Differences in Comorbidities Explain Black-White Disparities in Outcomes After Femoropopliteal Endovascular Intervention

Abstract

Background: Black adults have a higher incidence of peripheral artery disease and limb amputations than White adults in the United States. Given that peripheral endovascular intervention (PVI) is now the primary revascularization strategy for peripheral artery disease, it is important to understand whether racial differences exist in PVI incidence and outcomes.

Methods: Data from fee-for-service Medicare beneficiaries ≥66 years of age from 2016 to 2018 were evaluated to determine age- and sex-standardized population-level incidences of femoropopliteal PVI among Black and White adults over the 3-year study period. Patients' first inpatient or outpatient PVIs were identified through claims codes. Age- and sex-standardized risks of the composite outcome of death and major amputation within 1 year of PVI were examined by race.

Results: Black adults underwent 928 PVIs per 100 000 Black beneficiaries compared with 530 PVIs per 100 000 White beneficiaries (risk ratio, 1.75 [95% CI, 1.73-1.77]; P<0.01). Black adults who underwent PVI were younger (mean age, 74.5 years versus 76.4 years; P<0.01), were more likely to be female (52.8% versus 42.7%; P<0.01), and had a higher burden of diabetes (70.6% versus 56.0%; P<0.01), chronic kidney disease (67.5% versus 56.6%; P<0.01), and heart failure (47.4% versus 41.7%; P<0.01) than White adults. When analyzed by indication for revascularization, Black adults were more likely to undergo PVI for chronic limb-threatening ischemia than White adults (13 023 per 21 352 [61.0%] versus 59 956 per 120 049 [49.9%]; P<0.01). There was a strong association between Black race and the composite outcome at 1 year (odds ratio, 1.21 [95% CI, 1.16-1.25]). This association persisted after adjustment for socioeconomic status (odds ratio, 1.08 [95% CI, 1.03-1.13]) but was eliminated after adjustment for comorbidities (odds ratio, 0.96 [95% CI, 0.92-1.01]).

Conclusions: Among fee-for-service Medicare beneficiaries, Black adults had substantially higher population-level PVI incidence and were significantly more likely to experience adverse events after PVI than White adults. The association between Black race and adverse outcomes appears to be driven by a higher burden of comorbidities. This analysis emphasizes the critical need for early identification and aggressive management of peripheral artery disease risk factors and comorbidities to reduce Black-White disparities in the development and progression of peripheral artery disease and the risk of adverse events after PVI.

Keywords: healthcare disparities; peripheral arterial disease.

Figure 1.. Age- and sex-adjusted population-level incidence of PVI in Black and White Medicare beneficiaries from 2016–2018.

Black adults have a higher incidence of PVI than White adults from 2016 to 2018. Black beneficiaries underwent 928 PVIs per 100,000 Black beneficiaries compared with 530 PVIs per 100,000 White beneficiaries over the three-year study period (risk ratio [RR] = 1.75 for Black versus White, 95% CI 1.73–1.77, p<0.01).

Figure 2.. Relative risk of undergoing PVI in Black and White Medicare beneficiaries from 2016–2018 divided by census regions of the U.S.

Black adults are more likely to undergo PVI in all regions of the United States. There is a statistically significant difference in PVI incidence between Black and White adults in every census region (Table 1).