1
|
Campbell DB, Gutta G, Sobol CG, Atway SA, Haurani MJ, Chen XP, Rowe VL, Stacy MR, Go MR. How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01212-6. [PMID: 38906429 DOI: 10.1016/j.jvs.2024.05.033] [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: 04/07/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them. METHODS All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers. RESULTS From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance. CONCLUSIONS LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.
Collapse
Affiliation(s)
- Drayson B Campbell
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Goutam Gutta
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carly G Sobol
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Said A Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH
| | - Mounir J Haurani
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Xiaodong P Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Mitchel R Stacy
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| |
Collapse
|
7
|
Martelli E, Zamboni M, Sotgiu G, Saderi L, Federici M, Sangiorgi GM, Puci MV, Martelli AR, Messina T, Frigatti P, Borrelli MP, Ruotolo C, Ficarelli I, Rubino P, Pezzo F, Carbonari L, Angelini A, Galeazzi E, Di Pinto LC, Fiore FM, Palmieri A, Ventoruzzo G, Mazzitelli G, Ragni F, Bozzani A, Forliti E, Castagno C, Volpe P, Massara M, Moniaci D, Pagliasso E, Peretti T, Ferrari M, Troisi N, Modugno P, Maiorano M, Bracale UM, Panagrosso M, Monaco M, Giordano G, Natalicchio G, Biello A, Celoria GM, Amico A, Di Bartolo M, Martelli M, Munaó R, Razzano D, Colacchio G, Bussetti F, Lanza G, Cardini A, Di Benedetto B, De Laurentis M, Taurino M, Sirignano P, Cappiello P, Esposito A, Trimarchi S, Romagnoli S, Padricelli A, Giudice G, Crinisio A, Di Nardo G, Battaglia G, Tringale R, De Vivo S, Compagna R, Tolva VS, D’Alessio I, Curci R, Giovannetti S, D’Arrigo G, Basile G, Frigerio D, Veraldi GF, Mezzetto L, Ippoliti A, Oddi FM, Settembrini AM. Sex-Related Differences and Factors Associated with Peri-Procedural and 1 Year Mortality in Chronic Limb-Threatening Ischemia Patients from the CLIMATE Italian Registry. J Pers Med 2023; 13:jpm13020316. [PMID: 36836550 PMCID: PMC9959358 DOI: 10.3390/jpm13020316] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND Identifying sex-related differences/variables associated with 30 day/1 year mortality in patients with chronic limb-threatening ischemia (CLTI). METHODS Multicenter/retrospective/observational study. A database was sent to all the Italian vascular surgeries to collect all the patients operated on for CLTI in 2019. Acute lower-limb ischemia and neuropathic-diabetic foot are not included. FOLLOW-UP One year. Data on demographics/comorbidities, treatments/outcomes, and 30 day/1 year mortality were investigated. RESULTS Information on 2399 cases (69.8% men) from 36/143 (25.2%) centers. Median (IQR) age: 73 (66-80) and 79 (71-85) years for men/women, respectively (p < 0.0001). Women were more likely to be over 75 (63.2% vs. 40.1%, p = 0.0001). More men smokers (73.7% vs. 42.2%, p < 0.0001), are on hemodialysis (10.1% vs. 6.7%, p = 0.006), affected by diabetes (61.9% vs. 52.8%, p < 0.0001), dyslipidemia (69.3% vs. 61.3%, p < 0.0001), hypertension (91.8% vs. 88.5%, p = 0.011), coronaropathy (43.9% vs. 29.4%, p < 0.0001), bronchopneumopathy (37.1% vs. 25.6%, p < 0.0001), underwent more open/hybrid surgeries (37.9% vs. 28.8%, p < 0.0001), and minor amputations (22% vs. 13.7%, p < 0.0001). More women underwent endovascular revascularizations (61.6% vs. 55.2%, p = 0.004), major amputations (9.6% vs. 6.9%, p = 0.024), and obtained limb-salvage if with limited gangrene (50.8% vs. 44.9%, p = 0.017). Age > 75 (HR = 3.63, p = 0.003) is associated with 30 day mortality. Age > 75 (HR = 2.14, p < 0.0001), nephropathy (HR = 1.54, p < 0.0001), coronaropathy (HR = 1.26, p = 0.036), and infection/necrosis of the foot (dry, HR = 1.42, p = 0.040; wet, HR = 2.04, p < 0.0001) are associated with 1 year mortality. No sex-linked difference in mortality statistics. CONCLUSION Women exhibit fewer comorbidities but are struck by CLTI when over 75, a factor associated with short- and mid-term mortality, explaining why mortality does not statistically differ between the sexes.
