Income-based differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. Guideline-recommended therapy and specialized outpatient care are essential for optimal treatment. Income-based inequalities in diagnosis and treatment of cardiovascular diseases are present, while differences for PAD are scarse. Knowledge of the treatment structures in the outpatient setting are essential to identify and solve income-based inequalities in this high-risk population.

Purpose

Aim of the study was to identify income-based inequalities in outpatient treatment care and pharmacotherapy in PAD patients.

Methods

We analyzed income-based differences in PAD prevalence, pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, cardiology) in all statutorily insured patients with PAD presenting to outpatient care facilities in Germany between 2009 and 2018. The study is based on ambulatory claims data of the panel doctors' services according to §295 SGB V and drug prescription data according to §300 SGB V. Diagnosis of PAD was defined upon medical diagnoses of PAD ICD I70.2-9. Statistical analysis was performed with chi-squared test for trend and two-way Anova.

Results

Overall, 17,633,970 patients were included in the study. Prevalence of PAD was higher in low-income states. This income-driven gap widened between 2009 (2.3% vs 1.7%) and 2018 (4.4% vs 2.8%). Angiology outpatient care density was higher in low-income states, whereas vascular surgery and cardiology outpatient care density was higher in high-income states (p<0.05). While overall specialised outpatient care was underutilized, patients in low-income states were more likely to present to angiologists, while patients in high-income states more frequently presented to vascular surgeons. Patients with more progressed PAD stages were less likely to present to a specialist and to receive guideline recommended medical therapy, irrespective of the income-structure.

Pharmacotherapy also showed income-based differences. While overall prescription rates of statins and antiplatelet drugs were low, patients in low-income states had higher prescription rates than patients in high-income states. The income-driven gap decreased between 2009 and 2016 (statins: 2009 60% vs 48%; 2016 68% vs 65%; antiplatelets: 2009 50% vs 39%; 2016 53% vs 51%).

Conclusion

Our results demonstrate that income-based differences in pharmacotherapy and specialized outpatient care of PAD patients are evident in Germany. While overall outpatient treatment by vascular specialists and guideline recommended medical therapy with antiplatelets and statins are low, German low-income states have higher PAD prevalence, a higher angiology than vascular surgery density and higher prescription rates of guideline recommended pharmacotherapy.

Funding Acknowledgement

Type of funding sources: None.

Regional differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral arterial disease (PAD) is one of the most common diseases worldwide and affected patients have an increased risk for cardiovascular events. The main goals of PAD treatment include modification of risk factors and prevention of cardiovascular events by means of guideline-recommended and specialized ambulatory care. Knowledge on treatment regimens and outpatient care structures in different German states is essential to improve the overall quality of medical care as well as patient outcome.

Aim

The aim of this study was to analyze the care of PAD patients with emphasis on pharmacotherapy and outpatient treatment patterns with special focus on regional differences in Germany.

Methods

This study included data of 17.633.970 patients collected in Germany between 2009 and 2018. This data was provided by analyzing all statutory health insured patients with PAD in Germany. Ambulatory care structure included treatments by vascular surgeons, angiologists, cardiologist, internal medicine physician and primary care physicians. Furthermore, prescription of guideline-recommended pharmacotherapy (statins and antiplatelets) was analyzed for the period of 2012–2016. For our analysis we used chi-squared test and two-way Anova.

Results

Nationwide, prescription frequency of statins increased from 40% in 2009 to 50% (p<0,0001) in 2016. Similar results were seen in the prescription frequency of antiplatelet agents, which increased from 26% in 2009 to 30% (p<0,0001) in 2016. In fact, prescription frequency of both statins and antiplatelet drugs remained insufficient in every federal state (p>0,05), despite wide access to general practitioners. Nevertheless, there is a significant difference between rural and urban regions (Bavaria 46% vs. North Rhine-Westphalia 44%, p<0,05). However, in every federal state, treatment by the vascular specialist is low. In 2018 only 10% of patients were treated by vascular surgeons and 9% by angiologists.

Conclusion

Our study shows that, for PAD patients, outpatient care as well as prescription frequency of guideline-based therapy is insufficient in every federal German state. According to our data, there is a need to establish regional structures for PAD patients that can improve current care and ultimately reduce mortality in this high-risk population.

Funding Acknowledgement

Type of funding sources: None.

Gender-based differences in outpatient care of peripheral artery diseases in Germany

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. Guideline-recommended therapy and specialized outpatient care are essential for optimal treatment. Gender-based inequalities in diagnosis and treatment of cardiovascular diseases are still present, despite clear guideline recommendations. Knowledge of the treatment structures in the outpatient setting are essential to identify and solve gender-based inequalities in this high-risk population.

