Publications

BACKGROUND: Black patients, those with low socioeconomic status (SES), and those living in rural areas have elevated rates of major lower extremity amputation, which may be related to a lack of subspecialty chronic limb-threatening ischemia care. We evaluated the association between race, rurality, SES, and preamputation vascular care.

METHODS: Among patients aged 66 to 86 years with fee-for-service Medicare who underwent major lower extremity amputation for chronic limb-threatening ischemia from July 2010 to December 2019, we compared the proportion who received vascular care in the 12 months before amputation by race (Black versus White), rurality, and SES (dual eligibility for Medicaid versus no dual eligibility) using multivariable logistic regression adjusting for clinical and demographic covariates.

RESULTS: Among 73 237 patients who underwent major lower extremity amputation, 40 320 (55.1%) had an outpatient vascular subspecialist visit, 60 109 (82.1%) had lower extremity arterial testing, and 28 345 (38.7%) underwent lower extremity revascularization in the year before amputation. Black patients were less likely to have an outpatient vascular specialist visit (adjusted odds ratio [adjOR], 0.87 [95% CI, 0.84-0.90]) or revascularization (adjOR, 0.90 [95% CI, 0.86-0.93]) than White patients. Compared with patients without low SES or residing in urban areas, patients with low SES or residing in rural areas were less likely to have an outpatient vascular specialist visit (adjOR, 0.62 [95% CI, 0.60-0.64]; low SES versus nonlow SES; adjOR, 0.82 [95% CI, 0.79-0.85]; rural versus urban), lower extremity arterial testing (adjOR, 0.78 [95% CI, 0.75-0.81]; low SES versus nonlow SES; adjOR, 0.90 [95% CI, 0.0.86-0.94]; rural versus urban), or revascularization (adjOR, 0.65 [95% CI, 0.63-0.67]; low SES versus nonlow SES; adjOR, 0.89 [95% CI, 0.86-0.93]; rural versus urban).

CONCLUSIONS: Black race, rural residence, and low SES are associated with failure to receive subspecialty chronic limb-threatening ischemia care before amputation. To reduce disparities in amputation, multilevel interventions to facilitate equitable chronic limb-threatening ischemia care are needed.

BACKGROUND: Isolated subsegmental pulmonary embolism (issPE) is a commonly encountered diagnosis. Although the International Classification of Diseases (ICD)-10 codes are used for research, their validity for identifying issPE is unknown. Moreover, issPE diagnosis is challenging, and the findings from radiology reports may conflict with those from expert radiologists.

METHODS: Based on prespecified criteria, 1734 medical records of adult patients hospitalized within the Mass General Brigham health system (2016-2021) were selected in three equal groups: (1) patients with principal discharge diagnosis codes for PE, (2) patients with secondary discharge diagnosis codes for PE, and (3) patients with no PE codes. The accuracy of ICD-10 codes for issPE was verified by two independent physicians and weighted by total hospitalizations. In a randomly selected sample of 70 patients, the accuracy of initial radiology reports was determined through a blinded re-evaluation by two expert radiologists.

RESULTS: In weighted estimates, ICD-10 codes in primary or secondary discharge positions, compared with chart reviews, showed a low sensitivity (7.0 %) and positive predictive value (25.2 %). Evaluation by two expert radiologists noted that initial radiology reports were sensitive (97.1 %) for issPE but had a low specificity (40.0 %). Two (3.6 %) out of 55 patients with initial issPE reports did not have PE, while 19 (34.5 %) had more proximal PE.

CONCLUSIONS: ICD-10 codes for issPE have poor sensitivity and positive predictive value and should not be used for research or quality improvement. Radiology reports for issPE may be inaccurate regarding the location or, less often, the presence of PE.

Most of the 800 000 people living with end-stage kidney disease in the United States rely on a functioning vascular access to provide life-sustaining hemodialysis, yet one-third of arteriovenous fistulas experience early failures. Determining the safety and effectiveness of systemic heparin during fistula creation could improve the quality and quantity of life for these vulnerable patients. In this article, a pragmatic randomized trial was emulated to assess the effect of systemic heparin administration (vs none) during radiocephalic arteriovenous fistula creation on early bleeding and thrombosis, using data from 2 international, multicenter, randomized trials performed between 2014 and 2019. Marginal risks were estimated using inverse probability weighted parametric survival analysis and CIs were generated with bootstrapping. A total of 914 patients were enrolled and 61% received systemic heparin; their median (IQR) age was 58 (49, 67) years and 45% were on hemodialysis at enrollment. No difference in the risk of bleeding events was observed, with a risk difference (95% CI) at 14 days of -0.1% (-1.6 to 1.4). The risk of access thrombosis was lower in the heparin group, with a risk of 3.7% (2.6-4.8) after heparin and 5.3% (3.4-7.4) without heparin at 14 days (risk ratio = 0.72; 95% CI, 0.50-0.98). Trial registration: ClinicalTrials.gov. Identifiers: NCT02110901 and NCT02414841.

