1
|
Altin SE, Parise H, Hess CN, Rosenthal NA, Julien HM, Curtis JP. Co-Morbidity Differences Associated With Long-Term Amputation and Repeat Revascularization Rates After Femoropopliteal Artery Intervention for Intermittent Claudication by Sex, Race, and Ethnicity. Am J Cardiol 2024; 226:40-49. [PMID: 38834142 DOI: 10.1016/j.amjcard.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/29/2024] [Accepted: 05/11/2024] [Indexed: 06/06/2024]
Abstract
Use of peripheral vascular intervention (PVI) for intermittent claudication (IC) continues to expand, but there is uncertainty whether baseline demographics, procedural techniques and outcomes differ by sex, race, and ethnicity. This study aimed to examine amputation and revascularization rates up to 4 years after femoropopliteal (FP) PVI for IC by sex, race, and ethnicity. Patients who underwent FP PVI for IC between 2016 and 2020 from the PINC AI Healthcare Database were analyzed. The primary outcome was any index limb amputation, assessed by Kaplan-Meier estimate. Secondary outcomes included index limb major amputation, repeat revascularization, and index limb repeat revascularization. Unadjusted and adjusted hazard ratios (HRs) were estimated using Cox proportional hazard regression models. This study included 19,324 patients with IC who underwent FP PVI, with 41.2% women, 15.6% Black patients, and 4.7% Hispanic patients. Women were less likely than men to be treated with atherectomy (45.1% vs 47.8%, p = 0.0003); Black patients were more likely than White patients to receive atherectomy (50.7% vs 44.9%, p <0.001), and Hispanic patients were less likely than non-Hispanic patients to receive atherectomy (41% vs 47%, p = 0.0004). Unadjusted rates of any amputation were similar in men and women (6.4% for each group, log-rank p = 0.842), higher in Black patients than in White patients (7.8% vs 6.1%, log-rank p = 0.007), and higher in Hispanic patients than in non-Hispanic patients (8.8% vs 6.3%, log-rank p = 0.031). After adjustment for baseline characteristics, Black race was associated with higher rates of repeat revascularization (adjusted HR 1.13, 95% confidence interval 1.04 to 1.22) and any FP revascularization (adjusted HR 1.10, 95% confidence interval 1.01 to 1.20). No statistical difference in amputation rate was observed among comparison groups. Women and men with IC had similar crude and adjusted amputation and revascularization outcomes after FP PVI. Black patients had higher repeat revascularization and any FP revascularization rates than did White patients. Black and Hispanic patients had higher crude amputation rates, but these differences were attenuated by adjustment for baseline characteristics. Black patients were more likely to receive atherectomy and had higher rates of any repeat revascularization and specifically FP revascularization. Further study is necessary to determine whether these patterns are related to disease-specific issues or practice-pattern differences among different populations.
Collapse
Affiliation(s)
- S Elissa Altin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; West Haven VA Medical Center, West Haven, Connecticut.
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Connie N Hess
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado; CPC Clinical Research, Aurora, Colorado
| | - Ning A Rosenthal
- PINC AI Applied Sciences, Premier Inc., Charlotte, North Carolina
| | - Howard M Julien
- Division of Cardiovascular Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Penn Cardiovascular Outcomes, Quality & Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; The Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Health Equity Research and Promotion, Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania; Penn Cardiovascular Center for Health Equity and Social Justice, Philadelphia, Pennsylvania
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| |
Collapse
|
2
|
Dun C, Stonko DP, Bose S, Keegan AC, McDermott KM, Rumalla KC, Black JH, Kalbaugh CA, Makary MA, Hicks CW. Trends and Factors Associated With Peripheral Vascular Interventions for the Treatment of Claudication From 2011 to 2022: A National Medicare Cohort Study. J Am Heart Assoc 2024; 13:e033463. [PMID: 38958132 PMCID: PMC11292772 DOI: 10.1161/jaha.123.033463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 05/03/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Previous cross-sectional studies have identified wide practice pattern variations in the use of peripheral vascular interventions (PVIs) for the treatment of claudication. However, there are limited data on longitudinal practice patterns. We aimed to describe the temporal trends and charges associated with PVI use for claudication over the past 12 years in the United States. METHODS AND RESULTS We conducted a retrospective analysis using 100% Medicare fee-for-service claims data to identify all patients who underwent a PVI for claudication between January 2011 and December 2022. We evaluated the trends in utilization and Medicare-allowed charges of PVI according to anatomic level, procedure type, and intervention settings using generalized linear models. Multinomial logistic regressions were used to evaluate factors associated with different levels and types of PVI. We identified 599 197 PVIs performed for claudication. The proportional use of tibial PVI increased 1.0% per year, and atherectomy increased by 1.6% per year over the study period. The proportion of PVIs performed in ambulatory surgical centers/office-based laboratories grew at 4% per year from 12.4% in 2011 to 55.7% in 2022. Total Medicare-allowed charges increased by $11 980 035 USD/year. Multinomial logistic regression identified significant associations between race and ethnicity and treatment setting with use of both atherectomy and tibial PVI. CONCLUSIONS The use of tibial PVI and atherectomy for the treatment of claudication has increased dramatically in in ambulatory surgical center/office-based laboratory settings, non-White patients, and resulting in a significant increase in health care charges. There is a critical need to improve the delivery of value-based care for the treatment of claudication.
