Racial disparities in the outcomes of superficial vein treatments for chronic venous insufficiency

Disparities in access to endovenous treatment options in chronic lower extremity superficial venous insufficiency: A national 7-year analysis

OBJECTIVE

The goal of this study was to analyze trends in treatment access for chronic superficial venous disease and to identify disparities in care.

METHODS

This retrospective study was exempt from institutional review board approval. The American College of Surgeon National Surgical Quality Improvement Program database was used to identify patients who underwent vein stripping (VS) and endovenous procedures for treatment of chronic superficial venous disease. Endovenous options included radiofrequency ablation (RFA) and laser ablation. Data was available from 2011 to 2018 and demographic information was extracted for each patient identified by Current Procedural Terminology codes. For all racial and ethnic groups, trend lines were plotted, and the relative rate of change was determined within each specified demographic.

RESULTS

There were 21,025 patients included in the analysis. The overall mean age was 54.2 years, and the majority of patients were female (64.8%). In total, 27.9%, 55.2%, and 16.9% patients underwent VS, RFA, and laser ablation, respectively. Patients who received laser ablation were older (P < .001). Hispanic ethnicity was associated with significantly lower odds of receiving endovascular thermal ablation (EVTA) over VS (odds ratio [OR], 0.71; 95% confidence interval [CI], 0.64-0.78; P < .001). American Indian/Alaska Native patients were more likely to receive EVTA over VS (OR, 4.02; 95% CI, 2.48-6.86); similarly, Native Hawaiian/Pacific Islander patients were more likely to receive EVTA over VS, although this difference was not statistically significant (OR, 1.44; 95% CI, 0.93-2.27). On multinomial regression, Hispanic patients were less likely to receive RFA over VS, whereas American Indian/Alaskan Native patients were more likely to receive RFA over VS. In all racial and ethnic groups, the percentage of endovenous procedures increased, whereas vein stripping decreased.

CONCLUSIONS

Based on a hospital-based dataset, demographic indicators, including age, sex, race, and ethnicity, are associated with differences in endovenous treatments for chronic superficial venous insufficiency suggesting disparities in obtaining minimally invasive treatment options among certain patient groups.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

A Review of Healthcare Disparities Relevant to Interventional Radiology

Racial, ethnic, and gender disparities have received focused attention recently, as they became more visible in the COVID era. We continue to learn more about how healthcare disparities manifest for our patients and, more broadly, the structural underpinnings that result in predictable outcomes gaps. This review summarizes what we know about disparities relevant to interventional radiologists. The prevalence and magnitude of disparities are quantified and discussed where relevant. Specific examples are provided to demonstrate how factors like gender, ethnicity, social status, geography, etc. interact to create inequities in the delivery of interventional radiology (IR) care. Understanding and addressing health disparities in IR is crucial for improving real-world patient outcomes and reducing the economic burden associated with ineffective and low-value care. Finally, the importance of intentional mentorship, outreach, education, and equitable distribution of high-quality healthcare to mitigate these disparities and promote health equity in interventional radiology is discussed.

Race, sex, and socioeconomic disparities affect the clinical stage of patients presenting for treatment of superficial venous disease

OBJECTIVE

Superficial venous disease has a U.S. prevalence of nearly 30%, with advanced disease contributing to a significant healthcare burden. Although the risk factors for venous disease are well known, the correlation between race, sex, socioeconomic status, and disease severity on presentation is not well established. The area deprivation index (ADI) is a validated metric with respect to regional geography, social determinants of health, and degree of socioeconomic disadvantage. In the present study, we aimed to identify the disparities and the effect that the ADI, in addition to race and sex, has among patients associated with an advanced venous disease presentation.

METHODS

A retrospective review between 2012 and 2022 was performed at four tertiary U.S. institutions to identify patients who underwent endovenous closure of their saphenous veins. Patient demographics, state ADI, comorbidities, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, and periprocedural outcomes were included. Pearson's correlation was performed between the CEAP classification and ADI. Poisson regression analysis was performed to identify factors predicting for an increasing CEAP classification at presentation. Variables with P < .05 were deemed significant.

