Kim Joseph M, Li Siling, Song Yang, Parikh Sahil A, Schneider Peter A, Krishnan Prakash, Yeh Robert W, Secemsky Eric A
Richard A. and Susan F. Smith Center for Outcomes Research; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA.
Richard A. and Susan F. Smith Center for Outcomes Research; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA.
J Vasc Surg. 2025 Jul 28. doi: 10.1016/j.jvs.2025.07.032.
Chronic limb-threatening ischemia (CLTI), the most severe manifestation of peripheral artery disease (PAD), is associated with high risk of major amputation and mortality. While timely revascularization is a cornerstone of CLTI management, disparities in access to care and outcomes persist across US geographic regions. This study aims to evaluate variations in endovascular revascularization for CLTI, healthcare utilization patterns, and outcomes stratified by US regions to inform how we address these disparities.
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 US. 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 healthcare utilization before and after revascularization. Multivariable Cox proportional hazards regression models were used to adjust for demographic, clinical, and procedural characteristics.
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<0.0001) followed by the South (HR 1.11, 95% CI 1.10, 1.13, p<0.0001) and West (HR 1.04, 95% CI 1.02, 1.06, p<0.0001), all compared to the Northeast. Healthcare utilization analyses revealed fewer outpatient visits with a vascular provider before and after revascularization in all regions compared to the Northeast with the lowest rates in the Midwest (before revascularization: adjusted rate ratio [aRR]: 0.73; 95% CI: 0.72, 0.74; p<0.0001; after revascularization: aRR: 0.73; 95% CI: 0.72, 0.74; p<0.0001) CONCLUSIONS: Disparities in access to care and outcomes persist across U.S. regions for Medicare beneficiaries with CLTI and influence healthcare utilization and outcomes. The Midwest region in particular, that care for a high proportion of rural patients, experience the greatest risks of amputation and death related to CLTI, which may in part be due to less frequent healthcare contact following revascularization. Targeted improvements in healthcare access, especially in rural and economically disadvantaged regions, are needed to enhance outcomes in CLTI patients.
慢性肢体威胁性缺血（CLTI）是外周动脉疾病（PAD）最严重的表现形式，与大截肢和死亡的高风险相关。虽然及时血运重建是CLTI治疗的基石，但美国各地区在获得治疗的机会和治疗结果方面仍存在差异。本研究旨在评估美国各地区CLTI血管内血运重建的差异、医疗利用模式以及分层后的治疗结果，以便为我们解决这些差异提供参考。
2016年至2023年期间，纳入所有医疗保险按服务付费受益人中接受CLTI血管内血运重建的患者，并按美国东北部、南部、中西部和西部地区进行评估。随访持续至2023年12月31日，中位随访时间为625天（最长2921天）。主要结局是死亡或大截肢的复合结局。次要结局包括大截肢、全因死亡率、再次血运重建、活动状态变化以及血运重建前后的医疗利用情况。采用多变量Cox比例风险回归模型对人口统计学、临床和手术特征进行调整。
在381,173名受益人中，南部在整个研究期间进行了超过一半的血运重建手术（52.18%），其次是西部（17.3%）、东北部（16.2%）和中西部（13.9%）。调整后，中西部地区主要结局的风险最高（风险比[HR] 1.20，95%置信区间[CI]：1.18，1.22，p<0.0001），其次是南部（HR 1.11，95% CI 1.10，1.13，p<0.0001）和西部（HR 1.04，95% CI 1.02，1.06，p<0.0001），与东北部相比均如此。医疗利用分析显示，与东北部相比，所有地区血运重建前后与血管专科医生的门诊就诊次数均较少，中西部地区的就诊率最低（血运重建前：调整率比[aRR]：0.73；95% CI：0.72，0.74；p<0.0001；血运重建后：aRR：0.73；95% CI：0.72，0.74；p<0.0001）。结论：对于患有CLTI的医疗保险受益人，美国各地区在获得治疗的机会和治疗结果方面存在差异，并影响医疗利用和治疗结果。特别是中西部地区，该地区农村患者比例较高，经历与CLTI相关的截肢和死亡风险最大，这可能部分归因于血运重建后医疗接触频率较低。需要有针对性地改善医疗服务可及性，尤其是在农村和经济弱势地区，以提高CLTI患者的治疗效果。
