Non-Hispanic Black and Hispanic Patients Have Worse Outcomes Than White Patients Within Similar Stages of Peripheral Artery Disease

Co-Morbidity Differences Associated With Long-Term Amputation and Repeat Revascularization Rates After Femoropopliteal Artery Intervention for Intermittent Claudication by Sex, Race, and Ethnicity

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.

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons

Background

Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD).

Methods

The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias.

Results

There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making.

Conclusions

Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.

Risk score for one-year mortality following emergent infra-inguinal bypass

OBJECTIVE

The purpose of this study is to identify variables that place patients at higher risk for mortality following emergent infra-inguinal bypass. Further, this study will create a risk score for mortality following emergent infra-inguinal bypass to help tailor postoperative and long-term patient management.

METHODS

In the Vascular Quality Initiative, we identified 2126 patients who underwent emergent infra-inguinal artery bypass. Two primary outcomes were investigated: 30 day mortality following emergent infra-inguinal bypass; and 1-year mortality following emergent infra-inguinal bypass. The first step in analysis was univariable analysis for each outcome with χ2 analysis for categorical variables and Student t-test for comparison of means of ordinal variables. Next, binary logistic regression analysis was performed for each outcome utilizing variables that achieved a univariable P value ≤ .10. Factors with a multivariable P value ≤ .05 were included in the risk score, and points were weighted and assigned based on the respective regression beta-coefficient in the multivariable regression.

RESULTS

Variables with a significant multivariable association (P < .05) with 1-year mortality were: increasing age; body mass index less than 20 kg/m2; coronary artery disease; active hemodialysis at time of presentation; anemia at admission; prosthetic conduit for emergent bypass; postoperative myocardial infarction; postoperative acute renal insufficiency; perioperative stroke; baseline non-ambulatory status; new onset hemodialysis requirement perioperatively; need for bypass revision or thrombectomy during index admission; lack of statin prescription at discharge; lack of antiplatelet medication at discharge; and, lack of anticoagulation at time of hospital discharge. Pertinent negatives included all sociodemographic variables including rural living status, insurance status, and Area Deprivation Index home area. The risk score achieved an area under the curve of 0.820, and regression analysis of the risk score achieved an overall accuracy of 87.9% with 97.7% accuracy in predicting survival, indicating the model performs better in determining which patients will survive rather than precisely determining who will experience 1-year mortality.

CONCLUSIONS

Discharge medications are the primary modifiable variable impacting survival after emergent infra-inguinal bypass surgery. In the absence of contraindication, all these patients should be discharged on antiplatelet, statin, and anticoagulant medications after emergent infra-inguinal bypass as they significantly enhance survival. Social determinants of health do not impact survival among patients treated with emergent infra-inguinal bypass at Vascular Quality Initiative centers. A risk score for mortality at 1 year after emergent infra-inguinal bypass has been created that has excellent accuracy.

Risks and Benefits of the Proposed Amputation Reduction and Compassion Act for Disadvantaged Patients

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.

Peripheral Vascular Disease

Peripheral artery disease is most often caused by atherosclerosis. Arterial insufficiency from atherosclerotic blockages in the limbs can impair walking distance and put patients with severe disease at risk of limb loss. Management of the disease centers around early diagnosis, supervised exercise therapy and lifestyle modification, optimizing medical care (with the goal of reducing fatal cardiac and cerebrovascular events), and revascularization.

A Surgical Desirability of Outcome Ranking (DOOR) Reveals Complex Relationships Between Race/Ethnicity, Insurance Type, and Neighborhood Deprivation

OBJECTIVE

Develop an ordinal Desirability of Outcome Ranking (DOOR) for surgical outcomes to examine complex associations of Social Determinants of Health.

BACKGROUND

Studies focused on single or binary composite outcomes may not detect health disparities.

METHODS

Three health care system cohort study using NSQIP (2013-2019) linked with EHR and risk-adjusted for frailty, preoperative acute serious conditions (PASC), case status and operative stress assessing associations of multilevel Social Determinants of Health of race/ethnicity, insurance type (Private 13,957; Medicare 15,198; Medicaid 2835; Uninsured 2963) and Area Deprivation Index (ADI) on DOOR and the binary Textbook Outcomes (TO).