RESULTS

A total of 2346 patients underwent endovenous saphenous vein closure during the study period, of whom 7 were excluded because of a lack of follow-up data. The mean age was 60.4 ± 14.9 years, 65.9% were women, and 55.4% were White. Of the 2339 patients, 73.3% presented with an advanced CEAP class (≥3). The mean state ADI for the entire cohort was 4.9 ± 3.1. The percent change in the CEAP classification is an increase of 2% and 1% for every level increase in the state ADI for unadjusted (incidence rate ratio [IRR] = 1.02; P < .001) and adjusted (IRR = 1.01; P < .001) models, respectively. Black race has a 12% increased risk of a higher CEAP class on presentation compared with White race (IRR = 1.12; P = .005). Female sex had a 16% lower risk of a higher CEAP presentation compared with male sex (IRR = 0.84; P < .01).

CONCLUSIONS

Low socioeconomic status, Black race, and male sex are predictive of an advanced CEAP classification on initial presentation. These findings highlight the opportunity for improved mechanisms for identification of venous disease and at-risk patients before advanced disease progression in known disadvantaged patient populations.

Black or African American patients undergo great saphenous vein ablation procedures for advanced venous disease and have the least improvement in their symptoms after these procedures

OBJECTIVE

Chronic venous insufficiency is an increasingly prevalent problem in the United States, with >25 million individuals currently affected. Previous work has shown that racial minorities and low socioeconomic status are associated with a worse clinical presentation and response to treatment. The present study aimed to determine the relationship between race, patient variables, hospital outcomes, and response to treatment for patients presenting for chronic venous insufficiency intervention.

METHODS

We performed a retrospective analysis of all patients who underwent endovenous ablation (radiofrequency or laser) of the great saphenous vein to treat symptomatic, chronic venous insufficiency using Vascular Quality Initiative data from 2014 to 2020. Patient characteristics and outcomes were analyzed stratified by patient race. The χ2 test and the Kruskal-Wallis equality-of-populations rank test were used to measure the study outcomes. The primary outcomes were an improved venous clinical severity score and improvement in patient-reported outcomes. Patient characteristics, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, prior venous interventions, length of stay, and time to follow-up were compared between races.

RESULTS

The database consisted of 9009 predominantly female patients (n = 6041; 67.1%), with a mean age distribution of 56 years. Of the 9009 patients, 7892 are White (87.6%), 627 Hispanic (6.9%), and 490 Black or African American (18.3%). The Hispanic cohort was younger than their White and Black/African American counterparts. Black/African American patients presented with more advanced clinical stages than did the White and Hispanic groups. The clinical stage according to race was as follows: C3-Black/African American, 32.9%; Hispanic, 38.9%; White, 46%; C5-Black/African American, 4.7%; Hispanic, 2.1%; White, 2.3%; and C6-Black/African American, 12.7%; Hispanic, 3.2%; White, 6.2%. Black/African American patients were more likely to present as overweight or obese (66%; P < .001) and less likely to be taking anticoagulation medication preoperatively (11%; P < .001). Non-White race was associated with a higher probability of treatment in the hospital setting (Black/African American, 63.6%; Hispanic, 87.5%; P < .001). Black/African American patients (3.25 ± 4.4; P < .001) demonstrated lower mean improvement postoperatively in both the venous clinical severity score and patient-reported outcomes than their White (4.25 ± 4.13, P <.001) and Hispanic (4.42 ± 3.78; P < .001) counterparts.

CONCLUSIONS

Differences exist in the clinical severity and symptom presentation based on race. Black/African American patients present with more advanced chronic venous insufficiency than do their White and Hispanic counterparts. Furthermore, the postprocedural analysis showed inferior clinical and self-reported improvement in chronic venous insufficiency for the Black/African American patients. Although the Hispanic population was younger, the White and Hispanic patients experienced similar responses to treatment.

