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Mubarak E, Cleman J, Romain G, Mena-Hurtado C, Smolderen KG. Addressing Psychosocial Care Needs in Women with Peripheral Artery Disease. Curr Cardiol Rep 2024; 26:1085-1095. [PMID: 39073508 DOI: 10.1007/s11886-024-02106-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2024] [Indexed: 07/30/2024]
Abstract
PURPOSE OF REVIEW Peripheral artery disease (PAD) is a growing global epidemic. Women with PAD are at elevated risk of experiencing psychosocial stressors that influence the diagnosis, management, and course of their illness due to unique sex- and gender-based factors. RECENT FINDINGS We review existing evidence for increased psychosocial risk in women with PAD with a focus on mood disorders, chronic stress, pain experiences, substance use disorders, health behaviors and illness perceptions, and healthcare access. We discuss how these factors exacerbate PAD symptomatology and lead to adverse outcomes. Existing gaps in women's vascular care are reviewed and potential solutions to bridge these gaps through psychosocial care integration are proposed. Current care paradigms for women's vascular care do not adequately screen for and address psychosocial comorbidities. Clinician education, integration of evidence-based psychological care strategies, implementation of workflows for the management of individuals with PAD and mental health comorbidities, reform to reimbursement structures, and further advocacy are needed in this space. This review provides a construct for integrated behavioral health care for women with PAD and advocates for further integration of care.
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Affiliation(s)
- Eman Mubarak
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, 789 Howard Avenue, New Haven, CT, 06519, USA
| | - Jacob Cleman
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, 789 Howard Avenue, New Haven, CT, 06519, USA
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, 789 Howard Avenue, New Haven, CT, 06519, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, 789 Howard Avenue, New Haven, CT, 06519, USA.
| | - Kim G Smolderen
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
- Vascular Medicine Outcomes Program (VAMOS), Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, 789 Howard Avenue, New Haven, CT, 06519, USA
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Chyrek-Tomaszewska A, Popiołek AK, Piskunowicz M, Borkowska A, Budzyński J, Bieliński MK. Examining Psychological Factors in Peripheral Artery Disease: Affective Temperament, Anxiety, and Depression in Patients Undergoing Revascularization Procedures. Psychol Res Behav Manag 2024; 17:2533-2543. [PMID: 38973975 PMCID: PMC11226187 DOI: 10.2147/prbm.s463587] [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: 03/25/2024] [Accepted: 06/03/2024] [Indexed: 07/09/2024] Open
Abstract
Purpose This study aimed to assess the prevalence of depressive and anxiety symptoms in peripheral artery disease (PAD) patients, correlating these symptoms with clinical parameters and examining affective temperaments within the study group. Material and Methods A total of 159 PAD patients, predominantly male, admitted for vascular surgery due to lower limb atherosclerosis, participated in this cross-sectional study. Various assessments were conducted, including the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego-Autoquestionnaire (TEMPS-A) for affective temperaments, the Hospital Anxiety and Depression Scale (HADS) for anxiety and depression symptoms, and the Numerical Rating Scale (NRS) for pain intensity. Additionally, the Ankle-Brachial Index (ABI) was measured to assess circulation in the legs. Results The findings revealed a higher prevalence of depressive and anxiety symptoms in the PAD patient group compared to the control group. Notably, depressive and anxiety symptoms correlated with the severity of PAD, as indicated by lower ABI values in the operated leg. Patients undergoing surgical revascularizations exhibited higher depressive symptoms than those undergoing endovascular procedures. Furthermore, correlations were observed between depressive symptoms and the number of previous vascular procedures and amputations, alongside increased pain levels at admission. Clinical factors such as diabetes, hypertension, heart failure, ischemic heart disease, previous revascularization procedures, amputations, and the intensity of affective temperaments did not correlate with HADS scores. Discussion The study highlighted the intricate relationship between mood disorders and PAD severity, emphasizing the potential prognostic implications of untreated depression and anxiety in PAD patients. These findings suggest the importance of closely monitoring and addressing psychological well-being in PAD management. However, the study encountered limitations such as varying assessment timing and sample size discrepancies among comorbidities, impacting the observation of associations between mood disorders and certain conditions. Conclusion In conclusion, depressive and anxiety symptoms are often in PAD. Further research is needed to explore therapeutic interventions targeting mental health and pain management to improve the course and outcomes of PAD.
