduation controlling for entering interest. Discussion Gender, race, and specialty choice all had meaningful associations with a student's plans on practice in an underserved community. This study's findings can help support efforts to improve MS diversity nationally and drive study on cultural effects embedded within medical specialty identity.
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Affiliation(s)
- Rama A. Salhi
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA.,Address correspondence to: Rama A. Salhi, MD, MHS, MSc, Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street, Suite 920, Boston, MA 02114, USA,
| | - Ajith Dupati
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - John C. Burkhardt
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA.,Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, Michigan, USA
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20
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Lapica H, Ozery M, Raju H, Castro G, Rodriguez de la Vega P, Barengo NC. The Associations between Racial Disparities, Health Insurance, and the Use of Amputation as Treatment for Malignant Primary Bone Neoplasms in the US: A Retrospective Analysis from 1998 to 2016. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:6289. [PMID: 35627824 PMCID: PMC9140582 DOI: 10.3390/ijerph19106289] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/18/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
Primary bone neoplasms (PBNs) represent less than 1% of diagnosed cancers each year. Significant treatment disparities exist between racial and ethnic groups. We investigated patients with PBNs to determine an association between race/ethnicity and procedure-type selection. A non-concurrent cohort study was conducted using the SEER database. Patients diagnosed with PBNs between 1998 and 2016 were included (n = 5091). Patients were classified into three racial groups (Black, White and Asian Pacific Islanders) and were assessed by procedure-type received. The outcome was amputation. Race was not associated with increased amputation incidence. Hispanic patients had a 40% increased likelihood of amputation (OR 1.4; 95% CI 1.2-1.6). Insurance status was an independent predictor of procedure selection. Uninsured patients were 70% more likely to receive amputation than insured patients (OR 1.7; 95% CI 1.1-2.8). We recommend provider awareness of patients less likely to seek regular healthcare in the context of PBNs.
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Affiliation(s)
- Hans Lapica
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
| | - Matan Ozery
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
| | - Harsha Raju
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
| | - Grettel Castro
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
| | - Pura Rodriguez de la Vega
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
| | - Noël C. Barengo
- Department of Translational Medicine, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA; (H.L.); (M.O.); (H.R.); (G.C.); (P.R.d.l.V.)
- Department of Health Policy & Management, Robert Stempel College of Public Health & Social Work, Florida International University, 11200 SW 8th Street, Miami, FL 33199, USA
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21
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Predictors of amputation-free survival after endovascular intervention for chronic limb-threatening ischemia in the modern era. Ann Vasc Surg 2022; 86:268-276. [PMID: 35595207 DOI: 10.1016/j.avsg.2022.04.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/12/2022] [Accepted: 04/26/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival in a contemporary cohort treated with endovascular recanalization and assess its predictors. METHODS Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was amputation-free survival; a p-value < 0.05 was used for univariate screening and inclusion in a multivariable model. RESULTS 137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (p=0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%) although 26% were multilevel. Percutaneous atherectomy, stenting and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16 months (IQR=4-29 months), significant independent predictors of reduced AFS included non-white race (HR=2.96 [1.42-6.17]; p=0.004) and WIfI stage 4 wounds (HR=2.23 [1.10-4.52]; p=0.026). At one year following successful revascularization, only 59%±1% of patients were alive with their limb intact. CONCLUSIONS Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.
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22
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Bryce Y, Katzen B, Patel P, Moreira CC, Fakorede FA, Arya S, D'Andrea M, Mustapha J, Rowe V, Rosenfield K, Vedantham S, Abi-Jaoudeh N, Rochon PJ. Closing the Gaps in Racial Disparities in Critical Limb Ischemia Outcome and Amputation Rates: Proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel. J Vasc Interv Radiol 2022; 33:593-602. [PMID: 35489789 DOI: 10.1016/j.jvir.2022.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/15/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022] Open
Abstract
Minority patients such as Blacks, Hispanics, and Native Americans are disproportionately impacted by critical limb ischemia and amputation due to multiple factors such as socioeconomic status, type or lack of insurance, lack of access to health care, capacity and expertise of local hospitals, prevalence of diabetes, and unconscious bias. The Society of Interventional Radiology Foundation recognizes that it is imperative to close the disparity gaps and funded a Research Consensus Panel to prioritize a research agenda. The following research priorities were ultimately prioritized: (a) randomized controlled trial with peripheral arterial disease screening of at-risk patients with oversampling of high-risk racial groups, (b) prospective trial with the introduction of an intervention to alter a social determinant of health, and (c) a prospective trial with the implementation of an algorithm that requires criteria be met prior to an amputation. This article presents the proceedings and recommendations from the panel.
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Affiliation(s)
- Yolanda Bryce
- Interventional Radiology, Radiology Department, Memorial Sloan Kettering Cancer Center, New York, New York.