RESULTS

Patients living in highly deprived neighborhoods (ADI>85) had higher odds of PASC [adjusted odds ratio (aOR)=1.13, CI=1.02-1.25, P <0.001] and urgent/emergent cases (aOR=1.23, CI=1.16-1.31, P <0.001). Increased odds of higher/less desirable DOOR scores were associated with patients identifying as Black versus White and on Medicare, Medicaid or Uninsured versus Private insurance. Patients with ADI>85 had lower odds of TO (aOR=0.91, CI=0.85-0.97, P =0.006) until adjusting for insurance. In contrast, patients with ADI>85 had increased odds of higher DOOR (aOR=1.07, CI=1.01-1.14, P <0.021) after adjusting for insurance but similar odds after adjusting for PASC and urgent/emergent cases.

CONCLUSIONS

DOOR revealed complex interactions between race/ethnicity, insurance type and neighborhood deprivation. ADI>85 was associated with higher odds of worse DOOR outcomes while TO failed to capture the effect of ADI. Our results suggest that presentation acuity is a critical determinant of worse outcomes in patients in highly deprived neighborhoods and without insurance. Including risk adjustment for living in deprived neighborhoods and urgent/emergent surgeries could improve the accuracy of quality metrics.

Pathology, Progression, and Emerging Treatments of Peripheral Artery Disease-Related Limb Ischemia

PURPOSE

This narrative review summarizes recent research examining treatment targets for peripheral artery disease (PAD)-related limb ischemia.

METHODS

Targeted searches of the PubMed and clinical trial registry databases were performed to identify recent findings from animal models of limb ischemia and clinical studies examining PAD progression and treatment. Ongoing clinical trials testing new treatments for PAD were also reviewed. Relevant full-text articles were retrieved and critically reviewed. Where indicated, data were tabulated and summarized in the text.

FINDINGS

Most people with PAD need treatment to improve their walking and function and limit leg pain. Currently, the available treatments of cilostazol, exercise therapy, and revascularization have several deficiencies, including limited access, poor uptake, limited efficacy, and risk of complications. Severe PAD threatens limb viability and is treated by endovascular or open surgical revascularization but is not always successful in achieving limb salvage. Research is ongoing to develop and test new therapies, including new exercise programs, drugs, stem cell treatments and RNA therapeutics, so that new and adjunctive PAD treatments can be offered. Results from multiple clinical trials are expected within the next 5 years.

IMPLICATIONS

It is envisaged that a range of new therapies for PAD will be available in the future.

Direct and Indirect Effects of Race and Socioeconomic Deprivation on Outcomes After Lower Extremity Bypass

OBJECTIVE

To evaluate the potential pathway, through which race and socioeconomic status, as measured by the social deprivation index (SDI), affect outcomes after lower extremity bypass chronic limb-threatening ischemia (CLTI), a marker for delayed presentation.

BACKGROUND

Racial and socioeconomic disparities persist in outcomes after lower extremity bypass; however, limited studies have evaluated the role of disease severity as a mediator to potentially explain these outcomes using clinical registry data.

METHODS

We captured patients who underwent lower extremity bypass using a statewide quality registry from 2015 to 2021. We used mediation analysis to assess the direct effects of race and high values of SDI (fifth quintile) on our outcome measures: 30-day major adverse cardiac event defined by new myocardial infarction, transient ischemic attack/stroke, or death, and 30-day and 1-year surgical site infection (SSI), amputation and bypass graft occlusion.

RESULTS

A total of 7077 patients underwent a lower extremity bypass procedure. Black patients had a higher prevalence of CLTI (80.63% vs 66.37%, P < 0.001). In mediation analysis, there were significant indirect effects where Black patients were more likely to present with CLTI, and thus had increased odds of 30-day amputation [odds ratio (OR): 1.11, 95% CI: 1.068-1.153], 1-year amputation (OR: 1.083, 95% CI: 1.045-1.123) and SSI (OR: 1.052, 95% CI: 1.016-1.089). There were significant indirect effects where patients in the fifth quintile for SDI were more likely to present with CLTI and thus had increased odds of 30-day amputation (OR: 1.065, 95% CI: 1.034-1.098) and SSI (OR: 1.026, 95% CI: 1.006-1.046), and 1-year amputation (OR: 1.068, 95% CI: 1.036-1.101) and SSI (OR: 1.026, 95% CI: 1.006-1.046).

