Abstract
OBJECTIVE: Chronic limb threatening ischaemia (CLTI) requires timely and comprehensive management to improve limb salvage and survival rates. Socioeconomic disparities, including individual wealth, are critical determinants of healthcare access and outcomes.
METHODS: In this study, 333 173 Medicare beneficiaries who underwent CLTI revascularisation from 2016 - 2023 were analysed. Patients were stratified by dual enrolment in Medicaid, a marker of socioeconomic disadvantage, and outcomes were assessed using Kaplan-Meier methods and multivariable Cox proportional hazards models. The primary endpoint was a composite of major amputation or death. The study period was divided into pre-COVID-19 (January 2016 - March 2020), during COVID-19 (March 2020 - December 2021), and post-COVID-19 (December 2021 - December 2023) phases to evaluate pandemic related impacts on outcomes. Healthcare utilisation was compared between groups.
RESULTS: Among 333 173 Medicare beneficiaries who underwent endovascular revascularisation for CLTI, 26.2% were dual eligible (DE) patients. DE patients were younger, more often female, and had a higher burden of comorbidities compared with Medicare only beneficiaries. The crude cumulative incidence of the primary composite outcome was 80.1% for DE patients and 79.7% for Medicare only beneficiaries (unadjusted hazard ratio [HR] 1.07, 95% confidence interval [CI] 1.06 - 1.08; p < .001), but this difference was not statistically significant after adjustment (adjusted HR 1.00, 95% CI 0.99 - 1.01; p = .98). DE patients experienced higher rates of major amputation (17.8% vs. 12.7%; adjusted HR 1.10, 95% CI 1.07 - 1.12; p < .001), but no statistically significant differences in adjusted rates of repeat revascularisation (adjusted HR 1.00, 95% CI 0.99 - 1.01; p = .99) or all cause mortality (adjusted HR 0.99, 95% CI 0.98 - 1.00; p = .067). During the COVID-19 period, the adjusted HR for the primary outcome was statistically significantly elevated among DE vs. non-DE patients (adjusted HR 1.05, 95% CI 1.02 - 1.08; p < .001), while risks were similar pre-COVID (adjusted HR 1.00, 95% CI 0.98 - 1.02; p = .88) and post-COVID (adjusted HR 1.01, 95% CI 0.97 - 1.04; p = .67).
CONCLUSION: DE patients represent a socioeconomically disadvantaged group with higher baseline comorbidity burdens and slightly higher unadjusted risks of adverse outcomes.