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Affiliation(s)
- Aleksandra Chyrek-Tomaszewska
- Department of Clinical Neuropsychology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Rehabilitation and Experimental Cardiology, Władysław Biegański’s Regional Specialist Hospital, Grudziądz, Poland
| | - Alicja Katarzyna Popiołek
- Department of Clinical Neuropsychology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Internal Diseases, Jan Biziel’s University Hospital No. 2, Bydgoszcz, Poland
| | - Małgorzata Piskunowicz
- Department of Clinical Neuropsychology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Alina Borkowska
- Department of Clinical Neuropsychology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Jacek Budzyński
- Department of Vascular and Internal Diseases, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
| | - Maciej Kazimierz Bieliński
- Department of Clinical Neuropsychology, Collegium Medicum of Nicolaus Copernicus University, Bydgoszcz, Poland
- Department of Cardiac Rehabilitation and Experimental Cardiology, Władysław Biegański’s Regional Specialist Hospital, Grudziądz, Poland
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Callegari S, Feher A, Smolderen KG, Mena-Hurtado C, Sinusas AJ. Multi-modality imaging for assessment of the microcirculation in peripheral artery disease: Bench to clinical practice. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 42:100400. [PMID: 38779485 PMCID: PMC11108852 DOI: 10.1016/j.ahjo.2024.100400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/07/2024] [Indexed: 05/25/2024]
Abstract
Peripheral artery disease (PAD) is a highly prevalent disorder with a high risk of mortality and amputation despite the introduction of novel medical and procedural treatments. Microvascular disease (MVD) is common among patients with PAD, and despite the established role as a predictor of amputations and mortality, MVD is not routinely assessed as part of current standard practice. Recent pre-clinical and clinical perfusion and molecular imaging studies have confirmed the important role of MVD in the pathogenesis and outcomes of PAD. The recent advancements in the imaging of the peripheral microcirculation could lead to a better understanding of the pathophysiology of PAD, and result in improved risk stratification, and our evaluation of response to therapies. In this review, we will discuss the current understanding of the anatomy and physiology of peripheral microcirculation, and the role of imaging for assessment of perfusion in PAD, and the latest advancements in molecular imaging. By highlighting the latest advancements in multi-modality imaging of the peripheral microcirculation, we aim to underscore the most promising imaging approaches and highlight potential research opportunities, with the goal of translating these approaches for improved and personalized management of PAD in the future.
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Affiliation(s)
- Santiago Callegari
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
| | - Attila Feher
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
| | - Kim G. Smolderen
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Vascular Medicine Outcomes Program, Yale University, New Haven, CT, USA
| | - Albert J. Sinusas
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, USA
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, CT, USA
- Department of Biomedical Engineering, Yale University, New Haven, CT, USA
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Callegari S, Romain G, Cleman J, Scierka L, Jacque F, Smolderen KG, Mena‐Hurtado C. Long-Term Mortality Predictors Using a Machine-Learning Approach in Patients With Chronic Limb-Threatening Ischemia After Peripheral Vascular Intervention. J Am Heart Assoc 2024; 13:e034477. [PMID: 38761075 PMCID: PMC11179837 DOI: 10.1161/jaha.124.034477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Patients with chronic limb-threatening ischemia (CLTI) face a high long-term mortality risk. Identifying novel mortality predictors and risk profiles would enable individual health care plan design and improved survival. We aimed to leverage a random survival forest machine-learning algorithm to identify long-term all-cause mortality predictors in patients with CLTI undergoing peripheral vascular intervention. METHODS AND RESULTS Patients with CLTI undergoing peripheral vascular intervention from 2017 to 2018 were derived from the Medicare-linked VQI (Vascular Quality Initiative) registry. We constructed a random survival forest to rank 66 preprocedural variables according to their relative importance and mean minimal depth for 3-year all-cause mortality. A random survival forest of 2000 trees was built using a training sample (80% of the cohort). Accuracy was assessed in a testing sample (20%) using continuous ranked probability score, Harrell C-index, and out-of-bag error rate. A total of 10 114 patients were included (mean±SD age, 72.0±11.0 years; 59% men). The 3-year mortality rate was 39.1%, with a median survival of 1.4 years (interquartile range, 0.7-2.0 years). The most predictive variables were chronic kidney disease, age, congestive heart failure, dementia, arrhythmias, requiring assisted care, living at home, and body mass index. A total of 41 variables spanning all domains of the biopsychosocial model were ranked as mortality predictors. The accuracy of the model was excellent (continuous ranked probability score, 0.172; Harrell C-index, 0.70; out-of-bag error rate, 29.7%). CONCLUSIONS Our random survival forest accurately predicts long-term CLTI mortality, which is driven by demographic, functional, behavioral, and medical comorbidities. Broadening frameworks of risk and refining health care plans to include multidimensional risk factors could improve individualized care for CLTI.
