Geographic variation in endovascular revascularization for chronic limb-threatening ischemia care among Medicare beneficiaries (2016-2023).
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| Titel: | Geographic variation in endovascular revascularization for chronic limb-threatening ischemia care among Medicare beneficiaries (2016-2023). |
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| Autoren: | Kim JM; Richard 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., Li S; Richard 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., Song Y; Richard 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., Parikh SA; Center for Interventional Cardiovascular Care and Division of Cardiology, Columbia University Irving Medical Center, New York, NY., Schneider PA; Division of Vascular and Endovascular Surgery, University of California San Francisco Medical Center, San Francisco, CA., Krishnan P; Zena and Michael A. Weiner Cardiovascular Institute, Mount Sinai Fuster Heart Hospital, New York, NY., Yeh RW; Richard 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., Secemsky EA; Richard 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. Electronic address: esecemsk@bidmc.harvard.edu. |
| Quelle: | Journal of vascular surgery [J Vasc Surg] 2025 Dec; Vol. 82 (6), pp. 2102-2111.e18. Date of Electronic Publication: 2025 Jul 28. |
| Publikationsart: | Journal Article |
| Sprache: | English |
| Info zur Zeitschrift: | Publisher: Elsevier Country of Publication: United States NLM ID: 8407742 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1097-6809 (Electronic) Linking ISSN: 07415214 NLM ISO Abbreviation: J Vasc Surg Subsets: MEDLINE |
| Imprint Name(s): | Publication: <2008-> : New York, NY : Elsevier Original Publication: St. Louis, Mo. : Mosby, [c1984- |
| MeSH-Schlagworte: | Endovascular Procedures*/trends , Endovascular Procedures*/adverse effects , Endovascular Procedures*/mortality , Medicare*/trends , Healthcare Disparities*/trends , Peripheral Arterial Disease*/mortality , Peripheral Arterial Disease*/therapy , Peripheral Arterial Disease*/surgery , Ischemia*/mortality , Ischemia*/surgery , Ischemia*/therapy , Chronic Limb-Threatening Ischemia*/mortality , Chronic Limb-Threatening Ischemia*/surgery , Chronic Limb-Threatening Ischemia*/therapy , Practice Patterns, Physicians'*/trends, Humans ; United States/epidemiology ; Male ; Female ; Aged ; Amputation, Surgical/trends ; Aged, 80 and over ; Treatment Outcome ; Time Factors ; Retrospective Studies ; Risk Factors ; Risk Assessment ; Limb Salvage/trends ; Fee-for-Service Plans/trends ; Chronic Disease |
| Abstract: | Competing Interests: Disclosures J.M.K. reports research funding from National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) (T32HL160522). S.A.P. reports consulting fees from Abbott, Medtronic, Philips, BD, and Gore. P.A.S. reports consulting fees from Surmodics, Medtronic, Boston Scientific, Philips, Cagent, Acotec, Abbott, Endologix, Shockwave, Silk Road, Healthcare Inroads, Inari, and BD. P.K. reports research funding from Abbot, Boston Scientific, Medinol, Penumbra, Veryan, Concept Medical, Shockwave Medical, AVS, Acotec, Cagent, Akura Medical, and Philips; consulting fees from Inari, Terumo, Penumbra, and Abiomed; is on the advisory board of Abbott, Boston Scientific, Medtronic, Cordis, and Philips; and holds equity in Encompass Vascular, Advanced Nanotherapies, and eFemoral. R.W.Y. reports research funding from Boston Scientific, Abbott, and Medtronic; consulting fees from CMS, Boston Scientific, Abbott, Medtronic, Edwards, CathWorks, Magenta Medical, and Shockwave; is a special government employee at the U.S. Food and Drug Administration. E.A.S. reports research funding from NIH/NHLBI (K23HL150290), Food and Drug Administration, SCAI, Abbott/CSI, BD, Boston Scientific, Cook, Medtronic, and Philips; and consulting fees from Abbott/CSI, BD, BMS, Boston Scientific, Cagent, Conavi, Cook, Cordis, Endovascular Engineering, Gore, InfraRedx, Medtronic, Philips, RapidAI, Rampart, Shockwave, Terumo, Thrombolex, VentureMed, and Zoll. The remaining authors report no conflicts. 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. (Copyright © 2025 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.) |