Collapse
Affiliation(s)
- Eugenio Martelli
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 viale del Policlinico, 00161 Rome, Italy
- Medicine and Surgery School of Medicine, Saint Camillus International University of Health Sciences, 8 via di Sant’Alessandro, 00131 Rome, Italy
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
- Correspondence: ; Tel.: +39-3294003220
| | - Matilde Zamboni
- Division of Vascular Surgery, Saint Martin Hospital, 22 viale Europa, 32100 Belluno, Italy
| | - Giovanni Sotgiu
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Laura Saderi
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Massimo Federici
- Department of Systems Medicine, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Giuseppe M. Sangiorgi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Mariangela V. Puci
- Clinical Epidemiology and Medical Statistics Unit, Department of Medicine, Surgery and Pharmacy, University of Sassari, viale San Pietro, 07100 Sassari, Italy
| | - Allegra R. Martelli
- Medicine and Surgery School of Medicine, Campus Bio-Medico University of Rome, 21 via À. del Portillo, 00128 Rome, Italy
| | - Teresa Messina
- Division of Anesthesia and Intensive Care of Organ Transplants, Umberto I Polyclinic University Hospital, 155 viale del Policlinico, 00161 Rome, Italy
| | - Paolo Frigatti
- Divisions of Vascular Surgery, S. Maria Misericordia University Hospital, 15 Piazzale Santa Maria della Misericordia, 33100 Udine, Italy
| | - Maria Pia Borrelli
- Divisions of Vascular Surgery, S. Maria Misericordia University Hospital, 15 Piazzale Santa Maria della Misericordia, 33100 Udine, Italy
| | - Carlo Ruotolo
- Divisions of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131 Naples, Italy
| | - Ilaria Ficarelli
- Divisions of Vascular Surgery, Cardarelli Hospital, 9 Via A. Cardarelli, 80131 Naples, Italy
| | - Paolo Rubino
- Divisions of Vascular Surgery, Pugliese Ciaccio Hospital, 83 viale Pio X, 88100 Catanzaro, Italy
| | - Francesco Pezzo
- Divisions of Vascular Surgery, Pugliese Ciaccio Hospital, 83 viale Pio X, 88100 Catanzaro, Italy
| | - Luciano Carbonari
- Divisions of Vascular Surgery, Riuniti University Hospitals, 71 via Conca, Torrette (AN), 60126 Ancona, Italy
| | - Andrea Angelini
- Divisions of Vascular Surgery, Riuniti University Hospitals, 71 via Conca, Torrette (AN), 60126 Ancona, Italy
| | - Edoardo Galeazzi
- Divisions of Vascular Surgery, Treviso Hospital, 1 piazzale del’Ospedale, 31100 Treviso, Italy
| | - Luca Calia Di Pinto
- Divisions of Vascular Surgery, Treviso Hospital, 1 piazzale del’Ospedale, 31100 Treviso, Italy
| | - Franco M. Fiore
- Divisions of Vascular Surgery, SS. Annunziata Hospital, 31 via dei Vestini, 66100 Chieti, Italy
| | - Armando Palmieri
- Divisions of Vascular Surgery, SS. Annunziata Hospital, 31 via dei Vestini, 66100 Chieti, Italy
| | - Giorgio Ventoruzzo
- Divisions of Vascular Surgery, San Donato Hospital, 20 via Pietro Nenni, 52100 Arezzo, Italy
| | - Giulia Mazzitelli
- Divisions of Vascular Surgery, San Donato Hospital, 20 via Pietro Nenni, 52100 Arezzo, Italy
| | - Franco Ragni
- Divisions of Vascular Surgery, San Matteo Polyclinic, 19 viale Camillo Golgi, 27100 Pavia, Italy
| | - Antonio Bozzani
- Divisions of Vascular Surgery, San Matteo Polyclinic, 19 viale Camillo Golgi, 27100 Pavia, Italy
| | - Enzo Forliti
- Divisions of Vascular Surgery, Infermi Hospital, Via dei Ponderanesi 2, 13875 Ponderano, Italy
| | - Claudio Castagno
- Divisions of Vascular Surgery, Infermi Hospital, Via dei Ponderanesi 2, 13875 Ponderano, Italy