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Affiliation(s)
| | - Gaëlle Romain
- Vascular Medicine Outcomes ProgramYale UniversityNew HavenCT
| | - Jacob Cleman
- Vascular Medicine Outcomes ProgramYale UniversityNew HavenCT
| | - Lindsey Scierka
- Vascular Medicine Outcomes ProgramYale UniversityNew HavenCT
| | - Francky Jacque
- Vascular Medicine Outcomes ProgramYale UniversityNew HavenCT
| | - Kim G. Smolderen
- Vascular Medicine Outcomes ProgramYale UniversityNew HavenCT
- Department of PsychiatryYale School of MedicineNew HavenCT
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Amenyedor K, Lee M, Algara M, Siddiqui WT, Hardt M, Romain G, Mena-Hurtado C, Smolderen KG. Impact of comorbid opioid use disorder and major depressive disorder on healthcare utilization outcomes in patients with peripheral artery disease: A National Readmission Database analysis. Vasc Med 2024; 29:163-171. [PMID: 38391134 DOI: 10.1177/1358863x241228540] [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] [Indexed: 02/24/2024]
Abstract
BACKGROUND Prior research has demonstrated that individuals with peripheral artery disease (PAD) often have comorbid opioid use disorder (OUD) and major depressive disorder (MDD), with limited data regarding their impact on readmission outcomes, length of stay, and cost. This study aimed to investigate these healthcare utilization outcomes in patients with PAD who have comorbid OUD and MDD. METHODS Data were obtained from the National Readmission Database from 2011 through 2018. The study population included all hospitalizations with PAD as the primary or secondary diagnosis, from which hospitalizations with OUD and MDD were extracted using appropriate ICD-9/10 diagnosis codes. Primary outcomes were 30-day and 90-day readmission, total cost, and total length of stay within the calendar year. We created hierarchical multivariable logistic regression models examining OUD with and without MDD, with a random effect for healthcare facility location. RESULTS From 2011 to 2018, 13,265,817 weighted admissions with PAD were identified. These admissions were segmented into four categories: No OUD/No MDD (12,056,466), OUD/No MDD (323,762), No OUD/MDD (867,641), and OUD/MDD (17,948). The group with No OUD/No MDD was used as the reference group for all subsequent comparisons. Regarding 30-day and 90-day readmissions, patients with OUD/MDD had odds of 1.14 (95% CI 1.10, 1.18) and 1.09 (95% CI 1.06, 1.13), respectively. Patients with OUD/No MDD bore the highest median cost of $64,354 (IQR $30,797-137,074), and patients with OUD/MDD marked the lengthiest median stay of 6.01 days (IQR 2.01-13.30). CONCLUSION This study found a significant association between these comorbidities and outcomes and therefore calls for targeted interventions and pain management strategies.
