How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia

Abstract

Objective: Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them.

Methods: All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ², Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers.

Results: From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance.

Conclusions: LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.

Keywords: CLTI; Multidisciplinary; Socioeconomic.

Fig 1.

Kaplan-Meier plots are shown for the primary outcomes of the entire cohort of patients who received index revascularization: death (A), major adverse limb event (MALE) (B), and loss of patency (C). Functions are grouped by the clinic type at which they received treatment: multidisciplinary Limb Preservation Program (LPP) shown in dashed red and traditional clinics (TC) shown in solid black. Censored values are shown with “|.” Standard errors of curves do not exceed 10% for the time frames shown. Functions did not differ between groups for any outcome shown.

Fig 2.

Kaplan-Meier plots are shown for the primary outcomes of patients in the most deprived Area Deprivation Index (ADI) decile (ADI >90) who received index revascularization: death (A), major adverse limb event (MALE) (B), and loss of patency (C). Functions are grouped by the clinic type at which they received treatment: multidisciplinary Limb Preservation Program (LPP) shown in dashed red and traditional clinics (TC) shown in solid black. Censored values are shown with “|.” Standard errors of curves do not exceed 10% for the time frames shown. Functions differed between groups for patency loss (P = .0108, noted with a “*”) but not for death and MALE.