CONCLUSIONS

Black patients and socioeconomically disadvantaged patients tended to present with a more advanced disease, CLTI, which in mediation analysis was associated with increased odds of amputation and other complications after lower extremity bypass compared with White patients and those that were not socioeconomically disadvantaged.

Racial Disparities in Treatment Indications and Outcomes for Limb Ischemia

BACKGROUND

Studies suggest that the Affordable Care Act (ACA) of 2014 has improved access to vascular care and vascular outcomes among patients suffering from peripheral arterial disease (PAD). We sought to examine the racial disparities that exist in patients with PAD who have undergone lower extremity bypass (LEB) or a peripheral vascular intervention (PVI) using the Vascular Quality initiative (VQI) database.

METHODS

The VQI infrainguinal and PVI datasets were queried for patients receiving elective and urgent LEB or PVI between 2016, 2 years after ACA implementation, and in 2021. Patients undergoing interventions urgently/emergently or for aneurysm were excluded. The primary outcome was major adverse limb event (MALE-defined as any vascular reintervention or above-ankle amputation) free survival at 1 year. Standard statistical methods were utilized as appropriate.

RESULTS

A total of 17,455 LEB and 87,475 PVIs were included in this analysis. Black persons present at a younger age when compared to non-Hispanic White persons (NHW) and are more likely to have diabetes, hypertension, end-stage renal disease (ESRD), and higher rates of prior amputation. Black persons are more likely to present with chronic limb-threatening ischemia (CLTI) rather than claudication, and in a more urgent setting. Postoperative outcomes show higher rates of major amputations among racial minorities, specifically Black persons for both LEB (1.8% vs. 0.8% P < 0.001) and PVI (20.8% vs. 16.8% P < 0.001). Black persons are at higher risk of 1-year MALE for LEB (36.7% vs. 29.9% P < 0.001) and PVI (31.0% vs. 21.7%; P < 0.001). Even after adjusting for confounding variables, Black persons have a higher risk of 1-year MALE for LEB, with an adjusted hazard ratio (aHR) of 1.15 (95% CI [1.05-1.26], P = 0.003) and PVI (aHR 1.18 95% CI [1.12-1.24], P < 0.001). Other major determinates of 1-year MALE on multivariate Cox regression included CLTI (LEB aHR 1.57 95% CI [1.43-1.72], P < 0.001; PVI aHR 2.29 95% CI [2.20-2.39], P < 0.001) and history of prior amputation (LEB aHR 1.35 95% CI [1.17-1.56], P < 0.001; PVI aHR 1.5 95% CI [1.4-1.6], P < 0.001).

CONCLUSIONS

Compared to NHW persons, Black persons present with more advanced vascular disease regardless of the operative indication. Black persons are also at significantly higher risk of 1-year MALE. Despite some advances in more accessible care through the ACA of 2014, our observations suggest that Black persons still have significantly worse outcomes due to variety of variables that need further investigation.

Racial and Ethnic Disparities in Treatment of Critical Limb Ischemia: A National Perspective

Background Recent guidelines have emphasized the use of medical management, early diagnosis, and a multidisciplinary team to effectively treat patients with critical limb ischemia (CLI). Previous literature briefly highlighted the current racial disparities in its intervention. Herein, we analyze the trend over a 14-year time period to investigate whether the disparities gap in CLI management is closing. Methods and Results The National Inpatient Sample was queried between 2005 and 2018 for hospitalizations involving CLI. Nontraumatic amputations and revascularization were identified. Utilization trends of these procedures were compared between races (White, Black, Hispanic, Asian and Pacific Islander, Native American, and Other). Multivariable regression assessed differences in race regarding procedure usage. There were 6 904 562 admissions involving CLI in the 14-year study period. The rate of admissions in White patients who received any revascularization decreased by 0.23% (P<0.001) and decreased by 0.25% (P=0.025) for Asian and Pacific Islander patients. Among all patients, the annual rate of admission in White patients who received any amputation increased by 0.21% (P<0.001), increased by 0.19% (P=0.001) for Hispanic patients, and increased by 0.19% (P=0.012) for the Other race patients. Admissions involving Black, Hispanic, Asian and Pacific Islander, or Other race patients had higher odds of receiving any revascularization compared with White patients. All races had higher odds of receiving major amputation compared with White patients. Conclusions Our analysis highlights disparities in CLI treatment in our nationally representative sample. Non-White patients are more likely to receive invasive treatments, including major amputations and revascularization for CLI, compared with White patients.

