Racial Disparities in Treatment Indications and Outcomes for Limb Ischemia

Abstract

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. The VQI infrainguinal and PVI datasets were queried for patients receiving elective and urgent LEB or PVI between 2016, 2years 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 1year. Standard statistical methods were utilized as appropriate. 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). 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.