April 28, 2023

Community Distress Associated With Risk of Mortality and Major Amputation After Peripheral Vascular Intervention

April 28, 2023—In a retrospective review of prospectively collected data from the Vascular Quality Initiative (VQI) linked with Medicare claims data, Schenck et al found that high community distress is associated with increased risk of 24-month mortality and major amputation after peripheral vascular intervention (PVI). The study was published online in Journal of Vascular Surgery.

KEY FINDINGS

At 24 months post-PVI, rates of mortality and major amputation were both elevated in patients living in communities with high distress levels.
Adverse outcomes in patients with high community distress persisted even after adjusting for demographic and clinical characteristics.

Using the PVI module of the Vascular Quality Initiative (VQI) registry linked with Medicare claims data, Medicare beneficiaries were identified who were aged ≥ 18 years and underwent femoropopliteal PVI of the index limb for claudication or chronic limb-threatening ischemia (CLTI) between January 2017 and December 2018.

Patients were assigned a Distressed Communities Index (DCI) score, a composite metric of community distress measured at the zip code level and ranging from 0 (lowest community distress) to 100 (highest community distress). DCI score was then linked with clinical data using zip codes, which were ranked as prosperous (DCI quintile 1), comfortable (quintile 2), mid-tier (quintile 3), at-risk (quintile 4), or distressed (quintile 5).

Primary outcomes were 24-month mortality and major amputation.

A time-dependent receiver-operating characteristic curve analysis determined the optimal DCI value to stratify patients into risk factors for the primary outcomes, and mixed Cox regression models estimated the link between DCI and the primary outcomes.

Of the 16,864 patients included in the study, 3,672 patients were in DCI quintile 1; 3,512 in quintile 2; 3,452 in quintile 3; 3,207 in quintile 4; and 3,021 in quintile 5. High community stress was classified as DCI ≥ 70.

Mortality and major amputation at 24 months were both higher in patients with high versus lower community distress (30.7% vs 29.5%; P = .020 and 17.2% vs 13.1%; P < .001, respectively). A 10-point DCI increase was associated with both higher mortality and higher major amputation at 24 months and remained robust after adjustment for demographic characteristics, medical comorbidities, and disease severity.

Investigators concluded that future research must consider how the individual components of community distress affect risk in this patient population, as well as how individual- and policy-level interventions can address this distress and improve patient outcomes.

ENDOVASCULAR TODAY ASKS…

Carlos Mena-Hurtado, MD, and Kim G. Smolderen, PhD, with Yale School of Medicine in New Haven, Connecticut, provide insights into implications of the study results and future areas of research.

What did this study reveal about how community distress leads to worse outcomes after PVI?

This study highlights that increased exposures to community distress are associated with a higher risk of long-term amputation and mortality after undergoing a PVI. Community distress was measured based on patient zip code, which was then converted to an index called the DCI, which summarizes information derived from United States Census data on the percentage of adults aged ≥ 25 years without a high school diploma, poverty rate, percentage of adults aged 25 to 54 years not working, housing vacancy rate, median household income, change in unemployment rate, and change in number of business establishments. We documented these associations in the VQI registry, which was linked with Medicare outcomes data.

What would policies or interventions aimed at reducing this community-level socioeconomic distress look like?

There is an urgent need for policymakers to learn, understand, and implement changes at the reimbursement level, make investments in revitalizing local communities, and, along with partners at health system levels, work together to understand, evaluate, and redesign policies that impact social determinants of health in such a way that appropriately allocates resources in areas of need and development.

From the physician’s perspective, what changes are needed when it comes to the management and follow-up of patients from communities with high DCI scores?

Awareness, recognition, and understanding of why social determinants of health affect clinical outcomes and what the mechanisms are is critical. It should be part of the risk stratification process because it tremendously impacts outcomes, and interdisciplinary care should accommodate the needs of the patients who are treated. In addition, barriers in access to care and medications need to be recognized and addressed. As an example, guideline-directed medical therapy rates are low in patients with high neighborhood distress; not being able to get access to these medications further predisposes them to increased cardiovascular risk. Concerted efforts to improve access to care and medications are therefore needed.

What questions should be addressed in future studies of this population? How do these study results inform your group’s other research projects?

How can we design care to address the diverse needs that individuals with peripheral artery disease (PAD) have—not only focus on the blockage in the leg arteries? Revascularization efforts, although important, are just the tip of the iceberg. In an effort to make a dent in the increasing numbers of amputation and mortality in patients with PAD, there needs to be a paradigm shift, and this work demonstrates the need for it.

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