Collapse
Affiliation(s)
- Chen Dun
- Biomedical Informatics and Data ScienceJohns Hopkins University School of MedicineBaltimoreMD
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - David P. Stonko
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Alana C. Keegan
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
- Department of SurgerySinai Hospital of BaltimoreBaltimoreMDUSA
| | - Katherine M. McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Kranti C. Rumalla
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - James H. Black
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| | - Corey A. Kalbaugh
- Department of Epidemiology and BiostatisticsIndiana University School of Public Health‐ BloomingtonBloomingtonINUSA
| | - Martin A. Makary
- Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
- Johns Hopkins Carey Business SchoolBaltimoreMDUSA
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of SurgeryJohns Hopkins University School of MedicineBaltimoreMD
| |
Collapse
|
3
|
Tsou TC, Dun C, Bose S, McDermott KM, White M, Siracuse JJ, Weaver ML, Black JH, Makary MA, Hicks CW. Practice patterns of peripheral vascular interventions for peripheral artery disease in the office-based laboratory setting versus outpatient hospital. J Vasc Surg 2024:S0741-5214(24)01250-3. [PMID: 38908807 DOI: 10.1016/j.jvs.2024.06.006] [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: 04/15/2024] [Revised: 06/03/2024] [Accepted: 06/05/2024] [Indexed: 06/24/2024]
Abstract
OBJECTIVE Controversy exists regarding the value and limitations of different sites of service for peripheral artery disease treatment. We aimed to examine practice patterns associated with peripheral vascular interventions (PVIs) performed in the office-based laboratory (OBL) vs outpatient hospital site of service using a nationally representative database. METHODS Using 100% Medicare fee-for-service claims data, we identified all patients undergoing PVI for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2022. We evaluated the associations of patient and procedure characteristics with site of service using multivariable hierarchical logistic regression. We used multinomial regression models to estimate the relative risk ratios (RRRs) of site of service and intervention type (angioplasty, stent, or atherectomy) and intervention anatomic level (iliac, femoropopliteal, or tibial) after adjusting for baseline patient characteristics and clustering by physician. RESULTS Of 848,526 PVI, 485,942 (57.3%) were performed in an OBL. OBL use increased significantly over time from 48.3% in 2017 to 65.5% in 2022 (P < .001). Patients treated in OBLs were more likely to be Black (adjusted odds ratio [aOR], 1.14; 95% confidence interval [CI], 1.11-1.18) or other non-White race (aOR, 1.13; 95% CI, 1.08-1.18), have fewer comorbidities, and undergo treatment for claudication vs CLTI (aOR, 1.30; 95% CI, 1.26-1.33) compared with patients treated in outpatient hospital settings. Physicians with majority practice (>50% procedures) in an OBL were more likely to practice in urban settings (aOR, 21.58; 95% CI, 9.31-50.02), specialize in radiology (aOR, 18.15; 95% CI, 8.92- 36.92), and have high-volume PVI practices (aOR, 2.15; 95% CI, 2.10-2.29). The median time from diagnosis to treatment was shorter in OBLs, particularly for patients with CLTI (29 vs 39 days; P < .001). The OBL setting was the strongest predictor of patients receiving an atherectomy alone (adjusted RRR [aRRR] 6.67; 95% CI, 6.59-6.76) or atherectomy + stent (aRRR, 10.84; 95% CI, 10.64-11.05), and these findings were consistent in subgroup analyses stratified by PVI indication. The OBL setting was also associated with higher risk of tibial interventions for both claudication (aRRR, 3.18; 95% CI, 3.11-3.25) and CLTI (aRRR, 1.89; 95% CI, 1.86-1.92). The average reimbursement (including professional and facility fees) was slightly higher for OBLs compared with the hospital ($8742/case vs $8459/case; P < .001). However, in a simulated cohort resetting the OBL's intervention type distribution to that of the hospital, OBLs were associated with a hypothetical cost savings of $221,219,803 overall and $2602 per case. CONCLUSIONS The OBL site of service was associated with greater access to care for non-White patients and a shorter time from diagnosis to treatment, but more frequently performed high-cost interventions compared with the outpatient hospital setting. The benefit to patients from improved access to peripheral artery disease care in OBL settings must be balanced with the potential limitations of receiving differential care.
Collapse
Affiliation(s)
- Terrence C Tsou
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Chen Dun
- Department of Biomedical Informatics and Data Science, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Katherine M McDermott
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Midori White
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| |
Collapse
|
4
|
Woo HY, Joh JH, Kang JM, Yoo YS, Lee T, Ahn S. Comparison between intermittent claudication versus chronic limb-threatening ischemia in peripheral arterial disease: a retrospective multicenter cohort study. Ann Surg Treat Res 2024; 106:344-353. [PMID: 38868587 PMCID: PMC11164664 DOI: 10.4174/astr.2024.106.6.344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/29/2024] [Accepted: 04/11/2024] [Indexed: 06/14/2024] Open
Abstract
Purpose The anatomical distribution, characteristics of lesions, and treatment modalities for peripheral artery disease (PAD) are diverse. Endovascular intervention is popular for symptomatic PAD, for both intermittent claudication (IC) and chronic limb-threatening ischemia (CLTI). We aimed to investigate the endovascular devices used by comparing patients with PAD referred for endovascular revascularization with IC and CLTI. Methods We identified 736 patients with PAD enrolled in the multicenter PAD registry in South Korea from 2019 to 2022. Of these patients, 636 received endovascular treatment at the time of this study. After excluding missing data, we analyzed 506 patients with IC or CLTI. Patients' characteristics, target lesions, and endovascular device data such as type, length, balloon diameter, and stent, were examined. Procedure outcomes of the aortoiliac, femoropopliteal, and below-the-knee lesions were analyzed. Results Patients with CLTI were more likely to have diabetes mellitus, below-the-knee interventions, and multilevel PAD than the IC group. Patients with IC had more aortoiliac artery lesions and underwent atherectomies than the CLTI group (63.3% and 61.1% vs. 39.7% and 40.6%, respectively; P < 0.001). In patients with femoropopliteal lesions, those with CLTI were more revascularized with stents than the patients with IC, without significant differences (35.3% vs. 29.1%, P = 0.161). Compared to the IC group, the CLTI patients showed significantly worse rates of primary patency, amputation, and mortality (P = 0.029, P < 0.001, and P < 0.001, respectively). Conclusion Among Korean patients with PAD, there is a significant difference in baseline and lesion characteristics, endovascular strategies, and short-term follow-up outcomes among those with IC and CLTI.