A review of the current literature of ethnic, gender, and socioeconomic disparities in venous disease

Venous disease is prevalent, undertreated, and frequently unrecognized. During the past two decades, new treatment modalities have changed how venous disease is approached. Some of these treatment modalities are only available in certain centers or locations and access to care could be inequitable. Although venous disease affects millions in the United States, we have little understanding of the gender, socioeconomic, and ethnic disparities in both superficial and deep venous disease presentation. In an effort to better understand the treatment of male and female patients from different gender, ethnic, and socioeconomic backgrounds, literature searches were conducted to investigate how these patients were evaluated and treated. PubMed was used to search literature using the terms "venous insufficiency," "superficial venous disease," "venous thromboembolism," "deep vein thrombosis," "DVT," "May-Thurner," and "pulmonary embolism," with gender, sex, racial, and socioeconomic disparities and differences within the keywords. In addition, once articles were discovered, the "similar articles" function was used to expand the search. The included studies were restricted to those reported from 1995 to the present. Given the paucity of data, no study was excluded. It is readily apparent that there is not enough data to make decisions that would modify treatment to affect the outcomes of patients with differing backgrounds and gender. Studies currently are limited to evaluating patients by sex assigned at birth without interrogation of their identified gender. It is imperative that consideration is given to evaluating gender and ethnic differences, because treatment options might need to be tailored accordingly. Outreach and education for underserved patient populations with improvement in access to care must also be incorporated into the healthcare system. Additional work in this area is required. Further data collection and research related to demographic disparities among patients with venous disease is necessary to better understand the differences that could change treatment algorithms tailored to specific groups.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Heart Disease and Stroke Statistics-2022 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2022 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population and an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, and the global burden of cardiovascular disease and healthy life expectancy.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Pregnancy Conditions and Complications Associated with the Development of Varicose Veins

BACKGROUND

Pregnancy is a known risk factor for developing varicose veins (VV). However, pregnancy is often considered a homogeneous entity and few studies have examined if specific characteristics and complications of pregnancy may influence VV formation. This study sought to identify which pregnancy-specific factors are associated with the development of VV.

METHODS

All women who gave birth (live or still) between 1998-2020 within a multicenter healthcare system were retrospectively identified and followed through all hospital encounters (inpatient and outpatient). The primary outcome was VV, defined as any encounter with a primary diagnosis code for VV or procedure for VV. The study period for each woman was the time from the first to last encounter. Extended Cox regression modeling evaluated the association between VV and pregnancy-related factors as a time-varying covariates while controlling for patient comorbidities.

RESULTS

There were 156,622 women with a median follow-up of 8.3 years (IQR: 2.7-16.6 years) included. During this time, 225,758 deliveries occurred. The 10- and 20-year freedom from VV was 97.0% (95%CI: 96.8-97.1%) and 92.7% (95%CI: 92.4-93.0%), respectively, from the estimated start of first pregnancy. Overall, 4,028 (2.57%) developed VV during the follow-up period and 1,594 (1.02%) underwent a procedure for VV. After risk adjustment, increasing parity was significantly associated with VV, with each subsequent pregnancy increasing hazard of developing VV (parity=1: HR 1.78; 95%CI: 1.55-1.99; p<0.001; parity≥6: HR 4.83; 95%CI: 2.15-1.99-10.9; p<0.001), Other significant pregnancy factors included excessive weight gain in pregnancy (HR 1.44; 95%CI: 1.09-1.91; p=0.011), post-term pregnancy (HR 1.12; 95%CI: 1.02-1.21; p=0.021), preeclampsia (HR 0.79; 95%CI: 0.70-0.90; p<0.001), and postpartum transfusion of platelets, plasma, or cryoprecipitate (HR 2.05; 95%CI: 1.19-3.53; p=0.001).

CONCLUSION

Increasing parity, excessive weight gain in pregnancy, post-term pregnancy, and preeclampsia affect the development of VV after pregnancy. Though varicose veins after pregnancy are likely underreported and true incidence is unknown, women should be counseled about the impact of these factors on VV development after pregnancy.

