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Published on: September 22, 2020
Persistent Racial Disparities in Chronic Limb-Threatening Ischemia Outcomes and Utilization Among US Medicare
Lorenzo V Arvanitis1, Joseph M Kim2, Siling Li3
1Harvard Medical School, Boston, MA; Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA.
Insights
Black patients with chronic limb-threatening ischemia (CLTI) face higher amputation risks and less vascular care despite national efforts. This study highlights persistent racial disparities in CLTI treatment outcomes.
Area of Science:
- Vascular Surgery
- Health Disparities Research
- Health Services Research
Background:
- Chronic limb-threatening ischemia (CLTI) disproportionately impacts racial minorities, with Black patients experiencing worse outcomes and limited vascular care access.
- National campaigns targeting peripheral arterial disease (PAD) screening have not demonstrably improved CLTI outcomes for Black patients.
- Existing disparities in CLTI care necessitate an examination of temporal trends in treatment and outcomes.
Purpose of the Study:
- To evaluate temporal trends in endovascular revascularization treatments, patient outcomes, and healthcare utilization for Black versus White Medicare beneficiaries with CLTI.
- To identify disparities in care and outcomes between racial groups undergoing treatment for CLTI.
- To inform the development of targeted interventions to address racial inequities in CLTI management.
Main Methods:
- Retrospective cohort study utilizing Medicare claims data from January 2016 to December 2023.
- Inclusion criteria: Medicare beneficiaries aged ≥66 years undergoing endovascular revascularization for CLTI.
- Primary outcome: Composite of major amputation or death within 4 years; secondary outcomes: healthcare utilization metrics (vascular visits, ED use, hospital admissions).
Main Results:
- The cohort comprised 303,906 patients, with 17.2% identifying as Black; Black patients presented with more comorbidities and gangrene.
- Black patients had a higher risk of major amputation (HR 1.49) and lower mortality (HR 0.91) but received angioplasty more often than stents.
- Black patients had fewer pre- and post-revascularization vascular visits but higher rates of ED visits and hospital readmissions.
Conclusions:
- Despite national initiatives, significant racial disparities persist for Black patients with CLTI, including higher amputation rates.
- Black patients experience reduced access to consistent, longitudinal vascular care following revascularization.
- Sustained, equity-focused interventions are crucial to mitigate disparities and improve outcomes for Black patients with CLTI.
Background:
Chronic limb-threatening ischemia (CLTI) disproportionately affects racial minority populations, with Black patients experiencing higher amputation rates and reduced access to vascular care. Recent national campaigns have aimed to improve early screening and diagnosis of peripheral arterial disease (PAD), but it is unclear whether these efforts have improved outcomes.
Objectives:
To assess temporal trends in treatment, outcomes, and healthcare utilization for Black versus White Medicare beneficiaries with CLTI undergoing endovascular revascularization.
Methods:
We conducted a retrospective cohort study using Medicare claims data for beneficiaries aged ≥66 years who underwent endovascular revascularization for CLTI from January 2016 to December 2023. The primary outcome was a composite of major amputation or death over 4 years, evaluated using Cox models. Healthcare utilization was assessed via adjusted rate ratios (aRRs) for vascular provider visits, emergency department use, and hospital admissions.
Results:
Among 303,906 patients, 17.2% (N = 52,376) identified as Black. Black patients were younger, had more comorbidities, and more often presented with gangrene. They more frequently underwent angioplasty alone and less frequently received stents. Over a median 1.7 years of follow-up, Black patients had higher risk of major amputation (HR 1.49; 95% CI, 1.45-1.53) and lower mortality (HR 0.91; 95% CI, 0.90-0.93). They had fewer vascular visits before (aRR 0.91) and after (aRR 0.92) revascularization, but more ED visits (aRR 1.09) and hospital readmissions (aRR 1.28).
Conclusions:
Despite national initiatives, Black patients with CLTI continue to face higher amputation risk and reduced access to longitudinal vascular care, underscoring the need for sustained, equity-focused interventions.
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