Purpose

Aim of the study was to identify gender-based inequalities in an outpatient clinic setting in terms of treatment structures and pharmacotherapy in patients with PAD.

Methods

We analyzed gender-based differences in pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, internal medicine, cardiology) in 17.633.970 patients with PAD and statutorily insurance presenting to outpatient care facilities in Germany between 2009 and 2018. The study is based on the ambulatory claims data of the panel doctors' services according to § 295 SGB V and drug prescription data according to § 300 SGB V. Diagnosis of PAD was defined upon medical diagnoses of PAD ICD I70.2–9. Statistical analysis was performed with chi-squared test for trend and two-way Anova.

Results

Overall, 17.633.970 patients were included in the study and 53% were female. Only a minority of 37,1% presented to a vascular specialist (8,5% angiology, 10,2% vascular surgery, 24,6% cardiology) with no significant change over the course between 2009 and 2018. Interestingly, female patients were less likely to present to a vascular specialist and less likely to receive guideline recommended medical therapy.

The gender gap between male and female patients presenting to a vascular specialist, however, narrowed in the observed time frame (angiology in 2009 1,8% vs 2018 1,0%, p<0,0001; vascular surgery 2009 3,2% vs 2018 1,5%, p<0,0001).

Pharmacotherapy also significantly differed between female and male patients over the course of time. While prescription rates of statins and antiplatelet drugs increased in the observed time period (statins 42,8% vs 55,7% (male), 35,1% vs 45% (female); antiplatelets 29,2% vs 34,4% (male), 20,2 vs 24,3% (female)), the gender gap also increased between 2009 and 2018 (7,7% vs 10,7%, p<0,0001 (statins); 8,9% vs 10%, p<0,0001 (antiplatelets)).

Conclusion

Our results demonstrate that gender-based differences in pharmacotherapy and specialized outpatient care of patients with PAD are still evident in Germany. While overall outpatient treatment by a vascular specialist and guideline recommended medical therapy of PAD with antiplatelets and statins are overall remarkably low, female patients are even less likely to receive both, compared to male patients. While adherence to guideline recommended therapy is increasing, the gender-gap still continues to widen over the course of time.

Funding Acknowledgement

Type of funding sources: None.

Endovascular treatment of peripheral artery disease is associated with improved central hemodynamics and ventricular function

Background

Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. PAD itself is associated with increased arterial stiffness with impact on cardiac functions. Previous studies have demonstrated that augmentation index (AIx) and central blood pressure (CBP) correlate with increased cardiovascular mortality. This mechanism has been described as arterio-ventricular (AV) coupling with altered ventricular afterload and a depressed ventricular function, measured by global longitudinal strain (GLS). The impact of PAD-related endovascular treatment on arterial stiffness, central hemodynamics and potential impact on AV coupling has not been elucidated until now.

Purpose

Aim of the study was to investigate, if endovascular treatment of PAD improves cardiac function via enhanced central hemodynamics and AV coupling.

Methods

To this aim 77 patients with known symptomatic PAD who underwent interventions in the iliac and femoropopliteal arteries were included in a cross-sectional study. AIx, CBP and GLS were determined using dedicated waveform analysis and echocardiography before and after endovascular treatment.

Results

Mean age was 65.1±10.4 years with 66.2% male patients. Symptoms were classified by Fontaine classification (stage IIb 80.7%, stage III 5.8% and stage IV 13.5%). Iliac vessel intervention was performed in 16 and femoropopliteal intervention in 61 cases. A stentless approach was feasible in 55 patients with DCB treatment and atherectomy.

After endovascular treatment, peripheral perfusion was enhanced (ABI 0.45±0.6 vs 0.81±0.5, p<0.0001). Moreover, central hemodynamics were improved (AIX 33.7±3% vs 27.9±2%, p=0.0008; AP 17.8±2 mmHg vs 14.0±2 mmHg, p=0.0004; central PP 52.4±6 mmHg vs 46.4±6 mmHg, p=0.0001). Impressively, left ventricular function was also significantly improved (GLS −15.7±2.3% vs −17.1±2.8%, p=0.005) with an improvement in AV coupling (PWV/GLS ratio −0.58m/sec% vs −0.56m/sec%, p<0.01).

Conclusion

Our results demonstrate that endovascular treatment of the peripheral vessels is associated with an improvement of central hemodynamics and left ventricular function via enhanced AV coupling. These prognostic relevant markers of cardiovascular disease could point to an overall potential mortality benefit through PAD treatment. Further investigation of the underlying mechanisms of AV coupling in the setting of endovascular treatment of PAD with impact on cardiovascular mortality is needed in this high-risk population.

Funding Acknowledgement

Type of funding source: None