Racial differences in functional decline in peripheral artery disease and associations with socioeconomic status and education

Predictive Modeling for One-Year Lower Extremity Endovascular Revascularization Failure in Black Persons

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.

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

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.

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

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.

Overview and comparison of contemporary Society for Vascular Surgery, American Heart Association/American College of Cardiology, and European Society for Vascular Surgery guidelines for the management of patients with intermittent claudication

Intermittent claudication (IC) is a phenotype of peripheral artery disease that is characterized by pain in the lower extremity muscles during activity that is relieved by rest. Medical management, risk factor control, smoking cessation, and exercise therapy have historically been the mainstays of treatment for IC, but advances in endovascular technology have led to increasing use of peripheral vascular interventions in this patient population. There are meaningful differences in published society guidelines and appropriate use criteria relevant to the management of IC, especially regarding indications for peripheral vascular interventions. The current review aims to highlight similarities and differences between major society recommendations for the management of IC, and to discuss practice trends, disparities, and evidence gaps in the use of peripheral vascular interventions for IC in the context of existing guidelines.

Disparities in Diagnosis, Treatment, and Outcomes of Peripheral Artery Disease: JACC Scientific Statement

Disparities by sex, race, socioeconomic status, and geography exist in diagnosis, treatment, and outcomes for people with lower extremity peripheral artery disease (PAD). PAD prevalence is similar in men and women, but women have more atypical symptoms and undergo lower extremity revascularization at older ages compared to men. People who are Black have an approximately 2-fold higher prevalence of PAD, compared to people who are White and have more atypical symptoms, greater mobility loss, less optimal medical care, and higher amputation rates. Although fewer data are available for other races, people with PAD who are Hispanic have higher amputation rates than White people. Rates of amputation also vary by geography in the United States, with the highest rates of amputation in the southeastern United States. To improve PAD outcomes, intentional actions to eliminate disparities are necessary, including clinician education, patient education with culturally appropriate messaging, improved access to high-quality health care, science focused on disparity elimination, and health policy changes.

Global disease burden and its attributable risk factors of peripheral arterial disease

Peripheral arterial disease (PAD) is a prevalent subtype of atherosclerotic cardiovascular diseases. It is crucial to assess the PAD-related burden and its attributable risk factors. We use the Global Burden of Disease study 2019 database to calculate the incidence, prevalence, mortality, disability-adjusted life years (DALY), attributable risk factors and estimated annual percentage change. The disease burden of PAD grows significantly with age accompanied by prominent heterogeneity between male and female. Despite the increase in the absolute numbers of disease burden from 1990 to 2019, the global PAD-related age-standardized death rate (ASDR) and age-standardized disability-adjusted life years rate (ASDALYR) have a mild downward trend from 1990 to 2019, which negatively correlated with sociodemographic index (SDI). Smoking and high systolic blood pressure (SBP) were the primary attributable risk factors for males (ASDR: 33.4%; ASDALYR: 43.4%) and females (ASDR: 25.3%; ASDALYR: 27.6%), respectively. High fasting plasma glucose (FPG) had become the second risk factor for ASDR (males: 28.5%; females: 25.2%) and ASDALYR (males: 29.3%; females: 26.3%) with an upward tendency. Low-middle SDI regions were predicted to have the most remarkable upward trend of PAD-related burden caused by high FPG. Smoking caused more disease burden in males before 85-90 years old and females before 65-70 years old, while high FPG and high SBP caused more burden after that. The patterns of PAD-related burden and its attributable risk factors are heterogeneous across ages, genders, and SDI regions. To reduce disease burden, tailored strategies should be implemented.

Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association

Peripheral artery disease (PAD) affects 200 million individuals worldwide. In the United States, certain demographic groups experience a disproportionately higher prevalence and clinical effect of PAD. The social and clinical effect of PAD includes higher rates of individual disability, depression, minor and major limb amputation along with cardiovascular and cerebrovascular events. The reasons behind the inequitable burden of PAD and inequitable delivery of care are both multifactorial and complex in nature, including systemic and structural inequity that exists within our society. Herein, we present an overview statement of the myriad variables that contribute to PAD disparities and conclude with a summary of potential novel solutions.

Lower extremity symptoms and ankle-brachial index screening as predictors of cardiovascular outcomes in Black adults

BACKGROUND

The prevalence of peripheral artery disease (PAD) and leg symptoms are higher in Black than White adults. We studied the effects of self-reported lower extremity symptoms and ankle-brachial indices (ABI) groups on outcomes.