Collapse
Affiliation(s)
- Hye Young Woo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital, Seoul, Korea
| | - Jin Mo Kang
- Department of Surgery, Gachon University Gil Medical Center, Inchon, Korea
| | - Young Sun Yoo
- Department of Surgery, Chosun University College of Medicine, Gwangju, Korea
| | - Taeseung Lee
- Department of Surgery, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Sanghyun Ahn
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | | |
Collapse
|
5
|
Tan LT, McDermott KM, Hicks CW. 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. Semin Vasc Surg 2024; 37:188-209. [PMID: 39151998 DOI: 10.1053/j.semvascsurg.2024.04.006] [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: 04/08/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 08/19/2024]
Abstract
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.
Collapse
Affiliation(s)
- Li Ting Tan
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287
| | - Katherine M McDermott
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287
| | - Caitlin W Hicks
- Department of Surgery, The Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287.
| |
Collapse
|
6
|
White M, Kalbaugh CA, Hicks CW. Response to Letter to the Editor: "Risks and Benefits of the Proposed Amputation Reduction and Compassion Act for Disadvantaged Patients". Ann Vasc Surg 2024:S0890-5096(24)00257-7. [PMID: 38815901 DOI: 10.1016/j.avsg.2024.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Accepted: 05/05/2024] [Indexed: 06/01/2024]
Affiliation(s)
- Midori White
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Corey A Kalbaugh
- Department of Epidemiology and Biostatistics, Indiana University School of Public Health-Bloomington, Bloomington, IN
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| |
Collapse
|
7
|
Goetz ME, Ford CB, Greiner MA, Clark A, Johnson KG, Kaufman BG, Mantri S, Xian Y, O'Brien RJ, O'Brien EC, Lusk JB. Racial Disparities in Low-Value Care in the Last Year of Life for Medicare Beneficiaries With Neurodegenerative Disease. Neurol Clin Pract 2024; 14:e200273. [PMID: 38524836 PMCID: PMC10955333 DOI: 10.1212/cpj.0000000000200273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 01/09/2024] [Indexed: 03/26/2024]
Abstract
Background and Objectives There are racial disparities in health care services received by patients with neurodegenerative diseases, but little is known about disparities in the last year of life, specifically in high-value and low-value care utilization. This study evaluated racial disparities in the utilization of high-value and low-value care in the last year of life among Medicare beneficiaries with dementia or Parkinson disease. Methods This was a retrospective, population-based cohort analysis using data from North and South Carolina fee-for-service Medicare claims between 2013 and 2017. We created a decedent cohort of beneficiaries aged 50 years or older at diagnosis with dementia or Parkinson disease. Specific low-value utilization outcomes were selected from the Choosing Wisely initiative, including cancer screening, peripheral artery stenting, and feeding tube placement in the last year of life. Low-value outcomes included hospitalization, emergency department visits, neuroimaging services, and number of days receiving skilled nursing. High-value outcomes included receipt of occupational and physical therapy, hospice care, and medications indicated for dementia and/or Parkinson disease. Results Among 70,650 decedents, 13,753 were Black, 55,765 were White, 93.1% had dementia, and 7.7% had Parkinson disease. Adjusting for age, sex, Medicaid dual enrollment status, rural vs urban location, state (NC and SC), and comorbidities, Black decedents were more likely to receive low-value care including colorectal cancer screening (adjusted hazard ratio [aHR] 1.46 [1.32-1.61]), peripheral artery stenting (aHR 1.72 [1.43-2.08]), and feeding tube placement (aHR 2.96 [2.70-3.24]) and less likely to receive physical therapy (aHR 0.73 [0.64-0.85)], dementia medications (aHR 0.90 [0.86-0.95]), or Parkinson disease medications (aHR 0.88 [0.75-1.02]) within the last year of life. Black decedents were more likely to be hospitalized (aHR 1.28 [1.25-1.32]), more likely to be admitted to skilled nursing (aHR 1.09 [1.05-1.13]), and less likely to be admitted to hospice (aHR 0.82 [0.79-0.85]) than White decedents. Discussion We found racial disparities in care utilization among patients with neurodegenerative disease in the last year of life, such that Black decedents were more likely to receive specific low-value care services and less likely to receive high-value supportive care than White decedents, even after adjusting for health status and socioeconomic factors.