| | - Barry Katzen
- Miami Cardiac and Vascular Institute, Interventional Radiology, Radiology Department, Baptist Health South Florida, Miami, Florida
| | - Parag Patel
- Interventional Radiology, Radiology Department, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Carla C Moreira
- Vascular Surgery, Surgery Department, Alpert Medical School of Brown University, Providence, Rhode Island
| | - Foluso A Fakorede
- Cardiovascular Solutions of Central Mississippi/Fusion Vascular LLC, Cleveland, Mississippi
| | - Shipra Arya
- Vascular Surgery, Surgery Department, Stanford University School of Medicine, Stanford, California
| | - Melissa D'Andrea
- Vascular Surgery, Surgery Department, University of Arizona College of Medicine - Tucson, Tucson, Arizona
| | - Jihad Mustapha
- Cardiology, Medicine Department, Michigan State University College of Human Medicine, Grand Rapids, Michigan
| | - Vincent Rowe
- Vascular Surgery, Surgery Department, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Kenneth Rosenfield
- Vascular Surgery, Surgery Department, Massachusetts General Hospital, Boston, Massachusetts
| | - Suresh Vedantham
- Interventional Radiology, Radiology Department, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Nadine Abi-Jaoudeh
- Interventional Radiology, Radiology Department, University of California, Irvine, Irvine, California
| | - Paul J Rochon
- Interventional Radiology, Radiology Department, University of Colorado School of Medicine, Denver, Colorado
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23
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Scierka LE, Mena-Hurtado C, Shishehbor MH, Spertus JA, Nagpal S, Babrowski T, Bunte MC, Politano A, Humphries M, Chung J, Kirksey L, Alabi O, Soukas P, Parikh S, Faizer R, Fitridge R, Provance J, Romain G, McMillan N, Stone N, Scott K, Fuss C, Pacheco CM, Gosch K, Harper-Brooks A, Smolderen KG. The shifting care and outcomes for patients with endangered limbs - Critical limb ischemia (SCOPE-CLI) registry overview of study design and rationale. IJC HEART & VASCULATURE 2022; 39:100971. [PMID: 35198727 PMCID: PMC8850321 DOI: 10.1016/j.ijcha.2022.100971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/26/2022] [Accepted: 02/02/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Critical limb ischemia (CLI), the most severe form of peripheral artery disease, is associated with pain, poor wound healing, high rates of amputation, and mortality (>20% at 1 year). Little is known about the processes of care, patients' preferences, or outcomes, as seen from patients' perspectives. The SCOPE-CLI study was co-designed with patients to holistically document patient characteristics, treatment preferences, patterns of care, and patient-centered outcomes for CLI. METHODS This 11-center prospective observational registry will enroll and interview 816 patients from multispecialty, interdisciplinary vascular centers in the United States and Australia. Patients will be followed up at 1, 2, 6, and 12 months regarding their psychosocial factors and health status. Hospitalizations, interventions, and outcomes will be captured for 12 months with vital status extending to 5 years. Pilot data were collected between January and July of 2021 from 3 centers. RESULTS A total of 70 patients have been enrolled. The mean age was 68.4 ± 11.3 years, 31.4% were female, and 20.0% were African American. CONCLUSIONS SCOPE-CLI is uniquely co-designed with patients who have CLI to capture the care experiences, treatment preferences, and health status outcomes of this vulnerable population and will provide much needed information to understand and address gaps in the quality of CLI care and outcomes.ClinicalTrials.gov identifier (NCT Number): NCT04710563 https://clinicaltrials.gov/ct2/show/NCT04710563.
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Affiliation(s)
- Lindsey E. Scierka
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Carlos Mena-Hurtado
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Mehdi H. Shishehbor
- Case Western University School of Medicine/Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH, United States
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Sameer Nagpal
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | | | - Matthew C. Bunte
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Amani Politano
- Oregon Health & Science University, Portland, OR, United States
| | | | - Jayer Chung
- Baylor College of Medicine, Houston, TX, United States
| | - Lee Kirksey
- Cleveland Clinic, Cleveland, OH, United States
| | | | | | - Sahil Parikh
- Columbia University – Presbyterian, New York, NY, United States
| | - Rumi Faizer
- University of Minnesota, Minneapolis, MN, United States
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Jeremy Provance
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Gaëlle Romain
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Neil McMillan
- Discipline of Surgery, The University of Adelaide, Adelaide, Australia
| | - Nancy Stone
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kate Scott
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christine Fuss
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Christina M. Pacheco
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Kensey Gosch
- Saint Luke’s Mid America Heart Institute/University of Missouri Kansas City, Kansas City, MO, United States
| | - Avis Harper-Brooks
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
| | - Kim G. Smolderen
- Yale University, Department of Internal Medicine, Vascular Medicine Outcomes Program (VAMOS), New Haven, CT, United States
- Yale University, Department of Psychiatry, New Haven, CT, United States
- Corresponding author at: 789 Howard Avenue, New Haven, CT 06519, United States.
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24
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Penny CL, Tanino SM, Mosca PJ. Racial Disparities in Surgery for Malignant Bowel Obstruction. Ann Surg Oncol 2022; 29:3122-3133. [PMID: 35041096 DOI: 10.1245/s10434-021-11161-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 11/13/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Operative management of patients with malignant bowel obstruction (MBO) may provide effective palliation, but is associated with substantial risks. This study aimed to analyze racial and ethnic differences in surgical outcomes for patients with MBO. METHODS This retrospective study, using National Surgical Quality Improvement Program (NSQIP) registry data from 2010 to 2019, compared differences in outcomes by race and ethnicity for 2762 patients undergoing surgery for MBO. Multivariable logistic regression controlled for relevant covariates. RESULTS Black patients (n = 407) had higher rates of preoperative comorbidity and were more likely than White patients (n = 2081) to have major complications (28.5% vs 21.8%; p = 0.0031), overall complications (47.4% vs 40.4%; p = 0.0087), a longer median hospital stay (12 days; interquartile range [IQR, 8-19 days] vs 10 days [IQR, 7-17 days]; p = 0.0007), and unplanned readmission (17.1% vs 12.9%; p = 0.0266). Black patients had a similar mortality rate to that of White patients and were less frequently discharged to home (67.6% vs 73.0%; p = 0.0315). Differences in morbidity between Black patients and White patients persisted after controlling for potentially confounding variables. Hispanic patients had lower mortality than White patients (6.3% vs 13.1%; p = 0.0130) and a longer hospital stay (12 days [IQR, 8-18 days] vs 10 days [IQR, 7-17 days]; p = 0.0313). Outcomes did not differ between Asian patients and White patients. CONCLUSIONS This study demonstrated significant disparities for Black patients undergoing surgery for MBO. Understanding and addressing what drives these differences, including systemic inequalities such as access to care and racial biases, is essential to the achievement of more equitable, higher-quality patient care.
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Affiliation(s)
- Caitlin L Penny
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Sean M Tanino
- Duke University School of Medicine, Duke Health, Durham, NC, USA
| | - Paul J Mosca
- Duke University School of Medicine, Duke Health, Durham, NC, USA. .,Department of Surgery, Duke Health, Durham, NC, USA. .,Duke Network Services, Duke Health, Durham, NC, USA.