METHODS

Black participants in the Jackson Heart Study with baseline ABI and PAD symptom assessments (exertional leg pain by the San Diego Claudication questionnaire) were included. Abnormal ABI was < 0.90 or > 1.40. Participants were divided into (1) normal ABI, asymptomatic, (2) normal ABI, symptomatic, (3) abnormal ABI, asymptomatic, and (4) abnormal ABI, symptomatic to examine their associations with MACE (stroke, myocardial infarction, fatal coronary heart disease) and all-cause mortality, using Kaplan-Meier survival curves and stepwise Cox proportional hazard models adjusting for Framingham risk factors.

RESULTS

Of 4586 participants, mean age was 54.6 ± 12.6 years, with 63% women. Compared with participants with normal ABI who were asymptomatic, participants with abnormal ABI and leg symptoms had highest risk of MACE (adjusted HR 2.28; 95% CI 1.62, 3.22) and mortality (aHR 1.82; 95% CI 1.32, 2.56). Participants with abnormal ABI without leg symptoms had higher risk for MACE (aHR 1.49; 95% CI 1.06, 2.11) and mortality (aHR 1.44; 95% CI 1.12, 1.99). Participants with normal ABI and no leg symptoms did not have higher risks.

CONCLUSION

Among Black adults, the highest risk for adverse outcomes were in symptomatic participants with abnormal ABIs, followed by asymptomatic participants with abnormal ABIs. These findings underscore the need for further studies to screen for PAD and develop preventative approaches in Black adults with asymptomatic disease.

Impact of neighborhood social disadvantage on the presentation and management of peripheral artery disease

OBJECTIVE

Studies examining the relationship between socioeconomic disparities and peripheral artery disease (PAD) often focus on individual social health determinants and fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes. Area deprivation index (ADI), a validated measure of neighborhood adversity, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on PAD severity and its management.

METHODS

We identified all patients who underwent infrainguinal revascularization (open or endovascular) or amputation for symptomatic PAD in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing adversity. Patients were categorized by ADI quintiles (Q1-Q5). The outcomes of interest included indication for procedure (claudication, rest pain, or tissue loss) and rates of revascularization (vs primary amputation). Multinomial logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes.

RESULTS

Among the 79,973 patients identified, 9604 (12%) were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were significant trends toward lower rates of claudication (Q1: 39% vs Q5: 34%, P < .001), higher rates of rest pain (Q1: 12.4% vs Q5: 17.8%, P < .001) as the indication for intervention, and lower rates of revascularization (Q1: 80% vs Q5: 69%, P < .001) with increasing ADI quintiles. In adjusted analyses, there was a progressively higher likelihood of presenting with rest pain vs claudication, with patients in Q5 having the highest probability when compared with those in Q1 (relative risk: 2.0; 95% confidence interval: 1.8-2.2; P < .001). Patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss vs claudication (relative risk: 1.4; 95% confidence interval: 1.3-1.6; P < .001). Compared with patients in Q1, patients in Q2-Q5 had a lower likelihood of undergoing any revascularization procedure.

CONCLUSIONS

Among patients who underwent infrainguinal revascularization or amputation in the Vascular Quality Initiative, those with higher neighborhood adversity had more advanced disease at presentation and lower rates of revascularization. Further work is needed to better understand neighborhood factors that are contributing to these disparities in order to identify community-level targets for improvement.

Risk profiles, access to care, and outcomes in Hispanics hospitalized for lower extremity peripheral artery disease

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.

Disparities in peripheral artery disease care: A review and call for action

Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease that affects more than 6 million individuals 40 years and older in the United States, with sharp increases in prevalence with age. Morbidity and mortality rates in patients with PAD range from 30% to 70% during the 5- to 15-year period after diagnosis and PAD is associated with poor health outcomes and reduced functionality and quality of life. Despite advances in medical, endovascular, and open surgical techniques, there is striking variation in care among population subgroups defined by sex, race and ethnicity, and socioeconomic status, with concomitant differences in preoperative medication optimization, amputation risk, and overall health outcomes. We reviewed studies from 1995 to 2021 to provide a comprehensive analysis of the current impact of disparities on the treatment and management of PAD and offer action items that require strategic partnership with primary care providers, researchers, patients, and their communities. With new technologies and collaborative approaches, optimal management across all population subgroups is possible.