Collapse
Affiliation(s)
- Margarethe E Goetz
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Cassie B Ford
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Melissa A Greiner
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Amy Clark
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Kim G Johnson
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Brystana G Kaufman
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Sneha Mantri
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Ying Xian
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Richard J O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Emily C O'Brien
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| | - Jay B Lusk
- Departments of Neurology (MEG, KGJ, SM, RJOB, ECOB, JBL), Population Health Sciences (CBF, AC, BGK, ECOB, MAG), and Psychiatry and Behavioral Sciences (KGJ), Duke University, Durham, NC; Departments of Population and Data Sciences (YX), and Neurology (YX), University of Texas-Southwestern, Dallas; Duke University School of Medicine (JBL); and Duke University Fuqua School of Business (JBL), Durham, NC
| |
Collapse
|
8
|
White M, McDermott KM, Bose S, Wang C, Srinivas T, Kalbaugh C, Hicks CW. Risks and Benefits of the Proposed Amputation Reduction and Compassion Act for Disadvantaged Patients. Ann Vasc Surg 2024; 101:179-185. [PMID: 38142961 PMCID: PMC10957305 DOI: 10.1016/j.avsg.2023.12.003] [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: 12/06/2023] [Accepted: 12/06/2023] [Indexed: 12/26/2023]
Abstract
Racial, ethnic, and socioeconomic disparities in the major risk factors for vascular disease and access to vascular specialist care are well-documented.1-3 The higher incidence of diabetes, peripheral artery disease (PAD), and related nontraumatic lower extremity amputation among racial and ethnic minority groups, those of low socioeconomic status, and those with poor access to care based on geography (together, referred to below as disadvantaged groups) are particularly pervasive.1,4-9 Practitioners of vascular surgery and endovascular therapy are uniquely positioned to address health inequities in lower extremity screening, medical management, intervention, and limb preservation among the population of adults at the highest risk for limb loss.
Collapse
Affiliation(s)
- Midori White
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | | | - Sanuja Bose
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Caroline Wang
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Tara Srinivas
- Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Corey Kalbaugh
- Department of Epidemiology and Biostatistics, School of Public Health-Bloomington, Indiana University, Bloomington, IN
| | - Caitlin W Hicks
- Department of Surgery, Johns Hopkins University, Baltimore, MD.
| |
Collapse
|
9
|
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.
Collapse
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
| |
Collapse
|
10
|
Weaver ML, Neal D, Columbo JA, Holscher CM, Sorber RA, Hicks CW, Stone DH, Clouse WD, Scali ST. Market competition influences practice patterns in management of patients with intermittent claudication in the vascular quality initiative. J Vasc Surg 2023; 78:727-736.e3. [PMID: 37141948 PMCID: PMC10699768 DOI: 10.1016/j.jvs.2023.04.032] [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: 02/13/2023] [Revised: 04/06/2023] [Accepted: 04/24/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The Society for Vascular Surgery (SVS) clinical practice guidelines recommend best medical therapy (BMT) as first-line therapy before offering revascularization to patients with intermittent claudication (IC). Notably, atherectomy and tibial-level interventions are generally discouraged for management of IC; however, high regional market competition may incentivize physicians to treat patients outside the scope of guideline-directed therapy. Therefore, we sought to determine the association between regional market competition and endovascular treatment of patients with IC. METHODS We examined patients with IC undergoing index endovascular peripheral vascular interventions (PVI) in the SVS Vascular Quality Initiative from 2010 to 2022. We assigned the Herfindahl-Hirschman Index as a measure of regional market competition and stratified centers into very high competition (VHC), high competition, moderate competition, and low competition cohorts. We defined BMT as preoperative documentation of being on antiplatelet medication, statin, nonsmoking status, and a recorded ankle-brachial index. We used logistic regression to evaluate the association of market competition with patient and procedural characteristics. A sensitivity analysis was performed in patients with isolated femoropopliteal disease matched by the TransAtlantic InterSociety classification of disease severity. RESULTS There were 24,669 PVIs that met the inclusion criteria. Patients with IC undergoing PVI were more likely to be on BMT when treated in higher market competition centers (odds ratio [OR], 1.07 per increase in competition quartile; 95% confidence interval [CI], 1.04-1.11; P < .0001). The probability of undergoing aortoiliac interventions decreased with increasing competition (OR, 0.84; 95% CI, 0.81-0.87; P < .0001), but there were higher odds of receiving tibial (OR, 1.40; 95% CI, 1.30-1.50; P < .0001) and multilevel interventions in VHC vs low competition centers (femoral + tibial OR, 1.10; 95% CI, 1.03-1.14; P = .001). Stenting decreased as competition increased (OR, 0.89; 95% CI, 0.87-0.92; P < .0001), whereas exposure to atherectomy increased with higher market competition (OR, 1.15; 95% CI, 1.11-1.19; P < .0001). When assessing patients undergoing single-artery femoropopliteal intervention for TransAtlantic InterSociety A or B lesions to account for disease severity, the odds of undergoing either balloon angioplasty (OR, 0.72; 95% CI, 0.625-0.840; P < .0001) or stenting only (OR, 0.84; 95% CI, 0.727-0.966; P < .0001) were lower in VHC centers. Similarly, the likelihood of receiving atherectomy remained significantly higher in VHC centers (OR, 1.6; 95% CI, 1.36-1.84; P < .0001). CONCLUSIONS High market competition was associated with more procedures among patients with claudication that are not consistent with guideline-directed therapy per the SVS clinical practice guidelines, including atherectomy and tibial-level interventions. This analysis demonstrates the susceptibility of care delivery to regional market competition and signifies a novel and undefined driver of PVI variation among patients with claudication.
