Abstract
BACKGROUND: Prompt revascularization is crucial for managing for chronic limb-threatening ischemia (CLTI), but disparities in socioeconomic status (SES) and healthcare access affect outcomes. The COVID-19 pandemic exacerbated these inequities, yet their impact on CLTI outcomes remains underexplored.
OBJECTIVE: This study evaluated the association between regional SES, measured by the Distressed Communities Index (DCI), and outcomes-including mortality, major amputation, and repeat interventions-before, during, and after the COVID-19 pandemic in Medicare beneficiaries undergoing CLTI revascularization.
METHODS: From 2016 to 2023, Medicare beneficiaries undergoing CLTI endovascular revascularization were stratified by SES using the DCI (distressed: ≥80th percentile). The study periods were pre-pandemic (1/1/2016-3/31/2020), pandemic (3/31/2020-12/31/2021), and late-pandemic (12/31/2021-12/31/2023). Metrics were evaluated pre- and post-revascularization. Endpoints were analyzed using Kaplan-Meier and Cox models adjusted for demographics and clinical factors.
RESULTS: Among 333,173 beneficiaries, 66,757 (20.0%) lived in distressed communities, facing higher risks of major amputation and mortality (HR 1.04 [1.03-1.05], p<0.001). These disparities persisted across the entire study period, including pre-, during-, and post-pandemic eras. Pre-pandemic, risks were elevated (HR 1.01 [1.00-1.03], p=0.125), worsening during the pandemic (HR 1.06 [1.03-1.09], p<0.001) and late-pandemic (HR 1.07 [1.03-1.11], p<0.001). The proportion of percutaneous vascular interventions (PVIs) in distressed communities declined annually (-0.59% [-0.68% to -0.50%], p<0.0001). These patients had fewer vascular visits (pre: 5.62 vs. 6.63; post: 6.52 vs. 7.57; p<0.001) but more ED visits (0.04 vs. 0.03; p<0.001) and hospital readmissions (0.13 vs. 0.11; p<0.001).
CONCLUSION: Socioeconomic disparities, measured by DCI, affect outcomes and healthcare use in Medicare beneficiaries with CLTI undergoing revascularization. These gaps worsened during COVID-19 and persisted post-pandemic, highlighting the need for resources to bridge the care gap and improve CLTI management.