| References: | Health Serv Res. 2006 Feb;41(1):79-102. (PMID: 16430602) Circulation. 2017 Mar 21;135(12):e686-e725. (PMID: 27840332) J Vasc Surg. 2011 Aug;54(2):420-6, 426.e1. (PMID: 21571495) Eur J Vasc Endovasc Surg. 2019 Jul;58(1S):S1-S109.e33. (PMID: 31182334) Front Cardiovasc Med. 2021 May 24;8:692236. (PMID: 34109228) Clin Interv Aging. 2015 Jul 10;10:1147-53. (PMID: 26203234) Circ Cardiovasc Interv. 2024 Jan;17(1):e012798. (PMID: 38152880) J Am Podiatr Med Assoc. 1997 Jul;87(7):305-12. (PMID: 9241972) Semin Vasc Surg. 2021 Mar;34(1):38-46. (PMID: 33757634) J Am Heart Assoc. 2017 May 3;6(5):. (PMID: 28468784) Circulation. 2024 Jun 11;149(24):e1313-e1410. (PMID: 38743805) J Am Coll Cardiol. 2024 Jul 16;84(3):315-316. (PMID: 38986673) Public Health. 2015 Jun;129(6):611-20. (PMID: 26025176) J Vasc Surg. 2023 Apr;77(4):1155-1164.e2. (PMID: 36563711) JAMA Surg. 2025 Feb 26;:. (PMID: 40009363) J Vasc Surg. 2016 Feb;63(2 Suppl):3S-21S. (PMID: 26804367) J Vasc Surg. 2014 Mar;59(3):737-41. (PMID: 24246532) Circ Cardiovasc Qual Outcomes. 2025 Jan;18(1):e010931. (PMID: 39749477) Circulation. 2025 Jan 7;151(1):123-124. (PMID: 39723979) Eur Heart J Qual Care Clin Outcomes. 2022 May 5;8(3):298-306. (PMID: 33351089) |
| Grant Information: | K23 HL150290 United States HL NHLBI NIH HHS; T32 HL160522 United States HL NHLBI NIH HHS |
| Contributed Indexing: | Keywords: Chronic limb-threatening ischemia; Geographic differences; Peripheral artery disease |
| Entry Date(s): | Date Created: 20250730 Date Completed: 20251119 Latest Revision: 20251123 |
| Update Code: | 20251123 |
| PubMed Central ID: | PMC12320350 |
| DOI: | 10.1016/j.jvs.2025.07.032 |
| PMID: | 40738231 |
| Datenbank: | MEDLINE |
Nájsť tento článok vo Web of Science | Abstract: | Competing Interests: Disclosures J.M.K. reports research funding from National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute (NHLBI) (T32HL160522). S.A.P. reports consulting fees from Abbott, Medtronic, Philips, BD, and Gore. P.A.S. reports consulting fees from Surmodics, Medtronic, Boston Scientific, Philips, Cagent, Acotec, Abbott, Endologix, Shockwave, Silk Road, Healthcare Inroads, Inari, and BD. P.K. reports research funding from Abbot, Boston Scientific, Medinol, Penumbra, Veryan, Concept Medical, Shockwave Medical, AVS, Acotec, Cagent, Akura Medical, and Philips; consulting fees from Inari, Terumo, Penumbra, and Abiomed; is on the advisory board of Abbott, Boston Scientific, Medtronic, Cordis, and Philips; and holds equity in Encompass Vascular, Advanced Nanotherapies, and eFemoral. R.W.Y. reports research funding from Boston Scientific, Abbott, and Medtronic; consulting fees from CMS, Boston Scientific, Abbott, Medtronic, Edwards, CathWorks, Magenta Medical, and Shockwave; is a special government employee at the U.S. Food and Drug Administration. E.A.S. reports research funding from NIH/NHLBI (K23HL150290), Food and Drug Administration, SCAI, Abbott/CSI, BD, Boston Scientific, Cook, Medtronic, and Philips; and consulting fees from Abbott/CSI, BD, BMS, Boston Scientific, Cagent, Conavi, Cook, Cordis, Endovascular Engineering, Gore, InfraRedx, Medtronic, Philips, RapidAI, Rampart, Shockwave, Terumo, Thrombolex, VentureMed, and Zoll. The remaining authors report no conflicts.<br />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.<br />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.<br />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).<br />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.<br /> (Copyright © 2025 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.) |
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| ISSN: | 1097-6809 |
| DOI: | 10.1016/j.jvs.2025.07.032 |