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25
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Witrick B, Kalbaugh CA, Shi L, Mayo R, Hendricks B. Geographic Disparities in Readmissions for Peripheral Artery Disease in South Carolina. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 19:285. [PMID: 35010545 PMCID: PMC8751080 DOI: 10.3390/ijerph19010285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 12/22/2021] [Accepted: 12/24/2021] [Indexed: 06/14/2023]
Abstract
Readmissions constitute a major health care burden among peripheral artery disease (PAD) patients. This study aimed to 1) estimate the zip code tabulation area (ZCTA)-level prevalence of readmission among PAD patients and characterize the effect of covariates on readmissions; and (2) identify hotspots of PAD based on estimated prevalence of readmission. Thirty-day readmissions among PAD patients were identified from the South Carolina Revenue and Fiscal Affairs Office All Payers Database (2010-2018). Bayesian spatial hierarchical modeling was conducted to identify areas of high risk, while controlling for confounders. We mapped the estimated readmission rates and identified hotspots using local Getis Ord (G*) statistics. Of the 232,731 individuals admitted to a hospital or outpatient surgery facility with PAD diagnosis, 30,366 (13.1%) experienced an unplanned readmission to a hospital within 30 days. Fitted readmission rates ranged from 35.3 per 1000 patients to 370.7 per 1000 patients and the risk of having a readmission was significantly associated with the percentage of patients who are 65 and older (0.992, 95%CI: 0.985-0.999), have Medicare insurance (1.013, 1.005-1.020), and have hypertension (1.014, 1.005-1.023). Geographic analysis found significant variation in readmission rates across the state and identified priority areas for targeted interventions to reduce readmissions.
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Affiliation(s)
- Brian Witrick
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA; (C.A.K.); (L.S.); (R.M.)
| | - Corey A. Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA; (C.A.K.); (L.S.); (R.M.)
- Department of Bioengineering, Clemson University, Clemson, SC 29631, USA
| | - Lu Shi
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA; (C.A.K.); (L.S.); (R.M.)
| | - Rachel Mayo
- Department of Public Health Sciences, Clemson University, Clemson, SC 29631, USA; (C.A.K.); (L.S.); (R.M.)
| | - Brian Hendricks
- Department of Epidemiology and Biostatistics, West Virginia University School of Public Health, Morgantown, WV 26505, USA;
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Gandjian M, Sareh S, Premji A, Ugarte R, Tran Z, Bowens N, Benharash P. Racial disparities in surgical management and outcomes of acute limb ischemia in the United States. Surg Open Sci 2021; 6:45-50. [PMID: 34632355 PMCID: PMC8487073 DOI: 10.1016/j.sopen.2021.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 08/22/2021] [Accepted: 08/27/2021] [Indexed: 12/04/2022] Open
Abstract
Background Although significant racial disparities in the surgical management of lower extremity critical limb threatening ischemia have been previously reported, data on disparities in lower extremity acute limb ischemia are lacking. Methods The 2012–2018 National Inpatient Sample was queried for all adult hospitalizations for acute limb ischemia (N = 225,180). Hospital-specific observed-to-expected rates of major lower extremity amputation were tabulated. Multivariable logistic and linear models were developed to assess the impact of race on amputation and revascularization. Results Nonwhite race was associated with significantly increased odds of overall (adjusted odds ratio: 1.16, 95% confidence interval 1.06–1.28) and primary (adjusted odds ratio: 1.34, 95% confidence interval 1.17–1.53) major amputation, decreased odds of revascularization (adjusted odds ratio 0.79, 95% confidence interval 0.73–0.85), but decreased in-hospital mortality (adjusted odds ratio: 0.86, 95% confidence interval 0.74–0.99). The nonwhite group incurred increased adjusted index hospitalization costs (β: +$4,810, 95% confidence interval 3,280-6,350), length of stay (β: + 1.09 days, 95% confidence interval 0.70–1.48), and nonhome discharge (adjusted odds ratio: 1.15, 95% confidence interval 1.06–1.26). Conclusion Significant racial disparities exist in the management of and outcomes of lower extremity acute limb ischemia despite correction for variations in hospital amputation practices and other relevant hospital and patient characteristics. Whether the etiology lies primarily in patient, institution, or healthcare provider–specific factors has not yet been determined. Further studies of race-based disparities in management and outcomes of acute limb ischemia are warranted to provide effective and equitable care to all.
