Geographic Variation in Endovascular Revascularization for Chronic Limb-Threatening Ischemia Care Among Medicare Beneficiaries (2016-2023).

Abstract

Objective: Chronic limb-threatening ischemia (CLTI), the most severe manifestation of peripheral artery disease (PAD), is associated with high risk of major amputation and mortality. While timely revascularization is a cornerstone of CLTI management, disparities in access to care and outcomes persist across US geographic regions. This study aims to evaluate variations in endovascular revascularization for CLTI, healthcare utilization patterns, and outcomes stratified by US regions to inform how we address these disparities.

Methods: From 2016 through 2023, all endovascular revascularizations for CLTI among Medicare fee-for-service beneficiaries were included and evaluated by Northeast, South, Midwest, and West regions of the US. Follow-up continued through December 31, 2023, with a median duration of 625 days (maximum 2921 days). The primary outcome was a composite of death or major amputation. Secondary outcomes included major amputation, all-cause mortality, repeat revascularization, change in ambulatory status, and healthcare utilization before and after revascularization. Multivariable Cox proportional hazards regression models were used to adjust for demographic, clinical, and procedural characteristics.

Results: Among 381,173 beneficiaries, the South performed more than half of all revascularizations throughout the study period (52.18%), followed by the West (17.3%), Northeast (16.2%), and the Midwest (13.9%). After adjustment, the Midwest showed the highest risk for the primary outcome (hazard ratio [HR] 1.20, 95% confidence interval [CI]: 1.18, 1.22, p<0.0001) followed by the South (HR 1.11, 95% CI 1.10, 1.13, p<0.0001) and West (HR 1.04, 95% CI 1.02, 1.06, p<0.0001), all compared to the Northeast. Healthcare utilization analyses revealed fewer outpatient visits with a vascular provider before and after revascularization in all regions compared to the Northeast with the lowest rates in the Midwest (before revascularization: adjusted rate ratio [aRR]: 0.73; 95% CI: 0.72, 0.74; p<0.0001; after revascularization: aRR: 0.73; 95% CI: 0.72, 0.74; p<0.0001) CONCLUSIONS: Disparities in access to care and outcomes persist across U.S. regions for Medicare beneficiaries with CLTI and influence healthcare utilization and outcomes. The Midwest region in particular, that care for a high proportion of rural patients, experience the greatest risks of amputation and death related to CLTI, which may in part be due to less frequent healthcare contact following revascularization. Targeted improvements in healthcare access, especially in rural and economically disadvantaged regions, are needed to enhance outcomes in CLTI patients.