A global treatment algorithm was developed for the endovascular revascularization of femoropopliteal lesions and chronic total occlusions, aiming toward a more standardized approach to endovascular treatment in patients with peripheral artery disease. The following steps are proposed. 1) Evaluation of lesion morphology based on preprocedural imaging by Duplex sonography and intravenous ultrasound for selection of lesion preparation tools. Lesion characteristics are mainly defined by calcification, lesion length, and the presence of total occlusion and in-stent restenosis. 2) Selection of vessel preparation strategies, which encompass plain old balloon angioplasty, atherectomy, thrombectomy, intravascular lithotripsy and specialty balloons, or a combination of the preceding, based on lesion and patient-specific characteristics. In addition, a Delphi consensus was applied for the appropriateness of lesion preparation strategies, depending on lesion anatomy, length, plaque morphology, and subintimal versus intraluminal guidewire crossing. 3) Definitive lesion treatment strategies using drug-coated balloons, bare-metal stents, drug-eluting stents, and/or covered stents or a combination. By establishing this treatment algorithm in routine practice, improvements in vessel- and patient-specific outcomes are anticipated, which will be further enhanced by continuous collaboration among experts from different countries and disciplines and by randomized controlled trials.

OBJECTIVE: Routine imaging surveillance following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA) is critical for the timely diagnosis of late postoperative complications. Compliance with recommended EVAR surveillance is variable, and disparities in post-EVAR surveillance remain unclear. This study examines variability in EVAR surveillance and emergency health service use across several sociodemographic populations.

METHODS: All Medicare fee-for-service beneficiaries who underwent infrarenal EVAR for intact abdominal aortic aneurysm between January 2011 and December 2019 were included. Patients were stratified by several sociodemographic characteristics: age category (66-74, 75-84, >85 years), sex (male, female), race (White, Black, Asian, other), dual enrollment in Medicare and Medicaid (dual enrolled, Medicare only), and distressed communities index (distressed >80th percentile, nondistressed ≤80th percentile). The following postoperative health care use metrics were assessed: EVAR-related office visits, imaging studies, emergency department (ED) visits, and hospital readmissions. Annual incidence rates were calculated for each health care use metric at 2 and 5 years after EVAR and compared across groups using Poisson regression models, adjusting for sociodemographic and hospital characteristics and comorbidities.

RESULTS: In 111,381 Medicare beneficiaries who underwent EVAR, postoperative health care use varied substantially across sociodemographic groups. After adjustment, annual incidence rates of EVAR-related office visits at 2 years post EVAR were lower in patients who were >85 years vs 66-75 years (adjusted rate ratio [aRR], 0.95; 95% confidence interval [CI], 0.93-0.97), female vs male (aRR, 0.94; 95% CI, 0.93-0.95), dual enrolled vs Medicare only (aRR, 0.83; 95% CI, 0.81-0.85), and residing in distressed vs nondistressed communities (aRR, 0.95; 95% CI, 0.93-0.96). Rates of imaging studies were lower in patients who were >85 years (aRR, 0.98; 95% CI, 0.96-0.99), dual enrolled (0.97; 95% CI, 0.95-0.98), and residing in distressed communities (aRR, 0.97; 95% CI, 0.96-0.98). There was higher use of hospital services in patients who were >85 years (ED: aRR, 1.37; 95% CI, 1.33-1.41; readmission: aRR, 1.23; 95% CI,1.19, 1.28), female (ED: aRR, 1.19; 95% CI, 1.16-1.22; readmission: aRR, 1.15; 95% CI, 1.12-1.19), Black (ED: aRR, 1.10; 95% CI, 1.05-1.15; readmission: aRR, 1.15; 95% CI, 1.09-1.22), dual-enrolled (ED: 1.29; aRR, 95% CI, 1.26-1.33; readmission: aRR, 1.14; 95% CI, 1.09-1.18), and residing in distressed communities (ED: aRR, 1.03; 95% CI, 1.01-1.06; readmission: aRR, 1.02; 95% CI, 0.99-1.05). At 5 years post EVAR, similar trends across sociodemographic groups were observed, with the added finding of lower rates of EVAR-related office visits in Black vs White patients.

CONCLUSIONS: Significant variation in post-EVAR health care use exists among Medicare beneficiaries. Patients who were older age, of female sex, of Black race, or socioeconomically disadvantaged had lower rates of EVAR-specific follow-up and higher use of emergency health service. Barriers in access to care are apparent, underscoring the need for targeted interventions to enhance post-EVAR surveillance and improve outcomes in these populations.