Disparities in healthcare access and treatment outcomes for patients with chronic limb-threatening ischemia.

BACKGROUND: Chronic limb-threatening ischemia (CLTI) is clinically identified by the presence of a severe form of peripheral arterial disease that significantly affects the patient's quality of life. Despite improvements in medical and surgical interventions, social disparities in health care access remain a major determinant in clinical outcomes. This study uniquely examines disparities in revascularization, limb loss, and cardiovascular outcomes across multiple racial groups using a large national inpatient database.

HYPOTHESIS: We aim to explore the association between social determinants of health and hospital outcomes in CLTI among different socioeconomic groups.

METHODS: We queried the National Inpatient Sample (NIS) database from 2016 to 2021. ICD-10 codes were used to identify and compare interventions, including surgical bypass, endovascular interventions, and non-traumatic amputation, across socioeconomic groups. Major adverse limb events (MALE) and major adverse cardiovascular and cerebrovascular events (MACCE) were compared during the period of hospitalization. Multivariate regression adjusted for hypertension, diabetes, and hyperlipidemia. The trends of utilizing revascularization and amputation were examined over the six years.

RESULTS: The study reveals a rising prevalence of CLTI over the 6-year period. Surgical bypass and amputation rates have declined, while endovascular repair is increasingly utilized. There were 405,370 admissions; Caucasians comprised 63%, Blacks 21.9%, Hispanics 12.4%, and Asians 1.9%. Major comorbidities including hyperlipidemia, hypertension, cigarette use, and diabetes were similarly distributed across racial groups. Despite comparable risk profiles, significant disparities in treatment and outcomes were observed. Surgical bypass and endovascular revascularization were utilized more frequently among Caucasians, while amputation rates were disproportionately highest among Black and Hispanic patients. On multivariate analysis, Black patients were 18% less likely to undergo surgical bypass (aOR 0.82, 95% CI: 0.7-0.8, p < 0.001). Black and Hispanic patients were significantly more likely to undergo amputation (aOR 1.24, p < 0.001 and aOR 1.18, p < 0.001, respectively). Asian patients had 30% higher odds of in-hospital mortality (aOR 1.30, p < 0.001). Black patients also demonstrated significantly higher rates of cardiac and ventricular arrhythmias (p < 0.001). These findings persisted after adjustment for hypertension, diabetes, and hyperlipidemia, implicating social determinants of health as key drivers of disparate outcomes.

CONCLUSION: Black and Hispanic patients with CLTI face disproportionately higher amputation rates and adverse outcomes despite similar comorbidity burdens, reflecting inequities in access to limb-salvage interventions. Targeted strategies including improved access to vascular specialty care and policy interventions for underserved communities are essential for achieving equitable CLTI management.