| | - Pietro Volpe
- Divisions of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, 21 via G. Melacrino, 89124 Reggio di Calabria, Italy
| | - Mafalda Massara
- Divisions of Vascular Surgery, Bianchi-Melacrino-Morelli Hospital, 21 via G. Melacrino, 89124 Reggio di Calabria, Italy
| | - Diego Moniaci
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Elisa Pagliasso
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Tania Peretti
- Divisions of Vascular Surgery, San Giovanni Bosco Hospital, 3 piazza del Donatore di Sangue, 10154 Turin, Italy
| | - Mauro Ferrari
- Divisions of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 2 via Paradisa, 56124 Pisa, Italy
| | - Nicola Troisi
- Divisions of Vascular Surgery, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 2 via Paradisa, 56124 Pisa, Italy
| | - Piero Modugno
- Divisions of Vascular Surgery, Gemelli Molise Hospital, 1 largo A. Gemelli, 86100 Campobasso, Italy
| | - Maurizio Maiorano
- Divisions of Vascular Surgery, Gemelli Molise Hospital, 1 largo A. Gemelli, 86100 Campobasso, Italy
| | - Umberto M. Bracale
- Divisions of Vascular Surgery, Federico II Polyclinic, Department of Public Health and Residency Program in Vascular Surgery, University of Naples Federico II, 5 via S. Pansini, 80131 Naples, Italy
| | - Marco Panagrosso
- Divisions of Vascular Surgery, Federico II Polyclinic, Department of Public Health and Residency Program in Vascular Surgery, University of Naples Federico II, 5 via S. Pansini, 80131 Naples, Italy
| | - Mario Monaco
- Divisions of Vascular Surgery, Pineta Grande Hospital, Km. 30 via Domitiana, 81030 Castelvolturno, Italy
- Divisions of Vascular Surgery, Sanatrix Clinic, 31 via S. Domenico, 80127 Naples, Italy
| | - Giovanni Giordano
- Divisions of Vascular Surgery, Sanatrix Clinic, 31 via S. Domenico, 80127 Naples, Italy
| | - Giuseppe Natalicchio
- Divisions of Vascular Surgery, Venere Hospital, 1 via Ospedale di Venere, 70131 Bari, Italy
| | - Antonella Biello
- Divisions of Vascular Surgery, Venere Hospital, 1 via Ospedale di Venere, 70131 Bari, Italy
| | - Giovanni M. Celoria
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Alessio Amico
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Mauro Di Bartolo
- Divisions of Vascular Surgery, Sant’Andrea Hospital, 197 via Vittorio Veneto, 19121 La Spezia, Italy
| | - Massimiliano Martelli
- Divisions of Vascular Surgery, MultiMedica Hospital, 300 via Milenese, 20099 Sesto San Giovanni, Italy
| | - Roberta Munaó
- Divisions of Vascular Surgery, MultiMedica Hospital, 300 via Milenese, 20099 Sesto San Giovanni, Italy
| | - Davide Razzano
- Divisions of Vascular Surgery, San Pio Hospital, 1 via dell’angelo, 82100 Benevento, Italy
| | - Giovanni Colacchio
- Divisions of Vascular Surgery, F.Miulli Hospital, Strada Prov. 127 Acquaviva-Santeramo Km. 4, 70021 Acquaviva delle Fonti, Italy
| | - Francesco Bussetti
- Divisions of Vascular Surgery, F.Miulli Hospital, Strada Prov. 127 Acquaviva-Santeramo Km. 4, 70021 Acquaviva delle Fonti, Italy
| | - Gaetano Lanza
- Divisions of Vascular Surgery, Multimedica Hospital, 70 viale Piemonte, 21053 Castellanza, Italy
| | - Antonio Cardini
- Divisions of Vascular Surgery, Multimedica Hospital, 70 viale Piemonte, 21053 Castellanza, Italy
| | | | - Mario De Laurentis
- Divisions of Vascular Surgery, Monaldi Hospital, via L. Bianchi, 84100 Naples, Italy
| | - Maurizio Taurino
- Divisions of Vascular Surgery, Department of Molecular and Clinical Medicine, Sapienza University of Rome, Giorgio Nicola Papanicolau, 00189 Rome, Italy