Connecting the past to the present: A historical review of exercise training for peripheral artery disease

Peripheral artery disease (PAD), a prevalent manifestation of atherosclerosis, is associated with increased cardiovascular morbidity and mortality as well as decreased functional ability. Exercise training for PAD is acknowledged to be a highly effective treatment, which improves walking ability and cardiovascular risk. The historical development of this treatment has not been the focus of a report. Therefore, we present a historical review of research on exercise training for PAD. Overall, this body of knowledge has provided strong evidence of the efficacy of supervised exercise training (SET) to improve walking ability for patients with claudication due to PAD. SET, using intermittent bouts of walking exercise to moderate claudication pain on a treadmill, is considered the most efficacious mode of exercise to improve walking ability in patients with claudication. This compelling evidence published over the past 60 years was evaluated by the Centers for Medicare & Medicaid Services in 2017, which culminated in a national coverage determination for SET to improve symptomatic PAD. Future directions include determining optimal delivery strategies for SET and further elucidation of the mechanisms of improvement in walking ability resulting from SET. In addition, alternative forms of exercise should be evaluated and effective home- and community-based exercise interventions should be assessed. There is an enormous need to increase the inclusion of women and racial and ethnic minority groups in studies. It is to be hoped that researchers will continue with new innovative research and persistence in the treatment of claudication due to PAD.

The association of healthcare disparities and patient-specific factors on clinical outcomes in peripheral artery disease

BACKGROUND

PAD increases the risk of cardiovascular mortality and limb loss, and disparities in treatment and outcomes have been described. However, the association of patient-specific characteristics with variation in outcomes is less well known.

METHODS

Patients with PAD from Duke University Health System (DUHS) between January 1, 2015 and March 31, 2016 were identified. PAD status was confirmed through ground truth adjudication and predictive modeling using diagnosis codes, procedure codes, and other administrative data. Symptom severity, lower extremity imaging, and ankle-brachial index (ABI) were manually abstracted from the electronic health record (EHR). Data was linked to Centers for Medicare and Medicaid Services data to provide longitudinal follow up. Primary outcome was major adverse vascular events (MAVE), a composite of all-cause mortality, myocardial infarction (MI), stroke, lower extremity revascularization and amputation.

RESULTS

Of 1,768 patients with PAD, 31.6% were asymptomatic, 41.2% had intermittent claudication (IC), and 27.3% had chronic limb-threatening ischemia (CLTI). At 1 year, patients with CLTI had higher rates of MAVE compared with asymptomatic or IC patients. CLTI and Medicaid dual eligibility were independent predictors of mortality. CLTI and Black race were associated with amputation.

CONCLUSIONS

Rates of MAVE were highest in patients with CLTI, but patients with IC or asymptomatic disease also had high rates of adverse events. Black and Medicaid dual-eligible patients were disproportionately present in the CLTI subgroup and were at higher risk of amputation and mortality, respectively. Future studies must focus on early identification of high-risk patient groups to improve outcomes in patients with PAD.

Racial and Ethnic Disparities in Peripheral Artery Disease

Peripheral artery disease is an obstructive, atherosclerotic disease of the lower extremities causing significant morbidity and mortality. Black Americans are disproportionately affected by this disease while they are also less likely to be diagnosed and promptly treated. The consequences of this disparity can be grim as Black Americans bear the burden of lower extremity amputation resulting from severe peripheral artery disease. The risk factors of peripheral artery disease and how they differentially affect certain groups are discussed in addition to a review of pharmacological and nonpharmacological treatment modalities. The purpose of this review is to highlight health care inequities and provide a review and resource of available recommendations for clinical management of all patients with peripheral artery disease.

Disparities in Peripheral Artery Disease Hospitalizations Identified Among Understudied Race-Ethnicity Groups

Background: To assess racial/ethnic differences in disease severity, hospital outcomes, length of stay and healthcare costs among hospitalized patients with peripheral artery disease (PAD).

Methods: This study used data from the National Inpatient Sample (NIS) to explore the racial/ethnic disparities in PAD-related hospitalizations including presence of PAD with chronic limb threatened ischemia (CLI), amputation, in-hospital mortality, length of hospital stays and estimated medical costs. Race-ethnicity groups included non-Hispanic White, Black, Hispanic, Asian or Pacific Islander, Native American, and others (multiple races). Regression analyses adjusted for age, gender, Charlson Comorbidity Index, primary payer, patient location, bed size of the admission hospital, geographic region of the hospital, and rural/urban location of the hospital.