Racial and Ethnic Disparities in Peripheral Vascular Disease Admissions Using a Nationally Representative Sample

Our study aimed to identify clinical outcomes and resource utilization associated with race and ethnicity in patients admitted with peripheral vascular disease (PVD) across the United States. We queried the National Inpatient Sample database from 2015 to 2019 and identified 622,820 patients admitted with PVD. Patients across 3 major race and ethnic categories were compared in terms of baseline characteristics, inpatient outcomes, and resource utilization. Black and Hispanic patients were more likely to be younger and of the lowest median income but incur higher total hospital costs. Black race predicted higher rates of acute kidney injury, need for blood transfusion, and need for vasopressor but lower rates of circulatory shock, and mortality. Black and Hispanic patients were less likely to undergo limb-salvaging procedures and more likely to undergo amputation than White patients. In conclusion, our findings indicate that Black and Hispanic patients experience health disparities in resource utilization and inpatient outcomes for PVD admissions.

The importance of socio-economic determinants of health in the care of patients with peripheral artery disease: A narrative review from VAS

Socio-economic determinants of health (SDoH) include various nonmedical factors in the socio-economic sphere with a potentially significant impact on health outcomes. Their effects manifest through several mediators/moderators (behavioral characteristics, physical environment, psychosocial circumstances, access to care, and biological factors). Various critical covariates (age, gender/sex, race/ethnicity, culture/acculturation, and disability status) also interact. Analyzing the effects of these factors is challenging due to their enormous complexity. Although the significance of SDoH for cardiovascular diseases is well documented, research regarding their impact on peripheral artery disease (PAD) occurrence and care is less well documented. This narrative review explores to what extent SDoH are multifaceted in PAD and how they are associated with its occurrence and care. Additionally, methodological issues that may hamper this effort are addressed. Finally, the most important question, whether this association may contribute to reasonable interventions aimed at SDoH, is analyzed. This endeavor requires attention to the social context, a whole systems approach, multilevel-thinking, and a broader alliance that reaches out to more stakeholders outside the medical sphere. More research is needed to justify the power in this concept to improve PAD-related outcomes like lower extremity amputations. At the present time, some evidence, reasonable consideration, and intuitive reasoning support the implementation of various interventions in SDoH in this field.

Mortality differences by race over 20 years in individuals with peripheral artery disease

INTRODUCTION

Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality.

RESULTS

Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality.

CONCLUSIONS

In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.

Racial Differences in Vascular Assessment Prior to Amputation in the Veterans Health Administration

Purpose

It is unclear whether disparities in the care provided before lower extremity amputation (LEA) is driven by differences in receipt of diagnostic work-up versus revascularization attempts.

Methods

We performed a national cohort study of Veterans who underwent LEA between March 2010 and February 2020 to assess receipt of vascular assessment with arterial imaging and/or revascularization in the year prior to LEA.

Results

Among 19,396 veterans (mean age 66.8 years; 26.6% Black), Black veterans had diagnostic procedures more often than White veterans (47.5% vs. 44.5%) and revascularization as often (25.8% vs. 24.5%).

Conclusion

We must identify patient and facility-level factors associated with LEA as disparities do not appear related to differences in attempted revascularization.

Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease

INTRODUCTION

Prior studies have found considerable disparities in prevalence and outcomes for patients with peripheral arterial disease (PAD). This study compared rates of diagnostic testing, treatment patterns, and outcomes after diagnosis of PAD among commercially insured Black and White patients in the United States.

METHODS

Optum's de-identified Clinformatics® Data Mart Database (1/2016-6/2021) were used to identify Black and White patients with PAD; first PAD diagnosis was deemed study index date. Baseline demographics, markers of disease severity, and healthcare costs were compared between cohorts. Patterns of medical management and rates of major adverse limb events (MALE; including acute or chronic limb ischemia, lower-limb amputation) and cardiovascular (CV) events (stroke, myocardial infarction) during the available follow-up period were described. Outcomes were compared between cohorts using multinomial logistic regression models, Kaplan-Meier survival analysis, and Cox proportional hazards models.