Extended Center for Vein Restoration study assessing comparative outcomes for the treatment of chronic venous insufficiency in Medicare- and non-Medicare-eligible patients

BACKGROUND

We previously reported that chronic venous insufficiency treatment of Medicare-eligible patients achieved outcomes similar to those for non-Medicare-eligible patients. The goal of the present investigation was to assess the long-term treatment outcomes and the effect of race in a larger patient cohort.

METHODS

From January 2015 to December 2019, we retrospectively reviewed the data from 131,268 patients who had presented for a lower extremity venous evaluation. We divided the patients into two groups by age: group A was aged ≥65 years and group B, <65 years. The treatments analyzed in each group were axial thermal ablation (TA), axial Varithena ablation (VA), TA plus phlebectomy, VA plus phlebectomy, and TA or VA with phlebectomy and ultrasound-guided foam sclerotherapy (UGFS). The treatment outcomes were assessed using the revised venous clinical severity score (rVCSS) and Chronic Venous Insufficiency Quality of Life 20-item questionnaire (CIVIQ-20) scores at the initial consultation and 1, 6, and 12 months after completion of the treatment plan.

RESULTS

Of the 131,268 patients, 40,020 were in group A and 91,248 in group B, with an average age of 74.4 ± 6.6 and 49.9 ± 10.6 years, respectively. Of the 40,020 patients in group A, 15,697 (n = 25,234 limbs) had undergone TA and 1910 (n = 3222 limbs) had undergone VA. Of the 91,248 patients in group B, 35,220 (n = 53,717 limbs) had undergone TA and 2178 (n = 3672 limbs) had undergone VA. For the TA subgroups, all rVCSSs had significantly improved after treatment at each evaluation point (P ≤ .001). For the TA and VA plus phlebectomy with or without UGFS subgroup, the older patients (group A) required 6 months to develop the same degree of improvement as the younger patients (group B) at 1 month. When subdivided by race, all initial and 6-month rVCSSs and CIVIQ-20 scores within a race had improved and were better in group B, except for Asian and Hispanic patients (P ≤ .001). After TA or VA plus phlebectomy, with or without UGFS, the CIVIQ-20 outcomes had improved by 1 month in both groups, although the rVCSS lagged by 6 months in group A. No differences in the rVCSSs or CIVIQ-20 scores were observed between the groups treated with TA or VA.

CONCLUSIONS

Medicare-eligible beneficiaries demonstrated improved outcomes similar to those of non-Medicare-eligible beneficiaries after ablation. When TA or VA plus phlebectomy with or without UGFS were examined, group A required 6 months to demonstrate rVCSSs equivalent to those of group B at 1 month. The CIVIQ-20 scores had improved by 1 month in both groups, regardless of the treatment modality. The difference in rVCSSs appeared to be driven by African American and white patients because Hispanic and Asian patients demonstrated equivalent results regardless of age. Patients treated with TA or VA demonstrated equivalent results.

Defining the human and health care costs of chronic venous insufficiency

Chronic venous insufficiency (CVI) affects more than 25 million adults in the United States alone, and more 6 million with advanced stages of venous disease. The high incidence of CVI and the increasing costs of care, place a heavy financial burden on the US health care system. Recent studies estimate the total cost of care at more than $3 billion per year. These staggering numbers highlight the importance of timely diagnosis, treatment, and prevention of CVI. In this article, we review the epidemiology and prevalence of CVI, and its financial impact on national health care budget. Racial disparities in CVI and the impact of socioeconomic status on access to care are also discussed. Finally, we discuss CVI-related screening programs and the importance of preventative measures in venous disease.

Evaluating patient preferences for thermal ablation versus nonthermal, nontumescent varicose vein treatments

OBJECTIVE

To measure patient preferences for attributes associated with thermal ablation and nonthermal, nontumescent varicose vein treatments.