Results: A total of 341,480 PAD hospitalizations were identified. Compared with non-Hispanic Whites, Native Americans had the highest odds of PAD with CLI (OR = 1.77, 95% CI: 1.61, 1.95); Black (OR = 1.71, 95% CI: 1.66, 1.76) and Hispanic (OR = 1.36, 95% CI: 1.31,1.41) patients had higher odds of amputation; Asian or Pacific Islanders had a higher mortality (OR = 1.20, 95% CI: 1.01,1.43), whereas Black (OR = 0.81, 95% CI: 0.76, 0.87) patients has a lower mortality; Asian or Pacific Islanders incurred higher overall inpatient costs (Margin = 30093.01, 95% CI: 28827.55, 31358.48) and most prolonged length of stay (IRR = 0.14, 95% CI: 0.09, 0.18).

Conclusions: Our study identified elevated odds of amputation among Hispanic patients hospitalized with PAD as well as higher hospital mortality and medical expenses among Asian or Pacific Islander PAD inpatients. These two demographic groups were previously thought to have a lower risk for PAD and represent important populations for further investigation.

Polonsky T, Leeuwenburgh C, Ferrucci L, Peterson CA. Correlations of Calf Muscle Macrophage Content With Muscle Properties and Walking Performance in Peripheral Artery Disease

Background Peripheral artery disease (PAD) is a manifestation of atherosclerosis characterized by reduced blood flow to the lower extremities and mobility loss. Preliminary evidence suggests PAD damages skeletal muscle, resulting in muscle impairments that contribute to functional decline. We sought to determine whether PAD is associated with an altered macrophage profile in gastrocnemius muscles and whether muscle macrophage populations are associated with impaired muscle phenotype and walking performance in patients with PAD. Methods and Results Macrophages, satellite cells, and extracellular matrix in gastrocnemius muscles from 25 patients with PAD and 7 patients without PAD were quantified using immunohistochemistry. Among patients with PAD, both the absolute number and percentage of cluster of differentiation (CD) 11b+CD206+ M2-like macrophages positively correlated to satellite cell number (r=0.461 [P=0.023] and r=0.416 [P=0.042], respectively) but not capillary density or extracellular matrix. The number of CD11b+CD206- macrophages negatively correlated to 4-meter walk tests at normal (r=-0.447, P=0.036) and fast pace (r=-0.510, P=0.014). Extracellular matrix occupied more muscle area in PAD compared with non-PAD (8.72±2.19% versus 5.30±1.03%, P<0.001) and positively correlated with capillary density (r=0.656, P<0.001). Conclusions Among people with PAD, higher CD206+ M2-like macrophage abundance was associated with greater satellite cell numbers and muscle fiber size. Lower CD206- macrophage abundance was associated with better walking performance. Further study is needed to determine whether CD206+ macrophages are associated with ongoing reparative processes enabling skeletal muscle adaptation to damage with PAD. Registration URL: https://www.clini​caltr​ials.gov; Unique identifiers: NCT00693940, NCT01408901, NCT0224660.

Evidence-Based Medical Management of Peripheral Artery Disease

Peripheral artery disease is an atherosclerotic disease of the lower extremities associated with high cardiovascular mortality. Management of this condition may include lifestyle modifications, medical management, endovascular repair, or surgery. The medical approach to peripheral artery disease is multifaceted and includes cholesterol reduction, antiplatelet therapy, anticoagulation, peripheral vasodilators, blood pressure management, exercise therapy, and smoking cessation. Adherence to this regimen can reduce limb-related complications like critical limb ischemia and amputation, as well as systemic complications of atherosclerosis like stroke and myocardial infarction. Relative to coronary artery disease, peripheral artery disease is an undertreated condition. In this article, we explore the evidence behind medical therapies for the management of peripheral artery disease.

Outcomes after peripheral artery disease intervention among Medicare-Medicaid dual-eligible patients compared with the general medicare population in the Vascular Quality Initiative registry

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.

Efficacy of Community-Based Exercise Therapy Among African American Patients With Peripheral Artery Disease: A Randomized Clinical Trial

IMPORTANCE

African American individuals are 2 times more likely than non-Hispanic white individuals to have peripheral artery disease (PAD). Structured community-based exercise therapy improves walking distance among patients with PAD, but these patients require motivation to adhere to therapy.

