The Impact of Neighborhood Social Disadvantage on Peripheral Artery Disease Presentation and Management

Abstract

Studies examining the relationship between socioeconomic disparities and peripheral artery disease (PAD) often focus on individual social health determinants and thus fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes. The Area Deprivation Index (ADI), a validated measure of neighborhood adversity, provides a more comprehensive assessment of social disadvantage. Therefore, we examined the impact of ADI on PAD severity and its management. We identified all patients who underwent infrainguinal revascularization (open or endovascular) or amputation for symptomatic PAD in the Vascular Quality Initiative registry between 2003 and 2020. An ADI score of 1 to 100 was assigned to each patient based on their residential zip code, with higher ADI scores corresponding with increasing adversity. Patients were categorized by ADI quintiles (Q1-Q5). Outcomes of interest included indication for procedure (claudication, rest pain, or tissue loss) and rates of revascularization (vs primary amputation). Multinomial logistic regression was used to evaluate for an independent association between ADI quintile and these outcomes. Among the 79,973 patients identified, 9604 (12%) were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were significant trends toward lower rates of intervention for claudication (Q1 39% vs Q5 34%; P < .001), higher rates of intervention for rest pain (Q1 12.4% vs Q5 17.8%; P < .001), and lower rates of revascularization (Q1 80% vs Q5 69%; P < .001) with increasing ADI quintiles (Table I). In adjusted analyses, there was a progressively higher likelihood of presenting with rest pain vs claudication, with patients in Q5 having the highest probability when compared with those in Q1 (risk ratio, 2.0 95%confidence interval [CI], 1.8-2.2; P < .001) (Table II). Patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss vs claudication, (risk ratio, 1.4; 95% confidence interval, 1.3-1.6; P < .001) (Table II). Compared with patients in Q1, patients in Q2 to Q5 had a lower likelihood of undergoing any revascularization procedure (Table II). Among patients who underwent infrainguinal revascularization or amputation in the Vascular Quality Initiative, those with higher neighborhood adversity had more advanced disease at presentation and lower rates of revascularization. Further work is needed to better understand neighborhood factors that are contributing to these disparities to identify community-level targets for improvement.Table IIndication for initial procedure and revascularization rate based on ADI quintilesIndicationQ1 (n = 9604)Q2 (n = 14,961)Q3 (n = 19,800)Q4 (n = 21,735)Q5 (n = 13,873)P valueaClaudication (%)3937373634<.001Rest pain (%)1214161718<.001Tissue loss (%)4848474748.587Revascularization rate (%)8077767269<.001ADI, Area Deprivation Index.aP values refer to statistical significance in a Cochran-Armitage test for trend. Open table in a new tab Table IIRelative risk (RR) of presenting with rest pain or tissue loss versus claudication, and undergoing revascularization procedure versus amputationIndicationADI quintileRR95% confidence intervalP valueRest pain1Ref21.41.241.56<.00131.71.501.86<.00141.91.672.07<.001521.762.21<.001Tissue loss1Ref21.31.21.4<.00131.41.21.5<.00141.41.31.5<.00151.41.31.6<.001Revascularization1Ref20.750.650.86<.00130.750.650.87<.00140.600.520.69<.00150.590.510.70<.001ADI, Area Deprivation index.The RR was calculated using multinomial logistic regression, adjusted for age, race, gender, insurance, smoking status, hypertension, chronic obstructive pulmonary disease, diabetes, insulin dependent diabetes, coronary artery disease, congestive heart failure, dialysis dependence, center and surgeon volume, preoperative aspirin, statin, and p2y12 use. Open table in a new tab