METHODS

Data were collected from an electronic patient preference survey taken by 70 adult participants (aged 20 years or older) at three Center for Vein Restoration clinics in New Jersey from July 19, 2019, through August 13, 2019. Survey participation was voluntary and anonymous (participation rate of 80.5% [70/87]). Patients were shown 10 consecutive screens that displayed three hypothetical treatment scenarios with different combinations of six attributes of interest and a none option. Choice-based conjoint analysis estimated the relative importance of different aspects of care, trade-offs between these aspects, and total satisfaction that respondents derived from different healthcare procedures. Market simulation analysis compared clusters of attributes mimicking thermal ablation and nonthermal, nontumescent treatments.

RESULTS

Of the six attributes studied, out-of-pocket (OOP) expenditures were the most important to patients (37.2%), followed by postoperative discomfort (17.1%), risk of adverse events (16.3%), time to return to normal activity (11.0%), number of injections (10.0%), and number of visits (8.4%). Patients were willing to pay the most to avoid postoperative discomfort ($68.9) and risk of adverse events ($65.8). The market simulation analysis found that, regardless of the level of OOP spending, 60% to 80% of respondents favored attribute combinations corresponding with nonthermal, nontumescent procedures over thermal ablation, and that less than 1% of participants would forgo either treatment under no cost sharing.

CONCLUSIONS

Patients are highly sensitive to OOP costs for minimally invasive varicose vein treatments. Market simulation analysis favored nonthermal, nontumescent procedures over thermal ablation.

Effect of obesity on chronic venous insufficiency treatment outcomes

BACKGROUND

Obesity is a known risk factor for the development and progression of chronic venous disorders (CVDs). It is currently unknown whether the treatment outcomes, after an intervention for CVDs, are affected by obesity. The purpose of the present investigation was to assess the effectiveness of various CVD treatments in obese patients and determine what level of obesity is associated with poor outcomes.

METHODS

Data were prospectively collected in the Center for Vein Restoration electronic medical record system (NexGen Healthcare Information System, Irvine, Calif) and retrospectively analyzed. The patients and limbs were categorized by the following body mass index (BMI) categories: <25, 26 to 30, 31 to 35, 36 to 40, 41 to 45, and >46 kg/m². The changes in the revised venous clinical severity score and Chronic Venous Insufficiency Quality of Life Questionnaire 20-item (CIVIQ-20) quality of life survey were used to determine the CVD treatment effectiveness for patients who had undergone endovenous thermal ablation (TA), phlebectomy, or ultrasound-guided foam sclerotherapy (USGFS).

RESULTS

From January 2015 to December 2017, 65,329 patients (77% female; 23% male) had undergone a venous procedure. Of these patients, 25,592 (39,919 limbs) had undergone ablation alone, ablation with phlebectomy, or ablation with phlebectomy and USGFS. The number of procedures performed was as follows: TA, n = 37,781; USGFS, n = 22,964; and phlebectomy, n = 17,467. The degree of improvement at 6 months after the procedure was progressively less with an increasing BMI for the patients who had undergone TA, and the decrease was more significant for those patients with a BMI >35 kg/m² (P ≤ .001). The outcomes improved ∼12% with the addition of phlebectomy to TA. The patients who had undergone a combination of TA, phlebectomy, and USGFS demonstrated no additional improvement. Significantly inferior outcomes were noted in patients with a BMI ≥35 kg/m², with the poorest outcomes observed in patients with a BMI ≥46 kg/m² (P ≤ .001). The average number of TAs per patient increased with an increasing BMI and was significantly different compared with the number for those with a BMI <30 kg/m² (P ≤ .001). All pre- and post-CIVIQ-20 quality of life scores, within a BMI category, at 6 months were significantly different (P ≤ .01). No differences in the degree of improvement were observed in patients with a BMI ≥31 kg/m². Finally, multivariate logistic regression analysis indicated that when controlling for BMI, diabetes, a history of cancer, female gender, and black and Hispanic race were independently associated with poorer outcomes.

CONCLUSIONS

Progressive increases in BMI negatively affected CVD-related treatment outcomes as measured using the revised venous clinical severity score and CIVIQ-20. The outcomes progressively worsened with a BMI >35 kg/m² for patients undergoing CVD treatment. The treatment outcomes for patients with a BMI ≥46 kg/m² were so poor that weight loss management should be considered before offering CVD treatment.