OBJECTIVE

To assess whether motivational interviewing (MI) is more efficacious than Patient-Centered Assessment and Counseling for Exercise (PACE) or control to improve walking distance in African American patients with PAD.

DESIGN, SETTING, AND PARTICIPANTS

In this 3-group randomized clinical trial, 174 African American patients with PAD were studied from May 1, 2012, to November 30, 2016, at health care centers, churches, and health fairs in Wichita, Kansas; Kansas City, Kansas, and Kansas City, Missouri.

INTERVENTIONS

Patients were randomized in a 1:1:1 fashion to 1 of 3 groups (57 to MI, 57 to PACE, and 60 to control). The 2 counseling interventions were delivered biweekly for 3 months and monthly for 3 months followed by a 6-month maintenance phase with limited contact. Control participants received a mailing at 3 and 9 months.

MAIN OUTCOMES AND MEASURES

The primary outcome was 6-month change in 6-minute walking performance. Secondary outcomes included 12-month change in walking performance and 6- and 12-month changes in quality of life.

RESULTS

A total of 174 African American patients (mean [SD] age, 64.2 [11.2] years; 128 [74.0%] female) were studied. At 6 months, mean (SE) change in walking distance by group was as follows: MI, -3.42 (4.55) m; PACE, 2.74 (6.00) m; and control, -0.18 (4.40) m. At 12 months, mean (SE) change in walking distance by group was as follows: MI, -7.75 (5.50) m; PACE, 13.75 (6.13) m; and control, -1.08 (5.73) m. Comparing each of the intervention arms (MI and PACE) with the control arm, no statistically significant increases in walking distance at 6 months (MI: change, -2.10 m; 95% CI, -16.54 to 12.35 m; PACE: change, 2.31 m; 95% CI, -11.36 to 15.97 m) or 12 months (MI: change, -5.56 m; 95% CI, -21.18 to 10.06 m; PACE: change, 14.24 m; 95% CI, -1.85 to 30.34 m) were found. Compared with MI, PACE resulted in a statistically significant increase in walking distance at 12 months of 19.80 m (95% CI, 3.33-36.28 m).

CONCLUSIONS AND RELEVANCE

In a cohort of African American patients with PAD, MI was not efficacious in improving walking distance at 6 or 12 months. The results of this study do not support the use of MI to improve walking performance in African American patients with PAD.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01321086.

Racial Differences in the Effect of Granulocyte Macrophage Colony-Stimulating Factor on Improved Walking Distance in Peripheral Artery Disease: The PROPEL Randomized Clinical Trial

Background The effects of race on response to medical therapy in people with peripheral artery disease ( PAD ) are unknown. Methods and Results In the PROPEL (Progenitor Cell Release Plus Exercise to Improve Functional Performance in PAD) Trial, PAD participants were randomized to 1 of 4 groups for 6 months: supervised treadmill exercise+granulocyte-macrophage colony-stimulating factor ( GM - CSF ) (Group 1), exercise+placebo (Group 2), attention control+ GM - CSF (Group 3), or attention control+placebo (Group 4). Change in 6-minute walk distance was measured at 12- and 26-week follow-up. In these exploratory analyses, groups receiving GM - CSF (Groups 1 and 3), placebo (Groups 2 and 4), exercise (Groups 1 and 2), and attention control (Groups 2 and 4) were combined, maximizing statistical power for studying the effects of race on response to interventions. Of 210 PAD participants, 141 (67%) were black and 64 (30%) were white. Among whites, GM - CSF improved 6-minute walk distance by +22.0 m (95% CI : -4.5, +48.5, P=0.103) at 12 weeks and +44.4 m (95% CI : +6.9, +82.0, P=0.020) at 26 weeks, compared with placebo. Among black participants, there was no effect of GM - CSF on 6-minute walk distance at 12-week ( P=0.26) or 26-week (-5.0 m [-27.5, +17.5, P=0.66]) follow-up, compared with placebo. There was an interaction of race on the effect of GM - CSF on 6-minute walk change at 26-week follow-up ( P=0.018). Exercise improved 6-minute walk distance in black ( P=0.006) and white ( P=0.034) participants without interaction. Conclusions GM - CSF improved 6-minute walk distance in whites with PAD but had no effect in black participants. Further study is needed to confirm racial differences in GM - CSF efficacy in PAD . Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01408901.