Collapse
Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA.
| | - Dan Neal
- Department of Surgery, University of Florida, Gainesville, FL
| | - Jesse A Columbo
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca A Sorber
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD
| | - David H Stone
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - W Darrin Clouse
- Division of Vascular and Endovascular Surgery, University of Virginia Health System, Charlottesville, VA
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| |
Collapse
|
11
|
Allison MA, Armstrong DG, Goodney PP, Hamburg NM, Kirksey L, Lancaster KJ, Mena-Hurtado CI, Misra S, Treat-Jacobson DJ, White Solaru KT. Health Disparities in Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 148:286-296. [PMID: 37317860 DOI: 10.1161/cir.0000000000001153] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
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.
Collapse
|
12
|
Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Reprint of: Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:1720-1731.e3. [PMID: 37225352 PMCID: PMC10756146 DOI: 10.1016/j.jvs.2023.04.023] [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: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
Collapse
Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
13
|
Paraskevas KI, Dardik A, Gloviczki P. Racial disparities in vascular care need attention without delay. J Vasc Surg 2023; 77:1289-1291. [PMID: 36948682 DOI: 10.1016/j.jvs.2022.12.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 12/16/2022] [Indexed: 03/24/2023]
Affiliation(s)
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Yale School of Medicine, New Haven, CT
| | - Peter Gloviczki
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Rochester, MN
| |
Collapse
|
14
|
Sorber R, Dun C, Kawaji Q, Abularrage CJ, Black JH, Makary MA, Hicks CW. Early peripheral vascular interventions for claudication are associated with higher rates of late interventions and progression to chronic limb threatening ischemia. J Vasc Surg 2023; 77:836-847.e3. [PMID: 37276171 PMCID: PMC10242207 DOI: 10.1016/j.jvs.2022.10.025] [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: 07/12/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite societal guidelines that peripheral vascular intervention (PVI) should not be the first-line therapy for intermittent claudication, a significant number of patients will undergo PVI for claudication within 6 months of diagnosis. The aim of the present study was to investigate the association of early PVI for claudication with subsequent interventions. METHODS We evaluated 100% of Medicare fee-for-service claims to identify all beneficiaries with a new diagnosis of claudication from January 1, 2015 to December 31, 2017. The primary outcome was late intervention, defined as any femoropopliteal PVI performed >6 months after the claudication diagnosis (through June 30, 2021). Kaplan-Meier curves were used to compare the cumulative incidence of late PVI for claudication patients with early (≤6 months) PVI vs those without early PVI. A hierarchical Cox proportional hazards model was used to evaluate the patient- and physician-level characteristics associated with late PVIs. RESULTS A total of 187,442 patients had a new diagnosis of claudication during the study period, of whom 6069 (3.2%) had undergone early PVI. After a median follow-up of 4.39 years (interquartile range, 3.62-5.17 years), 22.5% of the early PVI patients had undergone late PVI vs 3.6% of those without early PVI (P < .001). Patients treated by high use physicians of early PVI (≥2 standard deviations; physician outliers) were more likely to have received late PVI than were patients treated by standard use physician of early PVI (9.8% vs 3.9%; P < .001). Patients who had undergone early PVI (16.4% vs 7.8%) and patients treated by outlier physicians (9.7% vs 8.0%) were more likely to have developed CLTI (P < .001 for both). After adjustment, the patient factors associated with late PVI included receipt of early PVI (adjusted hazard ratio [aHR], 6.89; 95% confidence interval [CI], 6.42-7.40) and Black race (vs White; aHR, 1.19; 95% CI, 1.10-1.30). The only physician factor associated with late PVI was a majority of practice in an ambulatory surgery center or office-based laboratory, with an increasing proportion of ambulatory surgery center or office-based laboratory services associated with significantly increased rates of late PVI (quartile 4 vs quartile 1; aHR, 1.57; 95% CI, 1.41-1.75). CONCLUSIONS Early PVI after the diagnosis of claudication was associated with higher late PVI rates compared with early nonoperative management. High use physicians of early PVI for claudication performed more late PVIs than did their peers, especially those primarily delivering care in high reimbursement settings. The appropriateness of early PVI for claudication needs critical evaluation, as do the incentives surrounding the delivery of these interventions in ambulatory intervention suites.
Collapse
Affiliation(s)
- Rebecca Sorber
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD.
| | - Chen Dun
- Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Qingwen Kawaji
- Department of Plastics and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD
| | - Martin A Makary
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Medical Institutions, Baltimore, MD; Johns Hopkins Surgery Center for Outcomes Research, Johns Hopkins University School of Medicine, Baltimore, MD
| |
Collapse
|
15
|
Robinson WP. The outcomes of lower extremity revascularization: What role do race, ethnicity, and socioeconomic status play? Semin Vasc Surg 2023; 36:69-77. [PMID: 36958900 DOI: 10.1053/j.semvascsurg.2023.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/31/2023] [Accepted: 01/31/2023] [Indexed: 02/05/2023]
Abstract
Lower extremity peripheral artery disease and the resultant complications disproportionately affect underrepresented racial and ethnic minority groups, as well as those with low socioeconomic status (SES). Revascularization, including both open surgical and endovascular techniques, is a mainstay of therapy for symptomatic peripheral artery disease; it is required to maximize limb salvage in chronic limb-threatening ischemia and used to improve function and quality of life in patients with claudication. The outcomes of lower extremity revascularization in Black and Hispanic patients, as well as patients with low SES, are not widely known and this knowledge gap formed the basis for this review. The preponderance of evidence suggests that Black, Hispanic, and low-SES patients have inferior limb-related outcomes after revascularization compared with White patients. Based solely on the limited published evidence in the revascularization literature, the specific reasons for these disparities are not clear. The high prevalence of comorbidities and risks factors, as well as the advanced presentation of peripheral artery disease in Black, Hispanic, and low-SES patients, appear to contribute to the inferior limb outcomes post revascularization seen in these groups, but do not account for all of the disparities. Undoubtedly, a complex interplay of social determinants underlies these disparities in care and outcomes at individual, community, and societal levels. Additional understanding of the underpinnings and mechanisms of inferior outcomes in these populations in the specific context of lower extremity revascularization is needed, as this would allow us to identify targets for intervention to improve post-revascularization outcomes in these at-risk populations.
