Racial Disparities in Treatment Indications and Outcomes for Limb Ischemia

Abstract

Studies suggest that the Affordable Care Act of 2014 has improved access to vascular care and vascular outcomes among patients suffering from peripheral arterial disease. We sought to examine the racial disparities that exist in patients with peripheral arterial disease who have undergone lower extremity bypass (LEB) or a peripheral vascular intervention (PVI) using the Vascular Quality Initiative database. The Vascular Quality Initiative infrainguinal and PVI datasets were queried for patients receiving elective and urgent LEB or PVI between 2016 and 2021. Patients undergoing interventions emergently or for aneurysm were excluded. The primary outcome was major adverse limb event (MALE; defined as any vascular reintervention or above ankle amputation) and MALE-free survival at 1 year. Standard statistical methods were used as appropriate. A total of 19,490 LEB and 90,532 PVIs were included in this analysis. Black patients present at a younger age when compared with non-Hispanic Whites and are more likely to have diabetes, hypertension, end-stage renal disease, and higher rates of prior amputation (Table). Black patients are more likely to present with chronic limb-threatening ischemia rather than claudication, and in an urgent setting (FigureF). Postoperative outcomes were similar except for higher rates of amputations among Black patients for both LEB (14.2% vs 9.4%; P < .001) and PVI (23.1% vs 20.6%; P < .001). Black patients are at higher risk of 1-year MALE for LEB (15.4% vs 13%; P < 0.001) and PVI (16.8% vs 12.3%; P < 0.001). Even after adjusting for confounding variables and accounting for interactions with indications, Black patients had a higher risk of 1-year MALE for LEB with a hazard ratio (HR) 1.33 (95% confidence interval [CI], 1.13-1.43; P < 0.001) and PVI (HR, 1.18; 95% CI, 1.05-1.32; P = .004). Other major determinates of 1-year MALE on multivariate Cox regression included chronic limb-threatening ischemia (LEB HR, 1.28; 95% CI, 1.13-1.43; P < .001 and PVI HR, 1.79; 95% CI,1.69-1.91; P < .001) and presenting in an urgent setting (LEB HR, 1.12; 95% CI, 1.01-1.23; P = .019 and PVI HR, 1.1; 95% CI, 1.03-1.15; P = .001). Compared with non-Hispanic Whites, Black patients present with more advanced vascular disease and in an urgent setting regardless of the operative indication. Black patients are also at significantly higher risk of 1-year MALE. Despite many advances in more accessible care through Affordable Care Act of 2014, our observations suggest that Black patients still have significantly worse outcomes owing to significant prevailing barriers to vascular care in this patient population.TableBasic demographics of lower extremity bypass (LEB) and peripheral vascular intervention (PVI) by raceFactorLEBPVINHWBlackHispanicOthers/unknownP valueNHWBlackHispanicOthers/unknownP value13055 (67.0%)3013 (15.5%)875 (4.5%)2547 (13.1%)66,911 (73.9%)14,577 (16.1%)5284 (5.8%)3760 (4.1%)Gender Male9196 (70.4%)1857 (61.6%)537 (61.4%)513 (69.8%)<.00141,502 (62.0%)7650 (52.5%)3022 (57.2%)2428 (64.6%)<.001 Female3859 (29.6%)1156 (38.4%)338 (38.6%)222 (30.2%)25,409 (38.0%)6927 (47.5%)2262 (42.8%)1332 (35.4%)Age, mean (SD)67.4 (10.4)64.7 (10.3)66.5 (10.9)66.9 (11.3)<.00169.2 (10.8)66.2 (11.3)67.8 (11.8)68.9 (11.2)<.001BMI in kg/m2, mean (SD)27.6 (5.9)27.2 (6.3)27.6 (5.5)26.7 (5.5)<.00128.1 (6.5)28.2 (6.9)27.9 (6.1)26.9 (7.9)<.001Hypertension11,508 (88.5%)2788 (93.3%)796 (91.5%)645 (88.2%)<.00158,287 (87.8%)13,453 (92.8%)4784 (91.3%)3266 (87.3%)<.001Diabetes6454 (49.5%)1728 (57.4%)662 (75.8%)457 (62.3%)<.00134,257 (51.2%)9394 (64.5%)4102 (77.7%)2433 (64.8%)<.001End-stage renal disease601 (4.6%)411 (13.6%)95 (10.9%)71 (9.7%)<.0014391 (6.6%)2947 (20.2%)993 (18.8%)631 (16.8%)<.001Coronary artery disease4356 (33.4%)834 (27.7%)272 (31.2%)242 (33.0%)<.00124,519 (36.7%)4475 (30.7%)1787 (33.8%)1314 (35.0%)<.001Congestive heart failure2419 (18.5%)628 (20.9%)181 (20.7%)121 (16.5%).00413,419 (20.1%)3722 (25.6%)1096 (20.8%)713 (19.0%)<.001Chronic obstructive pulmonary disease4105 (31.5%)652 (21.7%)154 (17.6%)177 (24.1%)<.00119,649 (29.4%)3105 (21.3%)857 (16.2%)711 (18.9%)<.001Prior leg artery bypass, endarterectomy, PVI10,446 (80.1%)2248 (74.6%)702 (80.2%)505 (19.8%).00934,489 (51.6%)7520 (51.6%)2753 (52.1%)1640 (43.7%)<.001Prior amputation587 (4.5%)233 (7.7%)65 (7.4%)32 (1.2%)<.00110,189 (15.2%)3618 (24.8%)1490 (28.2%)715 (19.0%)<.001Indications Claudication3433 (27.1%)521 (17.8%)146 (17.1%)159 (22.6%)<.00131,095 (48.0%)4945 (35.0%)1638 (31.9%)1414 (38.8%)<.001 Chronic limb-threatening ischemia9244 (72.9%)2399 (82.2%)708 (82.9%)543 (77.4%)33,652 (52.0%)9172 (65.0%)3499 (68.1%)2226 (61.2%)Smoking status Never1509 (11.6%)526 (17.5%)259 (29.6%)196 (26.7%)<.00112,342 (18.5%)3911 (26.9%)2088 (39.5%)1310 (34.9%)<.001 Prior6260 (48.0%)1188 (39.5%)396 (45.3%)267 (36.4%)32,062 (48.0%)5813 (39.9%)2124 (40.2%)1465 (39.0%) Current5276 (40.4%)1295 (43.0%)219 (25.1%)270 (36.8%)22,457 (33.6%)4838 (33.2%)1069 (20.2%)978 (26.1%)Admission status Elective11,010 (84.5%)2486 (82.7%)679 (77.7%)532 (72.5%)<.00159,103 (88.4%)12,493 (85.8%)4355 (82.5%)3191 (84.9%)<.001 Urgent2026 (15.5%)521 (17.3%)195 (22.3%)202 (27.5%)7757 (11.6%)2062 (14.2%)921 (17.5%)569 (15.1%)Aspirin9851 (75.6%)2209 (73.4%)657 (75.3%)496 (67.6%)<.00149,368 (73.8%)10,509 (72.1%)3741 (70.8%)2604 (69.3%)<.001Antiplatelets4659 (35.7%)1123 (37.3%)377 (43.2%)206 (28.1%)<.00130,070 (45.0%)6613 (45.4%)2518 (47.7%)1446 (38.5%)<.001Statins10,242 (78.6%)2366 (78.6%)719 (82.4%)583 (79.4%).06350,882 (76.1%)11,059 (75.9%)4099 (77.6%)2860 (76.1%)0.071Anticoagulation3033 (23.3%)551 (18.3%)154 (17.6%)139 (18.9%)<.00113,413 (20.1%)2339 (16.1%)879 (16.6%)623 (16.6%)<.001ACE inhibitors/ARBs6953 (53.3%)1526 (50.7%)506 (58.0%)404 (55.0%)<0.00135,751 (53.4%)7523 (51.6%)2881 (54.6%)1942 (51.7%)<.001Volume of surgeries per center Low3057 (23.4%)798 (26.5%)294 (33.6%)165 (22.4%)<.00116,341 (24.4%)3293 (22.6%)1528 (28.9%)1329 (35.3%)<.001 Medium6600 (50.6%)1683 (55.9%)393 (44.9%)344 (46.8%)33,668 (50.3%)7473 (51.3%)3003 (56.8%)1949 (51.8%) High3398 (26.0%)532 (17.7%)188 (21.5%)226 (30.7%)16,902 (25.3%)3811 (26.1%)753 (14.3%)482 (12.8%)ACE, Angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker; BMI, body mass index; NHW, non-Hispanic Whites; PVI, peripheral vascular intervention; SD, standard deviation. 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