Racial, Socioeconomic, and Geographic Disparities in Preamputation Vascular Care for Patients With Chronic Limb-Threatening Ischemia

Omar I Ramadan; Lin Yang; Kaitlyn Shultz; Elizabeth Genovese; Scott M Damrauer; Grace J Wang; Eric A Secemsky; Diane J Treat-Jacobson; Robin J Womeodu; Foluso A Fakorede; Ashwin S Nathan; Lauren A Eberly; Howard M Julien; Taisei J Kobayashi; Peter W Groeneveld; Jay Giri; Alexander C Fanaroff

doi:10.1161/CIRCOUTCOMES.124.010931

Racial, Socioeconomic, and Geographic Disparities in Preamputation Vascular Care for Patients With Chronic Limb-Threatening Ischemia

Circ Cardiovasc Qual Outcomes. 2025 Jan 3:e010931. doi: 10.1161/CIRCOUTCOMES.124.010931. Online ahead of print.

Authors

Omar I Ramadan^{1

2}, Lin Yang^{3

2}, Kaitlyn Shultz^{3

2}, Elizabeth Genovese^{1

3

2}, Scott M Damrauer^{1

3

4

2

5}, Grace J Wang^{1

3

2}, Eric A Secemsky⁶, Diane J Treat-Jacobson⁷, Robin J Womeodu⁸, Foluso A Fakorede⁹, Ashwin S Nathan^{3

10

2

5}, Lauren A Eberly^{3

10

2}, Howard M Julien^{3

10

2

5}, Taisei J Kobayashi^{3

10

2

5}, Peter W Groeneveld^{3

11

2

5}, Jay Giri^{3

10

2

5}, Alexander C Fanaroff^{3

10

2

12}

Affiliations

¹ Division of Vascular Surgery and Endovascular Therapy, Perelman School of Medicine, University of Pennsylvania, Philadelphia. (O.I.R., E.G., S.M.D., G.J.W.).
² Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia. (O.I.R., L.Y., K.S., E.G., S.M.D., G.J.W., A.S.N., L.A.E., H.M.J., T.J.K., P.W.G., J.G., A.C.F.).
³ Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia. (L.Y., K.S., E.G., S.M.D., G.J.W., A.S.N., L.A.E., H.M.J., T.J.K., P.W.G., J.G., A.C.F.).
⁴ Department of Genetics, Perelman School of Medicine, University of Pennsylvania, Philadelphia. (S.M.D.).
⁵ Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA (S.M.D., A.S.N., H.M.J., T.J.K., P.W.G., J.G.).
⁶ Smith Center for Cardiovascular Outcomes Research, Beth Israel Deaconess Medical Center, Harvard Medical School, Harvard University, Boston, MA (E.A.S.).
⁷ School of Nursing, University of Minnesota, Minneapolis (D.J.T.-J.).
⁸ Methodist Le Bonheur Healthcare, Memphis, TN (R.J.W.).
⁹ Cardiovascular Solutions of Central Mississippi, Cleveland (F.A.F.).
¹⁰ Cardiovascular Medicine Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia. (A.S.N., L.A.E., H.M.J., T.J.K., J.G., A.C.F.).
¹¹ General Internal Medicine Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia. (P.W.G.).
¹² Penn Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia. (A.C.F.).

PMID: 39749477
DOI: 10.1161/CIRCOUTCOMES.124.010931

Abstract

Background: Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care.

Methods: Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates.

Results: Among 73 237 patients who underwent major lower extremity amputation, 40 320 (55.1%) had an outpatient vascular subspecialist visit, 60 109 (82.1%) had lower extremity arterial testing, and 28 345 (38.7%) underwent lower extremity revascularization in the year before amputation. Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio [adjOR], 0.87 [95% CI, 0.84-0.90]) or revascularization (adjOR, 0.90 [95% CI, 0.86-0.93]) than White patients. Compared with patients without low SES or residing in urban areas, patients with low SES or residing in rural areas were less likely to have an outpatient vascular specialist visit (adjOR, 0.62 [95% CI, 0.60-0.64]; low SES versus nonlow SES; adjOR, 0.82 [95% CI, 0.79-0.85]; rural versus urban), lower extremity arterial testing (adjOR, 0.78 [95% CI, 0.75-0.81]; low SES versus nonlow SES; adjOR, 0.90 [95% CI, 0.0.86-0.94]; rural versus urban), or revascularization (adjOR, 0.65 [95% CI, 0.63-0.67]; low SES versus nonlow SES; adjOR, 0.89 [95% CI, 0.86-0.93]; rural versus urban).

Conclusions: Black race, rural residence, and low SES are associated with failure to receive subspecialty chronic limb-threatening ischemia care before amputation. To reduce disparities in amputation, multilevel interventions to facilitate equitable chronic limb-threatening ischemia care are needed.

Keywords: amputation, surgical; chronic limb-threatening ischemia; health services accessibility; healthcare disparities; peripheral arterial disease.