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Affiliation(s)
- Matthew Gandjian
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Sohail Sareh
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA.,Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Alykhan Premji
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ramsey Ugarte
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Nina Bowens
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, CA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories (CORELAB), David Geffen School of Medicine at UCLA, Los Angeles, CA
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27
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Short- and Long-Term Outcomes following Severe Traumatic Lower Extremity Reconstruction: The Value of an Orthoplastic Limb Salvage Center to Racially Underserved Communities. Plast Reconstr Surg 2021; 148:646-654. [PMID: 34432698 DOI: 10.1097/prs.0000000000008277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Previous studies have demonstrated that nonwhite race and disadvantaged socioeconomic status negatively impact outcomes following lower extremity reconstruction. The authors sought to characterize differences in outcomes between racial groups in patients necessitating traumatic lower extremity reconstruction at an orthoplastic limb salvage center. METHODS A retrospective review between 2002 and 2019 was conducted of patients who underwent free flap lower extremity reconstruction at an orthoplastic limb salvage center. Patient demographics were identified, and permanent addresses were used to collect census data. Short-term complications and long-term functional status were recorded. RESULTS One hundred seventy-three patients underwent lower extremity reconstruction and met inclusion criteria. Among all three groups, African American patients were more likely to be single (80 percent African American versus 49 percent Caucasian and 29.4 percent other; p < 0.05) and had significantly lower rates of private insurance compared with Caucasian patients (25 percent versus 56.7 percent; p < 0.05). African American patients demonstrated no significant differences in total flap failure (4.9 percent versus 8 percent and 5.6 percent; p = 0.794), reoperations (10 percent versus 5.8 percent and 16.7 percent; p = 0.259), and number of readmissions (2.4 versus 2.0 and 2.1; p = 0.624). Chronic pain management (53.3 percent versus 44.2 percent and 50 percent; p = 0.82), full weight-bearing status (84.2 percent versus 92.7 percent and 100 percent; p = 0.507), and ambulation status (92.7 percent versus 100 percent and 100 percent; p = 0.352) were similar among groups. CONCLUSIONS Outcomes are equivalent between racial groups presenting to an orthoplastic limb salvage center for lower extremity reconstruction. The postoperative rehabilitation strategies, follow-up, and overall support that an orthoplastic limb salvage center ensures may lessen the impact of socioeconomic disparities in traumatic lower extremity reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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28
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Criqui MH, Matsushita K, Aboyans V, Hess CN, Hicks CW, Kwan TW, McDermott MM, Misra S, Ujueta F. Lower Extremity Peripheral Artery Disease: Contemporary Epidemiology, Management Gaps, and Future Directions: A Scientific Statement From the American Heart Association. Circulation 2021; 144:e171-e191. [PMID: 34315230 PMCID: PMC9847212 DOI: 10.1161/cir.0000000000001005] [Citation(s) in RCA: 254] [Impact Index Per Article: 84.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Lower extremity peripheral artery disease (PAD) affects >230 million adults worldwide and is associated with increased risk of various adverse clinical outcomes (other cardiovascular diseases such as coronary heart disease and stroke and leg outcomes such as amputation). Despite its prevalence and clinical importance, PAD has been historically underappreciated by health care professionals and patients. This underappreciation seems multifactorial (eg, limited availability of the first-line diagnostic test, the ankle-brachial index, in clinics; incorrect perceptions that a leg vascular disease is not fatal and that the diagnosis of PAD would not necessarily change clinical practice). In the past several years, a body of evidence has indicated that these perceptions are incorrect. Several studies have consistently demonstrated that many patients with PAD are not receiving evidence-based therapies. Thus, this scientific statement provides an update for health care professionals regarding contemporary epidemiology (eg, prevalence, temporal trends, risk factors, and complications) of PAD, the present status of diagnosis (physiological tests and imaging modalities), and the major gaps in the management of PAD (eg, medications, exercise therapy, and revascularization). The statement also lists key gaps in research, clinical practice, and implementation related to PAD. Orchestrated efforts among different parties (eg, health care providers, researchers, expert organizations, and health care organizations) will be needed to increase the awareness and understanding of PAD and improve the diagnostic approaches, management, and prognosis of PAD.
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Hurwitz M, Norvell DC, Czerniecki JM. Racial and ethnic amputation level disparities in veterans undergoing incident dysvascular lower extremity amputation. PM R 2021; 14:1198-1206. [PMID: 34333862 DOI: 10.1002/pmrj.12682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 07/09/2021] [Accepted: 07/12/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND The choice of incident amputation level can have a profound effect on clinical outcomes. Amputations at the transmetatarsal (TM) or transtibial (TT) levels result in greater preservation of function and mobility, whereas transfemoral (TF) amputations typically result in a greater adverse impact. Prior investigations have explored racial/ethnic and regional variation in incident amputation level. This study overcomes some of the methodological limitations seen in prior research through the use of a large national, multiyear veteran sample and by including only those who have undergone an incident amputation. OBJECTIVES (1) Determine if there are national/regional differences in the frequency of incident TF amputation compared with TM and TT amputation, (2) Determine if race/ethnicity and geographic region are associated with incident TF amputation level, and (3) Determine if racial/ethnic disparities of incident TF amputation differ by the presence of diabetes or prior revascularization. DESIGN Retrospective cohort study of veterans undergoing an incident dysvascular lower extremity amputation. SETTING One hundred ten Veterans Affairs (VA) Medical Centers. PARTICIPANTS Seven thousand two hundred ninety-six Veterans undergoing incident unilateral dysvascular lower extremity amputation identified in the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database (2005-2014). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE Incident amputation level. RESULTS The White, Black, and Hispanic risk for an incident TF amputation was 31% (n = 1356), 35% (n = 810), and 46% (n = 293), respectively. In the Continental region, Blacks who had not had a prior revascularization were more likely to undergo a TF amputation compared to Whites both with and without diabetes (odds ratio [OR] = 1.4; 95% confidence interval [CI], 1.1, 1.9 and OR = 1.5; 95% CI, 1.1, 2.1, respectively). In the Southeast region, Hispanics compared with Whites were at increased odds of undergoing a TF amputation, irrespective of a diabetes or a prior revascularization (ORs ≥ 2.9). CONCLUSIONS Racial and ethnic disparities exist in choice of proximal compared with distal amputation in specific VA geographic regions.
