Study finds correlation between neighbourhood social disadvantage and PAD outcomes

A RECENT STUDY HAS FOUND that, among patients who underwent infrainguinal revascularisation or amputation in the Society for Vascular Surgery (SVS) Vascular Quality Initiative (VQI), those with higher neighbourhood adversity had more advanced peripheral arterial disease (PAD) at presentation and lower rates of revascularisation.

“Studies examining the relationship between socioeconomic disparities and PAD often focus on individual social health determinants and fail to account for the complex interplay between factors that ultimately impact disease severity and outcomes,” authors Lucas Mota (Beth Israel Deaconess Medical Center, Boston, USA) and colleagues write in the Journal of Vascular Surgery (JVS). They claim that area deprivation index (ADI), which they describe as a “validated measure of neighbourhood adversity,” provides a “more comprehensive assessment” of social disadvantage. For this reason, the investigators set out to examine the impact of ADI on PAD severity and its management.

First, the researchers identified all patients who underwent infrainguinal revascularisation—either open or endovascular—or amputation for symptomatic PAD in the VQI registry between 2003 and 2020. They assigned an ADI score of 1–100 to each patient based on their residential ZIP code, with higher ADI scores corresponding with increasing diversity, and categorised patients by ADI quintiles (Q1–Q5).

Mota et al note that the outcomes of interest included indication for procedure (claudication, rest pain or tissue loss) and rates of revascularisation (versus primary amputation). They used multimodal logistic regression to evaluate an independent association between ADI quintile and these outcomes.

The researchers identified 79,973 patients who met their criteria within the VQI database. Specifically, they communicate in JVS that 9,604 (12%) of these patients were in the lowest ADI quintile (Q1), 14,961 (18.7%) in Q2, 19,800 (24.8%) in Q3, 21,735 (27.2%) in Q4, and 13,873 (17.4%) in Q5. There were “significant trends” toward lower rates of claudication (Q1: 39% vs. Q5: 34%, p<0.001), higher rates of rest pain (Q1: 12.4% vs. Q5: 17.8%, p<0.001) as the indication for intervention, Mota and colleagues report in their JVS paper. They add that they found lower rates of revascularisation (Q1: 80% vs. Q5: 69%, p<0.001) with increasing ADI quintiles.

In adjusted analyses, the investigators relay, there was a “progressively higher likelihood” of presenting with rest pain versus claudication, with patients in Q5 having the highest probability when

Rouleaux Club announces Hurting Leg Competition winners

Vaux Robertson (Leicester Vascular Institute, Leicester, UK) and Natalie Yonan (Newcastle Hospitals, Newcastle, UK) were announced as the winners of the Rouleaux Club’s Hurting Leg Competition designed to create patientfacing infographics and infomercials on ‘the hurting leg’ at the 2023 Charing Cross (CX) International Symposium (25–27 April, London, UK).

YONAN WON THE INFOGRAPHIC category with an entry entitled “RING”, which plays on the theme of rest pain, impaired walking, non-healing ulcers and gangrene. Robertson claimed the prize in the infomercial section with a video called “Arterial disease can affect anyone”. The competition was organised by the UK’s vascular surgery trainee association compared with those in Q1 (relative risk: 2; 95% confidence interval [CI]: 1.8–2.2; p<0.001). The authors add that patients in Q5, when compared with those in Q1, also had a higher likelihood of presenting with tissue loss versus claudication (relative risk: 1.4; 95% CI: 1.3–1.6; p<0.001). They also reveal that patients in Q2–Q5 had a lower likelihood of undergoing any revascularisation procedure compared with patients in Q1.

“Further work is needed to better understand neighbourhood factors that are contributing to these disparities in order to identify community-level targets for improvement,” the authors write in their concluding remarks.

Healthcare disparities in the spotlight

Senior author Marc Schermerhorn (Beth Israel Deaconess Medical Center) and colleagues have conducted extensive research on the topic of health disparities in vascular care. At the CX Aortic Vienna 2022 Digital Edition (24–26 October), for example, Schermerhorn spoke on the impact of sex and racial and ethnic factors on abdominal aortic aneurysm (AAA) management and outcome. He concluded that disparities by sex, race and ethnicity “exist at all steps along AAA care,” including AAA detection, clinical trial enrolment and outcomes, among others. Disparities early in the care trajectory likely influence disparities observed later on, he added. in conjunction with CX and was open to medical students and trainees from across the world. Rouleaux Club executive committee member Claire Dawkins (Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK) explained why the society created the contest. “Chronic limbthreatening ischaemia [CLTI] and the hurting leg are a major issue,” she told CX 2023. “It is high prevalence, is increasing in incidence and is often, certainly in the UK and, from what I understand, globally there is often a delayed presentation. This has all been exacerbated by COVID, with many difficulties of the patient pathways and pressures on general practice, or family doctors.”

Earlier in the year, at the SVS Vascular Annual Meeting (VAM 2022; 15–18 June, Boston, USA), Aderike Anjorin (Duke University Medical Center, Durham, USA) presented the findings of a study of over 7,000 chronic limb-threatening ischaemia patients under the guidance of senior investigator Schermerhorn. She reported that Black and Hispanic patients had higher three-year amputation and reintervention rates. “Interventions to improve early diagnosis, risk factor modification, and postoperative surveillance in these populations may confer long-term limb salvage benefits,” the speaker told VAM attendees in closing her presentation.

Key are ways to get patients to present as early as possible, said Dawkins. There is little vascular surgery-specific [information] in the public domain in terms of patient awareness and education, she explained. “When I am talking to patients in the UK, they have very little awareness of peripheral arterial disease or CLTI. So, the aim for this is to really get that message out there.”

Rouleaux Club president Leanna Erete (Royal Free Hospital, London, UK) handed over cheques of £500 each to Robertson and Yonan.

“I think there are great things in all of those [entries],” said audience member Jonathon Boyle (Cambridge University Hospitals NHS Trust, Cambridge, UK). “One of the most successful campaigns has been the FAST campaign for stroke, and that is a very simplistic infographic—you have basically got four pictures and four letters pretty much. Take everything away and bring it all together. Have your prize winners today, but then take the best bits from every infographic and try and get one slightly more simplified than the ones you have shown. For the public, they need to be fairly easy to understand.”