Collapse
Affiliation(s)
- William P Robinson
- Division of Vascular Surgery, Southern Illinois University School of Medicine, Springfield, IL.
| |
Collapse
|
16
|
Jaramillo EA, Smith EJT, Matthay ZA, Sanders KM, Hiramoto JS, Gasper WJ, Conte MS, Iannuzzi JC. Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention. J Vasc Surg 2023; 77:848-857.e2. [PMID: 36334848 DOI: 10.1016/j.jvs.2022.10.043] [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: 07/27/2022] [Revised: 10/14/2022] [Accepted: 10/19/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (Wound, Ischemia, foot Infection) stage. METHODS The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis. RESULTS Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P < .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P < .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P < .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P < .001) compared with White race. CONCLUSIONS Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.
Collapse
Affiliation(s)
- Emanuel A Jaramillo
- Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA; Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Eric J T Smith
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Zachary A Matthay
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Katherine M Sanders
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Jade S Hiramoto
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Warren J Gasper
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - Michael S Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - James C Iannuzzi
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, San Francisco, San Francisco, CA.
| |
Collapse
|
17
|
Weaver ML, Sorber RA, Holscher CM, Cox ML, Henry BV, Brooke BS, Cooper MA. The measurable impact of a diversity, equity, and inclusion editor on diversifying content, authorship, and peer review participation in the Journal of Vascular Surgery. J Vasc Surg 2023; 77:330-337. [PMID: 36368645 DOI: 10.1016/j.jvs.2022.10.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/09/2022] [Accepted: 10/31/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Women and minorities remain under-represented in academic vascular surgery. This under-representation persists in the editorial peer review process which may contribute to publication bias. In 2020, the Journal of Vascular Surgery (JVS) addressed this by diversifying the editorial board and creating a new Editor of Diversity, Equity, and Inclusion (DEI). The impact of a DEI editor on modifying the output of JVS has not yet been examined. We sought to determine the measurable impact of a DEI editor on diversifying perspectives represented in the journal, and on contributing to changes in the presence of DEI subject matter across published journal content. METHODS The authorship and content of published primary research articles, editorials, and special articles in JVS were examined from November 2019 through July 2022. Publications were examined for the year prior to initiation of the DEI Editor (pre), the year following (post), and from September 2021 to July 2022, accounting for the average 47-week time period from submission to publication in JVS (lag). Presence of DEI topics and women authorship were compared using χ2 tests. RESULTS During the period examined, the number of editorials, guidelines, and other special articles dedicated to DEI topics in the vascular surgery workforce or patient population increased from 0 in the year prior to 4 (16.7%) in the 11-month lag period. The number of editorials, guidelines, and other special articles with women as first or senior authors nearly doubled (24% pre, 44.4% lag; P = .31). Invited commentaries and discussions were increasingly written by women as the study period progressed (18.7% pre, 25.9% post, 42.6% lag; P = .007). The number of primary research articles dedicated to DEI topics increased (5.6% pre, 3.3% post, 8.1% lag; P = .007). Primary research articles written on DEI topics were more likely to have women first or senior authors than non-DEI specific primary research articles (68.0% of all DEI vs 37.5% of a random sampling of non-DEI primary research articles; P < .001). The proportion of distinguished peer reviewers increased (from 2.8% in 2020 to 21.9% in 2021; P < .001). CONCLUSIONS The addition of a DEI editor to JVS significantly impacted the diversification of topics, authorship of editorials, special articles, and invited commentaries, as well as peer review participation. Ongoing efforts are needed to diversify subject matter and perspective in the vascular surgery literature and decrease publication bias.
Collapse
Affiliation(s)
- M Libby Weaver
- Division of Vascular and Endovascular Surgery, University of Virginia, Charlottesville, VA.