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Affiliation(s)
- Max Hurwitz
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel C Norvell
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Joseph M Czerniecki
- Rehabilitation Care Services, VA Puget Sound Health Care System, Seattle, Washington, USA.,Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, USA
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30
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Grines CL, Klein AJ, Bauser-Heaton H, Alkhouli M, Katukuri N, Aggarwal V, Altin SE, Batchelor WB, Blankenship JC, Fakorede F, Hawkins B, Hernandez GA, Ijioma N, Keeshan B, Li J, Ligon RA, Pineda A, Sandoval Y, Young MN. Racial and ethnic disparities in coronary, vascular, structural, and congenital heart disease. Catheter Cardiovasc Interv 2021; 98:277-294. [PMID: 33909339 DOI: 10.1002/ccd.29745] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022]
Abstract
Cardiovascular disease (CVD) remains the leading cause of death in the United States. However, percutaneous interventional cardiovascular therapies are often underutilized in Blacks, Hispanics, and women and may contribute to excess morbidity and mortality in these vulnerable populations. The Society for Cardiovascular Angiography and Interventions (SCAI) is committed to reducing racial, ethnic, and sex-based treatment disparities in interventional cardiology patients. Accordingly, each of the SCAI Clinical Interest Councils (coronary, peripheral, structural, and congenital heart disease [CHD]) participated in the development of this whitepaper addressing disparities in diagnosis, treatment, and outcomes in underserved populations. The councils were charged with summarizing the available data on prevalence, treatment, and outcomes and elucidating potential reasons for any disparities. Given the huge changes in racial and ethnic composition by age in the United States (Figure 1), it was difficult to determine disparities in rates of diagnosis and we expected to find some racial differences in prevalence of disease. For example, since the average age of patients undergoing transcatheter aortic valve replacement (TAVR) is 80 years, one may expect 80% of TAVR patients to be non-Hispanic White. Conversely, only 50% of congenital heart interventions would be expected to be performed in non-Hispanic Whites. Finally, we identified opportunities for SCAI to advance clinical care and equity for our patients, regardless of sex, ethnicity, or race.
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Affiliation(s)
- Cindy L Grines
- Cardiology, Northside Hospital Cardiovascular Institute, Atlanta, Georgia, USA
| | - Andrew J Klein
- Cardiology, Piedmont Heart Institute, Atlanta, Georgia, USA
| | - Holly Bauser-Heaton
- Pediatric Cardiology, Sibley Heart Center of Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | | | - Neelima Katukuri
- Cardiology, Orlando VA Medical Center, University of Central Florida, Orlando, Florida, USA
| | - Varun Aggarwal
- Pediatric Cardiology, University of Minnesota, Minneapolis, Minnesota, USA
| | - S Elissa Altin
- Cardiovascular Disease, Yale University, New Haven, Connecticut, USA
| | - Wayne B Batchelor
- Interventional Cardiology, Inova Heart and Vascular Institute, Fairfax, Virginia, USA
| | - James C Blankenship
- Internal Medicine, Cardiology Division, University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA
| | - Foluso Fakorede
- Interventional Cardiology, Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi, USA
| | - Beau Hawkins
- Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Gabriel A Hernandez
- Cardiology, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - Britton Keeshan
- Clinical Pediatrics, Yale New Haven Children's Hospital, New Haven, Connecticut, USA
| | - Jun Li
- Cardiology, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - R Allen Ligon
- Pediatric Cardiology, Joe DiMaggio Children's Hospital - Memorial Healthcare System, Hollywood, Florida, USA
| | - Andres Pineda
- Cardiology, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Michael N Young
- Cardiology, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
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Creager MA, Matsushita K, Arya S, Beckman JA, Duval S, Goodney PP, Gutierrez JAT, Kaufman JA, Joynt Maddox KE, Pollak AW, Pradhan AD, Whitsel LP. Reducing Nontraumatic Lower-Extremity Amputations by 20% by 2030: Time to Get to Our Feet: A Policy Statement From the American Heart Association. Circulation 2021; 143:e875-e891. [PMID: 33761757 DOI: 10.1161/cir.0000000000000967] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Nontraumatic lower-extremity amputation is a devastating complication of peripheral artery disease (PAD) with a high mortality and medical expenditure. There are ≈150 000 nontraumatic leg amputations every year in the United States, and most cases occur in patients with diabetes. Among patients with diabetes, after an ≈40% decline between 2000 and 2009, the amputation rate increased by 50% from 2009 to 2015. A number of evidence-based diagnostic and therapeutic approaches for PAD can reduce amputation risk. However, their implementation and adherence are suboptimal. Some racial/ethnic groups have an elevated risk of PAD but less access to high-quality vascular care, leading to increased rates of amputation. To stop, and indeed reverse, the increasing trends of amputation, actionable policies that will reduce the incidence of critical limb ischemia and enhance delivery of optimal care are needed. This statement describes the impact of amputation on patients and society, summarizes medical approaches to identify PAD and prevent its progression, and proposes policy solutions to prevent limb amputation. Among the actions recommended are improving public awareness of PAD and greater use of effective PAD management strategies (eg, smoking cessation, use of statins, and foot monitoring/care in patients with diabetes). To facilitate the implementation of these recommendations, we propose several regulatory/legislative and organizational/institutional policies such as adoption of quality measures for PAD care; affordable prevention, diagnosis, and management; regulation of tobacco products; clinical decision support for PAD care; professional education; and dedicated funding opportunities to support PAD research. If these recommendations and proposed policies are implemented, we should be able to achieve the goal of reducing the rate of nontraumatic lower-extremity amputations by 20% by 2030.
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32
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Kim TI, Mena C, Sumpio BE. The Role of Lower Extremity Amputation in Chronic Limb-Threatening Ischemia. Int J Angiol 2020; 29:149-155. [PMID: 32904807 DOI: 10.1055/s-0040-1710075] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Chronic limb-threatening ischemia (CLTI) is a severe form of peripheral artery disease associated with high rates of limb loss. The primary goal of treatment in CLTI is limb salvage via revascularization. Multidisciplinary teams provide improved care for those with CLTI and lead to improved limb salvage rates. Not all patients are candidates for revascularization, and a subset will require major amputation. This article highlights the role of amputations in the management of CLTI, and describes the patients who should be offered primary amputation.
