Striking Racial Gaps Exist in Care for Peripheral Interventions, Registry Affirms

Compared with white patients, Black patients with PAD who undergo peripheral revascularization have much more advanced disease at the time of their procedures and are less likely to receive necessary care thereafter to avoid major limb amputation, new data suggest.

“What we saw was that there wasn't a tremendous difference in the peripheral interventions in the intervention suite, but we did see significant differences in the presentation of patients. Black patients were sicker and less likely to receive revascularization methods in the year after their index procedure,” Howard M. Julien, MD, MPH (Penn Heart and Vascular Center, Philadelphia, PA), said in an interview with TCTMD. “We believe that these data show that the real focus of our efforts should be in identifying sicker Black patients earlier to provide them with preventive care as well as aftercare and longitudinal follow-up in the office.”

Julien's analysis showed a higher adjusted hazard for amputation in Black patients, although it did not reach statistical significance.

As TCTMD has previously reported, Black Americans are far more likely than their white peers to experience a major amputation—many of which are avoidable—as a result of advanced PAD. It’s a narrative that the Association of Black Cardiologist’s PAD Initiative, the American Heart Association, legislators, and others are working to change.

In a presentation at VIVA 2021, Julien showed that in-hospital outcomes like procedural success, major vascular complications, and bleeding complications did not differ between Black and white patients requiring revascularization. Yet the story was much different for cumulative rates of 1-year revascularization, with an approximately 60% lower incidence in Black patients (P < 0.001).

Julien said it’s important to acknowledge that “the tail end” of care is disproportionately worsening outcomes in Black patients.

“When we don't have a team approach to the care of these patients—when we don't have endocrinologists, we don't have the hypertension specialists in our follow-up—that is where the racial disparity, because of the higher comorbidity . . . in outcomes could actually vary,” observed Gary Ansel, MD (OhioHealth, Columbus), who co-moderated the late-breaking trial session.

Disparities Not Driven by Hospital Care

Using data from the National Cardiovascular Data Registry (NCDR) Peripheral Vascular Intervention (PVI) Registry, Julien’s study sought to evaluate whether the use of novel technologies such as drug-eluting devices, atherectomy, and intervascular imaging differed in the care of Black and white patients with PAD. Of the 63,150 patients in the registry who underwent lower-extremity peripheral endovascular intervention from April 2014 through March 2019, 7,431 were Black. Compared with white patients, those who were Black were less likely to have Medicare and more likely to have Medicaid, they also had higher scores on the Distressed Communities Index (DCI), an indicator of unemployment, education level, poverty rate, median income, business growth, and housing vacancies. Black patients also were more likely than white patients to report being unable to walk 200 meters, and they had higher rates of HF but slightly lower rates of CAD.

An all-hands-on-deck approach is what's needed. Howard M. Julien

After adjustment for demographic factors, use of paclitaxel-based DES or drug-coated balloons was slightly higher in Black patients than white patients (OR 1.14; 95% CI 1.06-1.23), with no differences in intravascular imaging (OR 1.03; 95% CI 0.88-1.23) or atherectomy (OR 0.98 0.91-1.05).

In a Centers for Medicare & Medicaid Services-linked analysis, revascularization was less likely to be pursued at 1 year in Black patients than it was in white patients (adjusted HR 0.38; 95% CI 0.28-0.54). However, there were no statistically significant differences seen at 1 year for death (adjusted HR 1.02; 95% CI 0.78-1.35), amputation (adjusted HR 2.5; 95% CI 0.82-7.63), or the endpoint of death or major amputation (adjusted HR 1.18; 95% CI 0.85-1.64). Julien noted that residual confounding cannot be completely eliminated given the retrospective nature of the study design.

Panelist Mark J. Garcia, MD (Vascular & Interventional Associates of Delaware, Wilmington), observed that given the desire expressed by the Biden administration to minimize disparity among minorities in the delivery of healthcare, it would be important to understand what is leading to the falloff of revascularization and surgery in the year after intervention. Possible reasons, he added, might be noncompliance with medications or exercise programs.

Julien said while the data don’t allow for drilling down into information on prescriptions, they do signal that patients of color may be falling between the cracks in their aftercare.

“The one thing that was striking for me in follow-up was the fact that these patients actually had decent outcomes from a cardiovascular standpoint but needed further reinterventions that weren't being pursued, and there was that trend toward increased amputations,” he added. Coupled with the good index procedural successes demonstrated among Black patients, he said, there is a need to understand what type of support is needed to help these patients before going on to amputation “and not necessarily giving up, if you will.”

To TCTMD, Julien echoed Ansel’s comments about the importance of a team-based approach to PAD.

“It should be on the shoulders of primary care and general cardiology, as well as on diabetologists and endocrinologists who are caring for many of the patients with diabetes who have peripheral arterial disease, to consider the vascular complications as well,” he stressed. “An all-hands-on-deck approach is what's needed.”