IYSC01 - The Impact of Regional Socioeconomic Wealth on Contemporary Outcomes After Chronic Limb-Threatening Ischemia Revascularization in Medicare Beneficiaries from 2016 to 2023.

Objectives: Prompt revascularization is the cornerstone of management for chronic limb-threatening ischemia (CLTI), but disparities in community socioeconomic status (SES) and access to healthcare can significantly influence outcomes. Community-level indicators, such as the Distressed Communities Index (DCI), capture regional disparities that may exacerbate vulnerability among certain populations. The COVID-19 pandemic further disrupted healthcare systems, potentially amplifying these inequities. This study evaluated the association between regional SES, measured by DCI, and outcomes—including mortality, major amputation, and repeat interventions—before, during, and after the COVID-19 pandemic in Medicare beneficiaries undergoing revascularization for CLTI.

Methods: From 2016 to 2023, Medicare beneficiaries undergoing CLTI revascularization were stratified by SES using the DCI (distressed: ≥80th percentile; non-distressed: < 80th). The study was divided into Pre-pandemic (Jan 1, 2016–Mar 31, 2020), Pandemic (Mar 31, 2020–Dec 31, 2021), and Post-pandemic (Dec 31, 2021–Dec 31, 2023). Metrics, including specialist visits, imaging, and emergency department (ED) visits, were assessed pre- and post-revascularization. Major amputation and mortality, the primary outcome, were analyzed using Kaplan-Meier and Cox models adjusted for demographics and clinical factors. Secondary outcomes included repeat revascularization rates and post-procedural healthcare utilization.

Results: Among 381,335 beneficiaries, 66,757 (17.5%) lived in distressed communities. These patients were more often Black (31.5% vs. 11.8%), had more comorbidities, and higher dual Medicare/Medicaid enrollment. Overall, patients from distressed communities experienced a significantly higher risk of major amputation and all-cause mortality compared to those from non-distressed communities during the study period (1.12, 95%CI 1.11–1.13, p< 0.001). This disparity persisted across the entire timeframe. Pre-pandemic: Patients in distressed communities had higher amputation and mortality risks (6-month unadjusted cumulative incidence: 20.77% vs. 19.40%; adjusted HR: 1.12 [95% CI 1.10–1.14, p< 0.001]). Pandemic: Disparities worsened (unadjusted cumulative incidence: 23.45% vs. 21.31%; adjusted HR: 1.15 [95% CI 1.12–1.18, p< 0.001]). Post-pandemic: Outcomes improved but remained elevated (unadjusted cumulative incidence: 21.83% vs. 20.12%; adjusted HR: 1.13 [95% CI 1.10–1.15, p< 0.001]). Notably, the proportion of PVIs performed in distressed communities declined annually (-0.59% [95% CI -0.68% to -0.50%, p< 0.0001]). These patients had fewer vascular visits (pre: 1.9 vs. 2.5; post: 6.5 vs. 7.6; p< 0.001), but higher ED visits (13.0% vs. 11.0%; p< 0.01) and hospital readmissions (16.2% vs. 12.8%; p< 0.001).

Conclusions: Socioeconomic disparities, measured by DCI, impact outcomes and healthcare use in Medicare beneficiaries with CLTI undergoing revascularization. These gaps worsened during COVID-19 and persist post-pandemic, requiring resources to bridge the care gap and support progress for the CLTI population.