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Affiliation(s)
- Tanner I Kim
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Carlos Mena
- Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Bauer E Sumpio
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.,Cardiology Section, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
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33
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Hurwitz M, Fuentes M. Healthcare Disparities in Dysvascular Lower Extremity Amputations. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00281-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Hua S, Isasi CR, Kizer JR, Matsushita K, Allison MA, Tarraf W, Qi Q, Ponce SG, Daviglus M, Kaplan RC. Underuse of Cardiovascular Medications in Individuals With Known Lower Extremity Peripheral Artery Disease: HCHS/SOL. J Am Heart Assoc 2020; 9:e015451. [PMID: 32752978 PMCID: PMC7660818 DOI: 10.1161/jaha.119.015451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Background Underuse of cardiovascular medications for secondary prevention among individuals with peripheral artery disease (PAD) has been reported. Little is known about PAD treatment status in the Hispanic/Latino population in the United States, who may have limited access to health care and who have worse clinical outcomes than non‐Hispanic individuals. Methods and Results We studied the use of cardiovascular therapies in 1244 Hispanic/Latino individuals recruited from 4 sites in the United States, including 826 individuals who reported diagnosis of PAD by physician and 418 individuals with coronary artery disease alone, in the Hispanic Community Health Study/Study of Latinos. We compared the prevalence of using antiplatelet therapy, lipid‐lowering therapy and antihypertensive therapy by PAD and coronary artery disease status. Among those with PAD, we studied factors associated with taking cardiovascular medications, including demographic and socioeconomic factors, acculturation, access to health care and comorbidities, using multivariable regression models. The overall prevalence for individuals with PAD taking antiplatelet therapy, lipid‐lowering therapy and, among hypertensive individuals, antihypertensive therapy was 31%, 26% and 57%, respectively. Individuals of Mexican background had the lowest use for all classes of cardiovascular medications. Older age, number of doctor visits and existing hypertension and diabetes mellitus were significantly associated with taking cardiovascular therapies in adjusted models. Compared with those with PAD alone, individuals with PAD and concurrent coronary artery disease were 1.52 (95% CI, 1.20–1.93) and 1.74 (1.30–2.32) times more likely to use antiplatelet agents and statins according to multivariable analysis. No significant difference of antihypertensive medication use was found among PAD patients with or without coronary artery disease. Conclusions Hispanic/Latino individuals with known PAD underuse cardiovascular medications recommended in clinical guidelines. More efforts should be directed to improve treatment in this important group.
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Affiliation(s)
- Simin Hua
- Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxNY
| | - Carmen R. Isasi
- Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxNY
| | - Jorge R. Kizer
- Cardiology SectionSan Francisco Veterans Affairs Health Care SystemSan FranciscoNYUSA
- Departments of Medicine, and Epidemiology and BiostatisticsUniversity of California San FranciscoSan FranciscoCA
| | - Kunihiro Matsushita
- Department of EpidemiologyJohns Hopkins University Bloomberg School of Public HealthBaltimoreMD
| | - Matthew A. Allison
- Department of Family Medicine and Public HealthUniversity of CaliforniaSan DiegoCA
| | - Wassim Tarraf
- Department of Healthcare SciencesWayne State UniversityDetroitMI
- Institute of GerontologyWayne State UniversityDetroitMI
| | - Qibin Qi
- Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxNY
| | - Sonia G. Ponce
- Department of Family Medicine and Public HealthUniversity of CaliforniaSan DiegoCA
| | - Martha Daviglus
- Institute for Minority Health ResearchUniversity of Illinois at ChicagoIL
- Department of MedicineUniversity of Illinois at ChicagoIL
- Department of Preventive MedicineNorthwestern UniversityChicagoIL
| | - Robert C. Kaplan
- Department of Epidemiology and Population HealthAlbert Einstein College of MedicineBronxNY
- Public Health Sciences DivisionFred Hutchinson Cancer Research CenterSeattleWA
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Gober L, Bui A, Ruddy JM. Racial and Gender Disparity in Achieving Optimal Medical Therapy for Inpatients with Peripheral Artery Disease. ANNALS OF VASCULAR MEDICINE AND RESEARCH 2020; 7:1115. [PMID: 33585679 PMCID: PMC7877491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Best medical therapy for peripheral artery disease (PAD) includes statin and anti-platelet agents, a combination shown to decrease rates of major cardiovascular events. Despite these findings, many patients remain undertreated and the objective of this project was to investigate the rate of initiating anti-platelet and statin therapy for inpatients newly diagnosed with PAD with a focus on disparities by race and sex. A retrospective chart review of inpatients with newly diagnosed PAD was performed between January 1, 2016 to December 31, 2016 at a single institution. Demographics and comorbid conditions were collected. Primary outcomes included antiplatelet and statin prescription at discharge. The 44 patients included in this study were predominantly male (59% vs. 41%) and African American (61% vs. 39%). Between admission and discharge, prescriptions rose from 70% to 82% for statin and 82% to 91% for anti-platelet agents. Vascular specialists were more successful than non-vascular specialists at initiating medical therapy, with statin prescriptions increasing 22% and anti-platelet prescriptions climbing 23% for those admitted to a vascular specialist. Interestingly, when the ABI was reported in the normal range, rates of statin initiation were particularly compromised at only 40%. For the total patient sample, those discharged without a statin were more commonly African American (63%) and the majority were female (67%). All patients discharged without an antiplatelet were African American and 50% were females. Despite national guidelines, patients with PAD continue to be discharged without optimal medical therapy. This study suggests that obstacles to initiation may include race, sex, admitting service, or presence of a normal ABI. Further investigation is warranted to determine effective avenues for provider education and system-wide initiatives.