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Affiliation(s)
- Kelvin Amenyedor
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Megan Lee
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Miguel Algara
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | | | - Madeleine Hardt
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
| | - Gaëlle Romain
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Carlos Mena-Hurtado
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kim G Smolderen
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Psychiatry, Yale School of Medicine, New Haven, CT, USA
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Smolderen KG, Samaan Z, Decker C, Collins T, Lazar RM, Itoga NK, Mena-Hurtado C. Association Between Mental Health Burden, Clinical Presentation, and Outcomes in Individuals With Symptomatic Peripheral Artery Disease: A Scientific Statement From the American Heart Association. Circulation 2023; 148:1511-1528. [PMID: 37781785 DOI: 10.1161/cir.0000000000001178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/03/2023]
Abstract
Along with the rising burden of peripheral artery disease (PAD), mental health concerns are increasingly being recognized as a comorbidity to address in the chronic disease management of symptomatic PAD. Apart from a high prevalence of comorbid mental health conditions, the role of pain and changing health behaviors and the broader impacts of illness and adaptation to living with PAD require specialized behavioral health expertise. This scientific statement builds a case that this expertise should be integrated within the multidisciplinary PAD team. Furthermore, areas such as cognitive dysfunction and palliative care are highlighted as needing psychological interventions. Although much of the evidence of the efficacy of psychological and psychotropic interventions has been extrapolated from other cardiovascular populations, evidence for the role of psychological interventions for behavior change, for example, uptake of exercise regimens, is increasingly being accrued within PAD. Areas for behavioral health needs and interactions with PAD treatment are discussed, including the use of opioids, depression management, anxiety and stress reduction interventions, the use of benzodiazepines and antidepressants, smoking cessation, rehabilitation trajectories after amputation, and the role of cognitive decline for PAD treatment and outcomes. A case summary highlights the stigma around mental health and vascular disease and the fragmentation of care. This scientific statement provides remarks for building a road map for integrated behavioral PAD care and potential solutions to overcome these barriers. Instrumental to reaching these changes are interprofessional advocacy efforts and initiatives that help break down the stigma around mental health and promote evidence-based collaborative, nonhierarchical, and multidisciplinary PAD care.
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Smolderen KG, Samaan Z, Ward-Zimmerman B, Fucito L, Goodney P, Le V, Abu Daya H, McNeal DM, Bonaca M, Mena-Hurtado C. Integrating Psychosocial Care in the Management of Patients With Vascular Disease. J Am Coll Cardiol 2023; 81:1201-1204. [PMID: 36948738 PMCID: PMC10514776 DOI: 10.1016/j.jacc.2023.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 01/04/2023] [Accepted: 01/19/2023] [Indexed: 03/24/2023]
Affiliation(s)
- Kim G Smolderen
- School of Medicine, Department of Internal Medicine, Cardiovascular Medicine Section, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA; School of Medicine, Department of Psychiatry, Psychology Section, Yale University, New Haven, Connecticut, USA.
| | - Zainab Samaan
- Department of Psychiatry and Behavioral Neurosciences, McMaster University, Hamilton, Ontario, Canada
| | - Barbara Ward-Zimmerman
- CT Psychological Association's Health Care Reform Task Force, North Haven, Connecticut, USA
| | - Lisa Fucito
- School of Medicine, Department of Psychiatry, Psychology Section, Yale University, New Haven, Connecticut, USA
| | - Philip Goodney
- Department of Surgery, The Dartmouth Institute, Dartmouth Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Viet Le
- Department of Cardiovascular Research, Intermountain Healthcare, Intermountain Heart Institute, Murray, Utah, USA
| | - Hussein Abu Daya
- Department of Internal Medicine, Cardiovascular Diseases Division, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Demetria M McNeal
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Marc Bonaca
- Department of Internal Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Carlos Mena-Hurtado
- School of Medicine, Department of Internal Medicine, Cardiovascular Medicine Section, Vascular Medicine Outcomes Program, Yale University, New Haven, Connecticut, USA. https://twitter.com/CarlosMenaYale
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Smolderen KG, Romain G, Provance JB, Scierka LE, Mao J, Goodney PP, Henke PK, Sedrakyan A, Mena-Hurtado C. Guideline-Directed Medical Therapy and Long-Term Mortality and Amputation Outcomes in Patients Undergoing Peripheral Vascular Interventions. JACC Cardiovasc Interv 2023; 16:332-343. [PMID: 36792257 PMCID: PMC10359106 DOI: 10.1016/j.jcin.2022.09.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 08/29/2022] [Accepted: 09/13/2022] [Indexed: 02/15/2023]
Abstract
BACKGROUND Lack of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) may increase mortality and amputation risk. OBJECTIVES The authors sought to study the association between GDMT and mortality/amputation and to examine GDMT variability among providers and health systems. METHODS We performed an observational study using patients in the Vascular Quality Initiative registry undergoing PVI between 2017 and 2018. Two-year all-cause mortality and major amputation data were derived from Medicare claims data. Compliance with GDMT was defined as receiving a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker if hypertensive. Propensity 1:1 matching was applied for GDMT vs no GDMT and survival analyses were performed to compare outcomes between groups. RESULTS Of 15,891 patients undergoing PVIs, 48.8% received GDMT and 6,120 patients in each group were matched. Median follow-up was 9.6 (IQR: 4.5-16.2) months for mortality and 8.4 (IQR: 3.5-15.4) for amputation. Mean age was 72.0 ± 9.9 years. Mortality risk was higher among patients who did not receive GDMT versus those on GDMT (31.2% vs 24.5%; HR: 1.37, 95% CI: 1.25-1.50; P < 0.001), as well as, risk of amputation (16.0% vs 13.2%; HR: 1.20; 95% CI: 1.08-1.35; P < 0.001). GDMT rates across sites and providers ranging from 0% to 100%, with lower performance translating into higher risk. CONCLUSIONS Almost one-half of the patients receiving PVI in this national quality registry were not on GDMT, and this was associated with increased risk of mortality and major amputation. Quality improvement efforts in vascular care should focus on GDMT in patients undergoing PVI.
