Outcomes, Trends, and Healthcare Disparities in Patients Hospitalized with Chronic Limb Threatening Ischemia
Authors: Torres Christian , Ujueta Francisco , Rogers Everett , Ghazzal Amre , Santos Radleigh , Koelbl Christian , Escolar Esteban , Lamas Gervasio A. , Parikh Sahil A , Beohar Nirat 
Published: June 2023

Background

Chronic limb threatening ischemia (CLTI) is the most severe form of peripheral artery disease (PAD) and is associated with poor patient outcomes and increased healthcare costs. While racial, socioeconomic, and other healthcare disparities are widely recognized to influence the management of CLTI, the extent of the role they play is still an area of intense investigation.

Methods

We analyzed data from the National Inpatient Sample (NIS) to identify all patients ≥18 years of age admitted with a primary diagnosis of CLTI from 2016 to 2019. Descriptive statistics were used to summarize patient baseline characteristics (age, gender, race, comorbidities, socioeconomic status, and procedural rates). Logistic regression models and temporal trends were used to determine predictors of major amputation and MACE, as well as in CLTI admissions during the 4-year study period, major amputation, endovascular intervention, and peripheral bypass further divided into racial cohorts.

Results

A total of 121,087,650 patients were hospitalized from 2016 to 2019 of which 4,707,657 (3.9%) hospitalized for CLTI. The mean age of patients admitted with CLTI was 60 ± 17 years. A majority were male (57.8%, p<0.001), and White (72.0%, p<0.001). They were more likely to be socioeconomically disadvantaged (32.8% with median household income 0-25thpercentile, p<0.001). Risk for hospitalization for CLTI varied inversely with increasing household income. During the hospitalization, 32.4% had invasive angiography, 0.6% had peripheral computed tomography angiogram (CTA), 3.3% underwent angioplasty, 1.6% peripheral bypass, and major amputation occurred in 9.2%. Black patients had the highest risk for amputation, followed by Native American and Hispanic patients. White patients made up the greatest percentage of CLTI admissions, but were not at increased risk for amputation. Asian and Pacific Islander patients were the only racial group at decreased risk for amputation. Temporal trends during the 4-year period revealed the strongest predictors of MACE were diabetes and a history of peripheral angioplasty or peripheral bypass. Overall, there was a 6.7% increase in hospitalizations, a 14.1% increase in peripheral angioplasty rates, and an 8.4% decrease in peripheral bypass rates for CLTI during the 4-year study period. There was a reduction in above the knee amputation rates for all racial cohorts except for Native Americans (23.5% increase) during the study period. There was a 26.4% total increase in below the knee amputation rates.

Conclusion

Despite increased awareness of health disparities, poor outcomes resulting from CLTI (such as amputation) continue to disproportionately affect racial and socioeconomic minority groups. Revascularization and amputations during hospital admission for CLTI is increasing, driven by peripheral angioplasty and BKA, respectively.