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Affiliation(s)
- Leah Gober
- School of Medicine, Mercer University School of Medicine, USA
| | - Allen Bui
- Division of Vascular Surgery, University of South Carolina, USA
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Alshwaily W, Nejim B, Aridi HD, Naazie IN, Locham S, Malas MB. Racial and Gender Disparity in Aortoiliac Disease Open Revascularization Procedures. J Surg Res 2020; 252:255-263. [PMID: 32304932 DOI: 10.1016/j.jss.2020.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 02/26/2020] [Accepted: 03/08/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The impact of race and gender on surgical outcomes has been studied in infrainguinal revascularization for peripheral arterial disease. The aim of this study is to explore how race and gender affect the outcomes of suprainguinal bypass (SIB) for aortoiliac occlusive disease. MATERIALS AND METHODS Patients who underwent SIB were identified from the procedure-targeted National Surgical Quality Improvement Program data set (2011-2016). Patients were stratified into four groups: nonblack males, black males (BM), nonblack females, and black females (BF). Primary outcomes were 30-d major adverse cardiac events, a composite of myocardial infarction, stroke, or death; postoperative bleeding requiring transfusion or intervention; major amputation and prolonged length of stay (>10 d). Predictors of outcomes were determined by multivariable logistic regression analysis. RESULTS About 5044 patients were identified. BM were younger, more likely to be smokers, less likely to be on antiplatelet drug or statin, and to receive elective SIB (all P ≤ 0.01). BFs were more likely to be diabetic and functionally dependent (all P ≤ 0.02). Major adverse cardiac events were not significantly different among all groups. BM had a threefold higher risk of amputation (adjusted odds ratio [OR] [95% confidence interval (95% CI)], 3.10 [1.50-6.43]; P < 0.002). Female gender was associated with bleeding in both races, that association was more drastic in BF (OR [95% CI], 2.43 [1.63-3.60]; P < 0.0001), whereas nonblack females (OR [95% CI], 1.46 [1.19-1.80]; P < 0.0001). BF had higher odds of prolonged length of stay (OR [95% CI]: 1.62 [1.08-2.42]; P < 0.019). CONCLUSIONS In this large retrospective study, we demonstrated the racial and gender disparity in SIB outcomes. BM had more than threefold increase in amputation risk as compared with nonblack males. Severe bleeding risk was more than doubled in BF. Race and gender consideration is warranted in risk assessment when patients are selected for aortoiliac disease revascularization, which in turn necessitate preoperative risk modification and optimization in addition to enhancing their access to primary preventive care measures.
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Affiliation(s)
- Widian Alshwaily
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Department of Surgery, Baltimore, Maryland
| | - Besma Nejim
- Johns Hopkins Bayview Vascular and Endovascular Research Center, Department of Surgery, Baltimore, Maryland
| | - Hanaa D Aridi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Isaac N Naazie
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Satinderjit Locham
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, California
| | - Mahmoud B Malas
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, California.
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Austin AM, Chakraborti G, Columbo J, Ramkumar N, Moore K, Scheurich M, Goodney P. Outcomes after peripheral artery disease intervention among Medicare-Medicaid dual-eligible patients compared with the general medicare population in the Vascular Quality Initiative registry. BMJ SURGERY, INTERVENTIONS, & HEALTH TECHNOLOGIES 2019; 1:e000018. [PMID: 32309802 PMCID: PMC7164790 DOI: 10.1136/bmjsit-2019-000018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective To determine whether patients from the Vascular Quality Initiative (VQI) registry who are Medicare–Medicaid dual-eligible have outcomes after surgical intervention with medical devices such as stents for peripheral artery disease comparable to the outcomes of those eligible for Medicare alone. Methods The study cohort included fee-for-service Medicare beneficiaries from 2010 to 2015 who underwent peripheral vascular intervention as determined by the VQI. We performed propensity matching between the dual-eligible and non-dual-eligible cohorts. Postintervention use, including imaging, amputation and death, was determined using Medicare claims data. Results Rates of major amputation were higher among dual-eligible patients (13.0% vs 10.5%, p<0.001), while time to amputation by disease severity was similar (p=0.443). For patients with more advanced disease (critical limb ischaemia (CLI) vs claudication), dual-eligible patients have significantly faster times to any amputation and death (p<0.001). For of postoperative imaging, 48.4% of dual-eligible patients receive at least one postoperative image, while the percentage for non-dual-eligible patients is 47.2% (p=0.187). Conclusions Patients with mild forms of peripheral artery disease (PAD), such as claudication, demonstrated similar outcomes regardless of dual-eligibility status. However, those with severe PAD, such as CLI, who were also dual-eligible had both inferior overall survival and amputation-free survival. Minimal differences were observed in process-driven aspects of care between dual-eligible and non-dual-eligible patients, including postoperative imaging. These findings indicate that despite receiving similar care, dual-eligible patients with severe PAD have inferior long-term outcomes, suggesting the Medicaid safety net is not timely enough to benefit from long-term outcomes for these patients.
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Affiliation(s)
- Andrea M Austin
- The Dartmouth Institute, Dartmouth College, Lebanon, New Hampshire, USA
| | - Gouri Chakraborti
- Analytics Institute, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jesse Columbo
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Kayla Moore
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | | | - Phil Goodney
- Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Peripheral Artery Disease and African Americans: Review of the Literature. CURRENT CARDIOVASCULAR RISK REPORTS 2019. [DOI: 10.1007/s12170-019-0621-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
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Mustapha J, Gray W, Martinsen BJ, Bolduan RW, Adams GL, Ansel G, Jaff MR. One-Year Results of the LIBERTY 360 Study: Evaluation of Acute and Midterm Clinical Outcomes of Peripheral Endovascular Device Interventions. J Endovasc Ther 2019; 26:143-154. [PMID: 30722718 PMCID: PMC6431778 DOI: 10.1177/1526602819827295] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Purpose: To report the 1-year results of a multicenter study of peripheral artery disease (PAD) treatment with a variety of endovascular treatment strategies employed in routine practice. Materials and Methods: The LIBERTY trial (ClinicalTrials.gov identifier NCT01855412) is a prospective, observational, core laboratory–assessed, multicenter study of endovascular device intervention in 1204 subjects (mean age 69.8±10.7 years; 770 men) stratified by Rutherford category (RC): claudicants (RC2,3; n=501) and critical limb ischemia (CLI) with no/minimal tissue loss (RC4,5; n=603) or significant tissue loss (RC6; n=100). Key outcomes included quality of life (QoL) measures (VascuQol and EuroQol) and freedom from major adverse events (MAE), defined as death (within 30 days), major amputation, and target vessel revascularization based on Kaplan-Meier analysis. Results: Successful revascularization was beneficial, with RC improvement noted across all groups. Thirty-day freedom from MAE estimates were high across all groups: 99.2% in RC2,3, 96.1% in RC4,5, and 90.8% in RC6. At 12 months, the freedom from MAE was 82.6% in RC2,3, 73.2% in RC4,5, and 59.3% in RC6 patients. Estimates for freedom from major amputation at 12 months were 99.3%, 96.0%, and 81.7%, respectively. QoL scores improved significantly across all domains in all groups with 12-month VascuQol total scores of 5.3, 5.0, and 4.8 for RC2,3, RC4,5, and RC6, respectively. Conclusion: The results indicate that peripheral endovascular intervention is a viable treatment option for RC2,3, RC4,5, and RC6 patients as evidenced by the high freedom from major amputation, as well as the improvement in QoL and the RC at 12 months. Furthermore, primary unplanned amputation is often not necessary in RC6.