| | - Rebecca A Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Courtenay M Holscher
- Division of Vascular Surgery and Endovascular Therapy, The Johns Hopkins Hospital, Baltimore, MD
| | - Morgan L Cox
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| | - Brandon V Henry
- Division of Vascular Surgery and Endovascular Surgery, Morehouse School of Medicine, Atlanta, GA
| | - Benjamin S Brooke
- Division of Vascular Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
| | - Michol A Cooper
- Division of Vascular Surgery and Endovascular Therapy, University of Florida, Gainesville, FL
| |
Collapse
|
18
|
Bose S, Dun C, Sorber R, Stonko DP, Solomon AJ, Black JH, Lum YW, Conte MS, Makary MA, Hicks CW. Practice patterns surrounding the use of tibial interventions for claudication in the Medicare population. J Vasc Surg 2023; 77:454-462.e1. [PMID: 36058433 PMCID: PMC9868091 DOI: 10.1016/j.jvs.2022.08.033] [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: 07/02/2022] [Revised: 08/12/2022] [Accepted: 08/23/2022] [Indexed: 01/26/2023]
Abstract
OBJECTIVE At present, no data are available to support the use of tibial interventions in the treatment of claudication. We characterized the practice patterns surrounding tibial peripheral vascular interventions (PVIs) for patients with claudication in the United States. METHODS Using 100% Medicare fee-for-service claims from 2017 to 2019, we conducted a retrospective analysis of all patients who underwent an index PVI for claudication. Patients with any previous PVI, acute limb ischemia, or chronic limb-threatening ischemia in the preceding 12 months were excluded. The primary outcome was the receipt or delivery of tibial revascularization during an index PVI for claudication, defined as tibial PVI with or without concomitant femoropopliteal PVI. Univariable comparisons and multivariable hierarchical logistic regression were used to assess the patient and physician characteristics associated with the use of tibial PVI for claudication. RESULTS Of 59,930 Medicare patients who underwent an index PVI for claudication between 2017 and 2019, 16,594 (27.7%) underwent a tibial PVI (isolated tibial PVI, 38.5%; tibial PVI with concomitant femoropopliteal PVI, 61.5%). Of the 1542 physicians included in our analysis, the median physician-level tibial PVI rate was 20.0% (interquartile range, 9.1%-37.5%). Hierarchical logistic regression suggested that patient-level characteristics associated with tibial PVI for claudication included male sex (adjusted odds ratio [aOR], 1.23), increasing age (aOR, 1.30-1.96), Black race (aOR, 1.47), Hispanic ethnicity (aOR, 1.86), diabetes (aOR, 1.36), no history of hypertension (aOR, 1.12), and never-smoking status (aOR, 1.64; P < .05 for all). Physician-level characteristics associated with tibial PVI for claudication included early-career status (aOR, 2.97), practice location in the West (aOR, 1.75), high-volume PVI practice (aOR, 1.87), majority of practice in an ambulatory surgery center or office-based laboratory setting (aOR, 2.37), and physician specialty. The odds of vascular surgeons performing tibial PVI were significantly lower compared with radiologists (aOR, 2.98) and cardiologists (aOR, 1.67; P < .05 for all). The average Medicare reimbursement per patient was dramatically higher for physicians performing high rates of tibial PVI (quartile 4 vs quartile 1-3, $12,023.96 vs $692.31 per patient; P < .001). CONCLUSIONS Tibial PVI for claudication was performed more often by nonvascular surgeons in high-volume practices and high-reimbursement settings. Thus, a critical need exists to reevaluate the indications, education, and reimbursement policies surrounding these procedures.
Collapse
Affiliation(s)
- Sanuja Bose
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Chen Dun
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Rebecca Sorber
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - David P. Stonko
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Alex J. Solomon
- Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD
| | - James H. Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Ying-Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Michael S. Conte
- Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Francisco Medical Center, San Francisco, CA
| | - Martin A. Makary
- Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, MD
| |
Collapse
|
19
|
Trivedi PS, Guerra B, Kumar V, Akinwande G, West D, Abi-Jaoudeh N, Salazar G, Rochon P. Healthcare Disparities in Interventional Radiology. J Vasc Interv Radiol 2022; 33:1459-1467.e1. [PMID: 36058539 DOI: 10.1016/j.jvir.2022.08.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 08/08/2022] [Accepted: 08/25/2022] [Indexed: 10/14/2022] Open
Abstract
Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.
Collapse
Affiliation(s)
- Premal S Trivedi
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Bernardo Guerra
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vishal Kumar
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Goke Akinwande
- Midwest Institute for Non-Surgical Therapy, St. Louis, Missouri
| | - Derek West
- Department of Radiology, Emory School of Medicine, Atlanta, Georgia
| | - Nadine Abi-Jaoudeh
- Department of Radiology, University of California Irvine, Irvine, California
| | - Gloria Salazar
- Department of Radiology, University of North Carolina, Chapel Hill, North Carolina
| | - Paul Rochon
- Department of Radiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| |
Collapse
|
20
|
O'Banion LA. Hemoglobin A1c monitoring practices may not predict outcomes, but A1C values do, especially in treatment of intermittent claudication. J Vasc Surg 2022; 76:265. [PMID: 35738782 DOI: 10.1016/j.jvs.2022.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/04/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Leigh Ann O'Banion
- Division of Vascular Surgery, Department of Surgery, University of California San Francisco-Fresno, Fresno, CA
| |
Collapse
|
21
|
Ho-Yan Lee M, Li PY, Li B, Shakespeare A, Samarasinghe Y, Feridooni T, Cuen-Ojeda C, Alshabanah L, Kishibe T, Al-Omran M. A systematic review and meta-analysis of sex- and gender-based differences in presentation severity and outcomes in adults undergoing major vascular surgery. J Vasc Surg 2022; 76:581-594.e25. [DOI: 10.1016/j.jvs.2022.02.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/24/2022] [Indexed: 11/25/2022]
|
22
|
Wallace BK, Miles CH, Anderson CB. Effects of race and socioeconomic status on treatment for localized renal masses in New York City. Urol Oncol 2021; 40:65.e19-65.e26. [PMID: 34876349 DOI: 10.1016/j.urolonc.2021.11.004] [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: 08/10/2021] [Revised: 10/21/2021] [Accepted: 11/04/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Partial nephrectomy (PN) is the preferred treatment for localized renal masses (LRM), however its use is not uniform across patient socioeconomic (SES) factors. Our hypothesis is that the effect of increased SES on surgical management of LRMs in New York City (NYC) will not be the same for Black and White patients. PATIENTS AND METHODS Patients were identified from the New York State Cancer Registry (NYSPACED) treated for LRMs with PN or radical nephrectomy from 2004 to 2016. We identified patients' home neighborhoods through Public Use Microdata Areas (PUMA) in NYSCAPED and used a US Census SES index. Logistic regression was used to determine the association of race and SES on receipt of PN, controlling for age, ethnicity, gender, and diagnosis year. RESULTS On unadjusted analyses, patients from higher PUMA SES quartiles were more likely to receive PN (OR = 1.07, P < 0.05), while Black patients were less likely to receive PN as compared to White patients (OR = 0.66, P < 0.001). Multivariable analysis showed a significant interaction between race and SES quartile (interaction P = 0.005) such that the effect of PUMA SES on receipt of PN was modified by race. PN receipt for Black vs. White patients was significantly different within the highest SES quartile (OR = 0.44, P < 0.001), but not within the lowest. CONCLUSION In NYC, patients from higher SES quartile neighborhoods had significantly increased odds for receipt of PN for LRMs. As neighborhood SES quartile increased, White patients were significantly more likely to receive PN, while Black patients were not.