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Affiliation(s)
- Kim G Smolderen
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Psychology Section, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Gaëlle Romain
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy B Provance
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lindsey E Scierka
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jialin Mao
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Phillip P Goodney
- Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Dartmouth College, Lebanon, New Hampshire, USA
| | - Peter K Henke
- Section of Vascular Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Art Sedrakyan
- Population Health Sciences, Weill Cornell Medicine, Cornell University, New York, New York, USA
| | - Carlos Mena-Hurtado
- Vascular Medicine Outcomes Program, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
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Luna P, Harris K, Castro-Dominguez Y, Algara M, Severiche-Mena C, Smolderen KG, Mena-Hurtado C. Risk profiles, access to care, and outcomes in Hispanics hospitalized for lower extremity peripheral artery disease. J Vasc Surg 2023; 77:216-224.e15. [PMID: 36037965 DOI: 10.1016/j.jvs.2022.08.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 08/17/2022] [Accepted: 08/19/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Previous studies have shown that Hispanics have worse clinical outcomes for lower extremity peripheral artery disease (PAD) than non-Hispanic White (NHWs). Using a national database, this study aimed to document the contemporary burden of PAD in Hispanics by evaluating their risk profiles, access to care, and outcomes compared with NHWs. METHODS Hospitalizations of Hispanics and NHWs with a primary diagnosis of PAD were identified using 2011-2017 National Inpatient Sample data. Patient sociodemographic characteristics, comorbidities, whether the admission was through the emergency department (ED) or elective, length of stay, and costs accrued were compared by ethnicity. Temporal trends in revascularizations, amputations, and ED admissions by year were evaluated with the Cochran-Mantel-Haenszel test and stratified by ethnicity. Data were combined across years and multivariable logistic regression was used to evaluate the association of ethnicity with inpatient revascularization, amputation, and mortality, adjusting for sociodemographic and cardiovascular risk factors. RESULTS From 2011 to 2017, there were a total of 1,018,220 PAD hospitalizations among Hispanics (13.9%) and NHWs (86.1%) between 2011 and 2017. Hispanics were more often low income and uninsured and presented with higher burden of comorbidities including diabetes, renal failure, prior amputations, and chronic limb-threatening ischemia compared with NHWs. Most Hispanics were admitted via the ED compared with NHWs (58.0% vs 36.7%; d = 0.48), and median length of stay was almost a day longer (4.5 days vs 3.7 days). Hispanic ethnicity was associated with lower odds of surgical (odds ratio [OR], 0.62; 95% confidence interval [CI], 0.57-0.67) and endovascular revascularization (OR, 0.94; 95% CI, 0.89-0.996) and mortality (OR, 0.83; 95% CI, 0.75-0.93), but higher odds of minor (OR, 1.25; 95% CI, 1.20-1.31) and major (OR, 1.08; 95% CI, 1.03-1.14) amputation. CONCLUSIONS Two tiers of health care consumption for inpatient PAD care and outcomes manifested among Hispanics and NHWs. First, Hispanics with PAD had a more vulnerable socioeconomic profile and presented with more severe PAD than NHWs. Second, they sought care more disproportionately through the ED and underwent more amputations than NHWs. To eradicate these inequities in PAD care and risk, strategies that improve access to outpatient care and expand health care coverage, as well as targeted management of risk factors in these vulnerable minority groups are needed.
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Affiliation(s)
- Paulina Luna
- Yale University School of Medicine, New Haven, CT; Weill Cornell Medicine, New York, NY
| | | | - Yulanka Castro-Dominguez
- Yale University School of Medicine, New Haven, CT; Case Western Reserve University, Cleveland, OH
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