A recent study published in Circulation concerning patients with chronic limb-threatening ischemia (CLTI) in the USA, has found that patients of low-income status and those who attended “safety-net” hospitals—facilities that treat patients regardless of insurance status or ability to pay—were more likely to receive low-intensity vascular care, which was associated with decreased long-term event-free survival.
As a precursor to their findings, lead investigator Eric A Secemsky (Beth Israel Deaconess Medical Centre, Boston, USA) et al detailed that inequities related to gender, race, ethnicity and socioeconomic factors, and subsequent risk of amputation in patients with CLTI, is “well documented”. However, the authors state that prior to their investigation little was known about how intensity of treatment drives clinical outcomes.
Using data from Medicare inpatient and outpatient hospital claims made between 2016–2019, beneficiaries over the age of 65 who were diagnosed with CLTI and underwent a major lower-limb amputation were identified. Patients were required to have at least one year of Medicare enrolment before major amputation to allow for the ascertainment of intensity of vascular care, and two years enrolment following the procedure to ensure adequate follow-up.
Secemsky and colleagues identified a total of 33,036 Medicare beneficiary major amputations, 7,885 (23.9%) of these which met inclusion criteria and were included in the study. Within this figure, they stated that 4,988 (68%) patients received low-intensity and 2,897 (36.7%) received high-intensity vascular care. The mean age of this cohort was 76.6 years of age, included 38.9% women, 24.5% Black patients, and 35.2% of reported low-income.
After multivariable adjustment, those of low income (odds ratio (OR)=0.65; 95% CI, 0.58–0.72]; P<0.001), male (OR=0.89, 95% CI, 0.81–0.98; P=0.019), and those who received care at a safety-net hospital (OR=0.87, 95% CI, 0.78–0.97; P=0.012) were most likely to receive low intensity of care before amputation. Conversely, the investigators highlight that high-intensity care was associated with a lower risk of all-cause mortality two years following amputation.
The authors emphasise that vascular care has “significantly improved” over the last 25 years and has gained a “better understanding of pathophysiology, greater pharmacological treatment options, and refinement of endovascular techniques”, which has caused the rate of major lower extremity amputations to “plateau”. However, Secemsky et al hazard caution at “[celebrating]” progress made before reflecting on the inequitable distribution of scientific advancements to all demographic communities.
“Disparities related to gender, race, ethnicity, and socioeconomic factors continue to affect chronically marginalised populations. Prior analyses have shown that low income and racial/ethnic minority adults are significantly more likely to undergo major lower extremity amputation. Our findings provide insights that may inform clinical, health system, and public health strategies to ensure more uniform and equitable delivery of vascular care in the USA.”
Regarding actions that are being taken to address these issues, the investigators highlight a recent update to the American Heart Association’s policy statement of guidelines to include a goal of reducing nontraumatic lower extremity amputations by 20% by 2030.
Secemsky and colleagues convey that this update advocates for “heightened awareness, improved clinician education, early detection, and systematic use of evidence-based therapies for peripheral arterial disease [PAD]”. The investigators concluded by stating that as efforts to raise public awareness of PAD and its risks continue, addressing “persistent” disparities in vascular care will be an “important extension” of this work.