- Divisions of Vascular Surgery, Sant’Andrea University Hospital, 1035/1039 via di Grottarossa, 00189 Rome, Italy
| | - Pasqualino Sirignano
- Department of General and Specialist Surgery Paride Stefanini, Faculty of Pharmacy and Medicine, Sapienza University of Rome, 155 viale del Policlinico, 00161 Rome, Italy
- Divisions of Vascular Surgery, Sant’Andrea University Hospital, 1035/1039 via di Grottarossa, 00189 Rome, Italy
| | - Pierluigi Cappiello
- Divisions of Vascular Surgery, San Carlo Hospital, via Potito Petrone, 85100 Potenza, Italy
| | - Andrea Esposito
- Divisions of Vascular Surgery, San Carlo Hospital, via Potito Petrone, 85100 Potenza, Italy
| | - Santi Trimarchi
- Divisions of Vascular Surgery, Department of Clinical and Community Sciences, University of Milan, 19 via della Commenda, 20122 Milan, Italy
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
| | - Silvia Romagnoli
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
| | - Andrea Padricelli
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
| | - Giorgio Giudice
- Division of Vascular Surgery, Department of Cardiovascular Sciences, S. Anna and S. Sebastiano Hospital, via F. Palasciano, 81100 Caserta, Italy
| | - Adolfo Crinisio
- Divisions of Vascular Surgery, Salus Clinic, 4 via F. Confalonieri, 84091 Battipaglia, Italy
| | - Giovanni Di Nardo
- Divisions of Vascular Surgery, Salus Clinic, 4 via F. Confalonieri, 84091 Battipaglia, Italy
| | - Giuseppe Battaglia
- Divisions of Vascular Surgery, San Marco Hospital, viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Rosario Tringale
- Divisions of Vascular Surgery, San Marco Hospital, viale Carlo Azeglio Ciampi, 95121 Catania, Italy
| | - Salvatore De Vivo
- Divisions of Vascular Surgery, Pellegrini Hospital, 41 via Portamedina alla Pignasecca, 80134 Naples, Italy
| | - Rita Compagna
- Divisions of Vascular Surgery, Pellegrini Hospital, 41 via Portamedina alla Pignasecca, 80134 Naples, Italy
| | - Valerio S. Tolva
- Divisions of Vascular Surgery, Niguarda Hospital, Piazza dell’Ospedale Maggiore 3, 20161 Milan, Italy
| | - Ilenia D’Alessio
- Divisions of Vascular Surgery, Niguarda Hospital, Piazza dell’Ospedale Maggiore 3, 20161 Milan, Italy
| | - Ruggiero Curci
- Divisions of Vascular Surgery, Maggiore Hospital, 10 Piazza Ospitale, 26900 Lodi, Italy
| | - Simona Giovannetti
- Divisions of Vascular Surgery, Maggiore Hospital, 10 Piazza Ospitale, 26900 Lodi, Italy
| | - Giuseppe D’Arrigo
- Divisions of Vascular Surgery, Garibaldi-Nesima Hospital, 636 via Palermo, 95122 Catania, Italy
| | - Giusi Basile
- Divisions of Vascular Surgery, Garibaldi-Nesima Hospital, 636 via Palermo, 95122 Catania, Italy
| | - Dalmazio Frigerio
- Divisions of Vascular Surgery, Vimercate Hospital, 10 via Cosma e Damiano, 20871 Vimercate, Italy
| | - Gian Franco Veraldi
- Divisions of Vascular Surgery, University Hospital Pietro Confortini, 1 Piazzale Aristide Stefani, 37126 Verona, Italy
| | - Luca Mezzetto
- Divisions of Vascular Surgery, University Hospital Pietro Confortini, 1 Piazzale Aristide Stefani, 37126 Verona, Italy
| | - Arnaldo Ippoliti
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Fabio M. Oddi
- Department of Biomedicine and Prevention, University of Rome Tor Vergata, 1 viale Montpellier, 00133 Rome, Italy
| | - Alberto M. Settembrini
- Divisions of Vascular Surgery, Maggiore Polyclinic Hospital Ca’ Granda IRCCS and Foundation, 35 via Francesco Sforza, 20122 Milan, Italy
| |
Collapse
|