Geographic variation in endovascular revascularization for chronic limb-threatening ischemia care among Medicare
Joseph M Kim1, Siling Li1, Yang Song1
1Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
Insights
Regional disparities in chronic limb-threatening ischemia (CLTI) care persist. The Midwest faces the highest risks for amputation and death, linked to lower healthcare utilization, especially for rural patients.
Area of Science:
- Vascular Surgery
- Health Services Research
- Public Health
Background:
- Chronic limb-threatening ischemia (CLTI) is a severe peripheral artery disease complication with high amputation and mortality rates.
- Existing disparities in CLTI care access and outcomes exist across U.S. geographic regions.
- Understanding regional variations is crucial for addressing these healthcare inequities.
Purpose of the Study:
- To evaluate geographic variations in endovascular revascularization for CLTI among Medicare beneficiaries.
- To analyze differences in healthcare utilization patterns across U.S. regions.
- To identify regional disparities in CLTI outcomes and inform targeted interventions.
Main Methods:
- Analysis of Medicare fee-for-service beneficiaries undergoing endovascular revascularization for CLTI from 2016-2023.
- Stratification of data by U.S. geographic regions (Northeast, South, Midwest, West).
- Primary outcome: composite of death or major amputation; secondary outcomes included amputation, mortality, repeat procedures, and healthcare utilization. Multivariable Cox regression was used for adjustment.
Main Results:
- The South performed the most revascularizations (52.18%), followed by the West, Northeast, and Midwest.
- The Midwest region exhibited the highest adjusted risk for the primary outcome (death or major amputation) (HR: 1.20).
- Lower healthcare utilization, including fewer outpatient vascular provider visits, was observed in the Midwest and other regions compared to the Northeast.
Conclusions:
- Significant regional disparities in CLTI care and outcomes persist for Medicare beneficiaries.
- The Midwest region, with a high proportion of rural patients, faces the greatest risks, potentially due to reduced healthcare contact.
- Targeted improvements in healthcare access, particularly in rural and underserved areas, are essential to improve CLTI patient outcomes.
Objective:
Chronic limb-threatening ischemia (CLTI), the most severe manifestation of peripheral artery disease, is associated with high risk of major amputation and mortality. Although timely revascularization is a cornerstone of CLTI management, disparities in access to care and outcomes persist across U.S. geographic regions. This study aims to evaluate variations in endovascular revascularization for CLTI, health care utilization patterns, and outcomes stratified by U.S. regions to inform how we address these disparities.
Methods:
From 2016 through 2023, all endovascular revascularizations for CLTI among Medicare fee-for-service beneficiaries were included and evaluated by Northeast, South, Midwest, and West regions of the United States. Follow-up continued through December 31, 2023, with a median duration of 625 days (maximum 2921 days). The primary outcome was a composite of death or major amputation. Secondary outcomes included major amputation, all-cause mortality, repeat revascularization, change in ambulatory status, and health care utilization before and after revascularization. Multivariable Cox proportional hazards regression models were used to adjust for demographic, clinical, and procedural characteristics.
Results:
Among 381,173 beneficiaries, the South performed more than half of all revascularizations throughout the study period (52.18%), followed by the West (17.3%), Northeast (16.2%), and the Midwest (13.9%). After adjustment, the Midwest showed the highest risk for the primary outcome (hazard ratio [HR]: 1.20; 95% confidence interval [CI]: 1.18, 1.22; P < .0001), followed by the South (HR: 1.11; 95% CI: 1.10, 1.13; P < .0001) and West (HR: 1.04; 95% CI: 1.02, 1.06; P < .0001), all compared with the Northeast. Health care utilization analyses revealed fewer outpatient visits with a vascular provider before and after revascularization in all regions compared with the Northeast with the lowest rates in the Midwest (before revascularization: adjusted rate ratio: 0.73; 95% CI: 0.72, 0.74; P < .0001; after revascularization: adjusted rate ratio: 0.73; 95% CI: 0.72, 0.74; P < .0001).
Conclusions:
Disparities in access to care and outcomes persist across U.S. regions for Medicare beneficiaries with CLTI and influence health care utilization and outcomes. The Midwest region, in particular, that cares for a high proportion of rural patients experiences the greatest risks of amputation and death related to CLTI, which may in part be due to less frequent health care contact after revascularization. Targeted improvements in health care access, especially in rural and economically disadvantaged regions, are needed to enhance outcomes in patients with CLTI.
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