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Affiliation(s)
- Jihad Mustapha
- 1 Advanced Cardiac and Vascular Amputation Prevention Centers, Grand Rapids, MI, USA.,2 Michigan State University, E. Lansing, MI, USA
| | - William Gray
- 3 Main Line Health, Lankenau Heart Institute, Wynnewood, PA.,4 Columbia University Medical Center, New York, NY, USA
| | - Brad J Martinsen
- 5 Scientific Affairs, Cardiovascular Systems, Inc, St Paul, MN, USA
| | - Ryan W Bolduan
- 5 Scientific Affairs, Cardiovascular Systems, Inc, St Paul, MN, USA
| | - George L Adams
- 6 North Carolina Heart and Vascular, Rex Hospital, UNC School of Medicine, Raleigh, NC, USA
| | - Gary Ansel
- 7 Riverside Methodist Hospital, Columbus, OH, USA
| | - Michael R Jaff
- 8 Harvard Medical School, Boston, MA, USA.,9 Newton-Wellesley Hospital, Newton, MA, USA
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Disparities in outcomes of patients admitted with diabetic foot infections. PLoS One 2019; 14:e0211481. [PMID: 30716108 PMCID: PMC6361439 DOI: 10.1371/journal.pone.0211481] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 01/15/2019] [Indexed: 12/31/2022] Open
Abstract
Objective The purpose of this study was to evaluate the disparities in the outcomes of White, African American (AA) and non-AA minority (Hispanics and Native Americans (NA)), patients admitted in the hospitals with diabetic foot infections (DFIs). Research design and methods The HCUP-Nationwide Inpatient Sample (2002 to 2015) was queried to identify patients who were admitted to the hospital for management of DFI using ICD-9 codes. Outcomes evaluated included minor and major amputations, open or endovascular revascularization, and hospital length of stay (LOS). Incidence for amputation and open or endovascular revascularization were evaluated over the study period. Multivariable regression analyses were performed to assess the association between race/ethnicity and outcomes. Results There were 150,701 admissions for DFI, including 98,361 Whites, 24,583 AAs, 24,472 Hispanics, and 1,654 Native Americans (NAs) in the study cohort. Overall, 45,278 (30%) underwent a minor amputation, 9,039 (6%) underwent a major amputation, 3,151 underwent an open bypass, and 8,689 had an endovascular procedure. There was a decreasing incidence in major amputations and an increasing incidence of minor amputations over the study period (P < .05). The risks for major amputation were significantly higher (all p<0.05) for AA (OR 1.4, 95%CI 1.4,1.5), Hispanic (OR 1.3, 95%CI 1.3,1.4), and NA (OR 1.5, 95%CI 1.2,1.8) patients with DFIs compared to White patients. Hispanics (OR 1.3, 95%CI 1.2,1.5) and AAs (OR 1.2, 95%CI 1.1,1.4) were more likely to receive endovascular intervention or open bypass than Whites (all p<0.05). NA patients with DFI were less likely to receive a revascularization procedure (OR 0.6, 95%CI 0.3, 0.9, p = 0.03) than Whites. The mean hospital length of stay (LOS) was significantly longer for AAs (9.2 days) and Hispanics (8.6 days) with DFIs compared to Whites (8.1 days, p<0.001). Conclusion Despite a consistent incidence reduction of amputation over the past decade, racial and ethnic minorities including African American, Hispanic, and Native American patients admitted to hospitals with DFIs have a consistently significantly higher risk of major amputation and longer hospital length of stay than their White counterparts. Native Americans were less likely to receive revascularization procedures compared to other minorities despite exhibiting an elevated risk of an amputation. Further study is required to address and limit racial and ethnic disparities and to further promote equity in the treatment and outcomes of these at-risk patients.
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Girijala RL, Bush RL. Review of Socioeconomic Disparities in Lower Extremity Amputations: A Continuing Healthcare Problem in the United States. Cureus 2018; 10:e3418. [PMID: 30542632 PMCID: PMC6284870 DOI: 10.7759/cureus.3418] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Lower extremity amputation is one of the most unfortunate, yet preventable, consequences of uncontrolled lower limb ischemia occurring secondary to diabetes mellitus or peripheral arterial disease. In the United States, racial and socioeconomic disparities are associated with significant differences seen in the incidence and type or level of lower extremity amputation among patients. Due to shifting demographics and the uncertain state of healthcare coverage, lower extremity amputation rates are only projected to increase in the future. Given the potential societal and individual costs associated with the loss of a limb, this review seeks to summarize the recent findings on disparities in the identification, treatments offered, and outcomes of lower limb ischemia in order to elucidate potential interventions at the practitioner and policy levels.
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Affiliation(s)
| | - Ruth L Bush
- Surgery, University of Houston College of Medicine, Houston, USA
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Jean RA, Chiu AS, O'Neill KM, Lin Z, Pei KY. The influence of sociodemographic factors on operative decision-making in small bowel obstruction. J Surg Res 2018; 227:137-144. [DOI: 10.1016/j.jss.2018.02.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/22/2018] [Accepted: 02/14/2018] [Indexed: 11/25/2022]
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