Collapse
Affiliation(s)
- Brendan K Wallace
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Caleb H Miles
- Department of Biostatistics, Mailman School of Public Health, Columbia University, NY
| | | |
Collapse
|
23
|
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.
Collapse
|
24
|
Hicks CW, Ding N, Kwak L, Ballew SH, Kalbaugh CA, Folsom AR, Heiss G, Coresh J, Black JH, Selvin E, Matsushita K. Risk of peripheral artery disease according to race and sex: The Atherosclerosis Risk in Communities (ARIC) study. Atherosclerosis 2021; 324:52-57. [PMID: 33823370 PMCID: PMC8096721 DOI: 10.1016/j.atherosclerosis.2021.03.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 03/13/2021] [Accepted: 03/24/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS Previous community-based studies have demonstrated sex and race-based disparities in the risk of cardiovascular disease. We sought to examine the association of sex and race with incident peripheral artery disease (PAD-) and critical limb ischemia (CLI-) related hospitalizations. METHODS In 13,451 Black and White ARIC participants without prevalent PAD at baseline (1987-89), we estimated the cumulative incidence of PAD- and CLI-related hospitalization over a median follow-up of 26 years. We quantified hazard ratios (HRs) using Cox models across four sex- and race-groups. PAD and CLI were defined by hospitalization discharge codes. RESULTS The cumulative incidence of PAD-related hospitalization was higher in males than females in Whites (5.1% vs. 2.7%; p<0.001) but not in Blacks (5.7% vs. 5.0%; p=0.39). The cumulative incidence of CLI-related hospitalization differed significantly by race more than sex, occurring in 3.1% Black males, 3.1% Black females, 1.4% White males, and 0.8% White females (p<0.001). After risk factor adjustment, the risk of incident PAD-related hospitalization was similar for White males vs. White females [HR 1.14, 95%CI 0.90-1.45], and slightly higher for Black males [HR 1.26, 95%CI 0.92-1.72] and Black females [HR 1.39, 95%CI 1.03-1.87] compared to White females. The adjusted risk of incident CLI-related hospitalization was similar for White males vs. White females [HR 1.15, 95%CI 0.75-1.76], and significantly higher for Black males [HR 1.96, 95%CI 1.22-3.16] and Black females [HR 2.06, 95%CI 1.31-3.24] compared to White females. CONCLUSIONS These data suggest that there are both sex- and race-specific patterns of PAD-related hospitalization that lead to differences in clinical disease risk and presentation.
Collapse
Affiliation(s)
- Caitlin W Hicks
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Ning Ding
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Lucia Kwak
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shoshana H Ballew
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Corey A Kalbaugh
- Department of Public Health Sciences, Clemson University, Clemson, SC, USA
| | - Aaron R Folsom
- Division of Epidemiology & Community Health, University of Minnesota, Minneapolis, MN, USA
| | - Gerardo Heiss
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Josef Coresh
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - James H Black
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Elizabeth Selvin
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
25
|
Etherington N, Wu M, Boet S. Sex/gender and additional equity characteristics of providers and patients in perioperative anesthesia trials: a cross-sectional analysis of the literature. Korean J Anesthesiol 2020; 74:6-14. [PMID: 32164399 PMCID: PMC7862933 DOI: 10.4097/kja.19484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/13/2020] [Indexed: 11/10/2022] Open
Abstract
Sex and gender, among other equity-related characteristics, influence the process of care and patients’ outcomes. Currently, the extent to which these characteristics are considered in the anesthesia literature remains unknown. This study assesses their incorporation in randomized controlled trials (RCTs) on anesthesia-related interventions, for both patients and healthcare providers. This is a cross-sectional analysis using an existing dataset derived from the anesthesia literature. The dataset originated from a scoping review searching MEDLINE, Embase, CINAHL, CENTRAL, and the Cochrane Database of Systematic reviews. RCTs investigating the effect of anesthesia-related interventions on mortality for adults undergoing surgery were included. Equity outcome measures were recorded for both patients and providers and assessed for inclusion in the study design, reporting of results, and analysis of intervention effects. Three-hundred sixty-one RCTs (n = 144,674) were included. Most RCTs (91%) reported patient sex/gender, with 58% of patients identified as male. There were 139 studies (39%), where 70% or more of the sample was male, compared to just 14 studies (4%), where 70% or more of the sample was female. Only 10 studies (3%) analyzed results by patient sex/gender, with one reporting a significant effect. There was substantial variation in how age was reported, although nearly all studies (98%) reported some measure of age. For healthcare providers, equity-related information was never available. Better consideration of sex/gender and additional health equity parameters for both patients and providers in RCTs is needed to improve evidence quality, and ultimately, patient care and outcome.
Collapse
Affiliation(s)
- Nicole Etherington
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Wu
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sylvain Boet
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Ottawa, ON, Canada
| |
Collapse
|