RESULTS

A total of 669,939 patients were identified, with 454,382 White patients and 96,162 Black patients. Black patients were younger on average (71.8 years vs. 74.2 years), but had higher comorbid burden, concomitant risk factors, and CV medication use at baseline. Prevalence of diagnostic testing, revascularization procedures, and medication use was numerically higher among Black patients. Black patients were also more likely than the White patients to receive medical therapy without a revascularization procedure [adjusted odds ratio with 95% confidence interval (CI) = 1.47 (1.44-1.49)]. However, Black patients with PAD had higher incidence of MALE and CV events than White patients [adjusted hazard ratio for composite event (95% CI) = 1.13, (1.11-1.15)]. Except myocardial infarction, the hazards of individual components of MALE and CV events were also significantly higher among Black patients with PAD.

CONCLUSIONS

Results of this real-world study suggest that Black patients with PAD have higher disease severity at the time of diagnosis and are at increased risk of experiencing adverse outcomes following diagnosis.

The association of racial and ethnic disparities and frailty in geriatric patients undergoing revascularization for peripheral artery disease

Frailty is defined as a state of decreased physiologic reserve contributing to functional decline and adverse outcomes. Racial disparities in frail patients have been described sparsely in the literature. We aimed to assess whether race influences frailty status in geriatric patients undergoing revascularization for peripheral artery disease (PAD) with chronic limb-threatening ischemia (CLTI). A 5-year analysis of the National Surgical Quality Improvement Program database included all geriatric (65 years and older) patients who underwent revascularization for lower extremity PAD with CLTI. The frailty index was calculated using a 11-variable modified frailty index and a cutoff of 0.27 indicated frail status. The primary outcome was an association of race or ethnicity with frailty status. We included 7,837 geriatric patients who underwent a surgical procedure (open: 55.2%) for PAD with CLTI. Mean age of patients was 75.4 years, 63.8% were male, 24.1% (n = 1,889) were frail, and 21.8% (n = 1,710) were African American (AA). Overall complication rate was 11.2% (n = 909) and overall mortality rate was 1.9% (n = 148). AA patients were more likely to be frail than White patients (29.6% v 23.9%; P = .03). AA and Hispanic patients were more likely to have complications (P = .03 and P = .001) and require readmission (P = .015 and P = .001) compared with White and non-Hispanic patients, respectively. Frail AA and frail Hispanic patients were more likely to have 30-day complications and readmission compared with frail White and frail non-Hispanic patients, respectively. Race and ethnicity influence frailty status in geriatric patients with PAD and CLTI. These disparities exist regardless of age, sex, comorbid conditions, and type of operative procedure. Additional studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors to improve outcomes.

The outcomes of lower extremity revascularization: What role do race, ethnicity, and socioeconomic status play?

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.

Racial and ethnic disparities in major adverse limb events persist for chronic limb threatening ischemia despite presenting limb threat severity after peripheral vascular intervention

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.

A systematic review of racial/ethnic disparities in pharmacotherapy and surgical treatment outcomes in peripheral arterial disease among African American/non-Hispanic Black, non-Hispanic White and Hispanic patients

Background

Lower extremity peripheral arterial disease (PAD) is associated with significant morbidity and mortality in racial/ethnic diverse populations. However, limited data exist on treatment outcome disparities in racial/ethnic diverse populations, particularly in AA/NHB populations.

Objective

The aim of this systematic review is to analyze disparities in the outcomes of PAD treatments, particularly pharmacotherapy and surgery, among racial/ethnic groups in the US.

Methods

A comprehensive search of original investigations pertaining to PAD treatments between 2015 and 2021 was performed. Quality assessment of the studies was also completed.

Results

Fourteen studies were included. Thirteen studies reported differences in treatment outcomes for surgical intervention, and one study reported differences for concurrent surgical and pharmacotherapy. NHB and Hispanic/Latinx ethnicities were associated with decreased overall and perioperative mortality in four studies. Six studies noted increased amputation risk among racial/ethnic diverse populations. Only one study noted significant survival benefit by race/ethnicity. Three studies noted increased risk of major adverse limb events and post-operative complications. One study noted increased limb patency after intervention in racial/ethnic cohorts. Overall, all studies reported high methodological quality with adequate assessment of outcomes and follow-up of cohort.

Conclusion

In this analysis, the predominant intervention reported is surgical. Overall, racial/ethnic populations are less likely to experience PAD-associated mortality but are more likely to experience adverse events. Further studies are necessary to include all racial/ethnic diverse populations in assessing PAD therapeutic intervention outcomes. Moreover, targeted public health efforts are necessary to increase PAD educational awareness, community-driven risk modification, and patient-centered care planning.

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

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