Closer distance to primary care raises likelihood of vascular assessment before amputation

Key takeaways:

• Peripheral artery disease, or PAD, is a leading cause of lower extremity amputations in the U.S.
• Health care use and primary care distance were linked to PAD treatment intensity before amputation in veterans.

Veterans who lived within 13 miles of a primary care facility were more likely to receive vascular assessments before undergoing amputation compared with those further away, according to researchers.

“What we know from this study is that veterans who present with severe disease that leads to amputation are for the most part getting the vascular assessments they need, and they are getting them at a higher proportion than those patients who are treated in the private sector,” Olamide Alabi, MD, an assistant professor of vascular surgery at Emory University School of Medicine, told Healio. “Perhaps there is something to being served in an integrated health care model that lends to this? That is unclear at this time.”

Alabi and colleagues’ study aimed to examine how certain factors — health care utilization, geographic region and distance to primary care — affected vascular care in veterans prior to lower extremity amputation (LEA), often caused by peripheral artery disease, or PAD. According to the researchers, PAD affects more than 10 million individuals in the United States and is a leading cause of the 185,000 major LEAs that are performed annually.

Previous research has shown that vascular care is notably inconsistent among patients, with reasons unknown.

“For example, only 35% of patients have a noninvasive vascular laboratory study prior to LEA,” Alabi and colleagues wrote in JAMA Surgery.

For the study, the researchers used data from the Veterans Affairs (VA) Corporate Data Warehouse on 19,396 veterans (mean age, 66 years; 98.5% men) who had an LEA between March 1, 2010, to Feb. 28, 2020.

Compared with veterans who had four to 11 primary care visits in the year prior to LEA, Alabi and colleagues reported that those with fewer visits were less likely to receive a vascular assessment (adjusted OR [aOR)]) = 0.9; 95% CI, 0.82-0.99).

Veterans who lived more than 13 miles from a primary care clinic were also less likely to receive a vascular assessment compared with veterans who lived within 13 miles (aOR = 0.88; 95% CI, 0.8-0.95).

When examining trends by region, the researchers found that veterans who lived in the Midwest were the most likely to undergo a vascular assessment.

Although the researchers hypothesized that Black veterans would be less likely to receive a vascular assessment compared with white veterans, Alabi said there were no significant racial disparities.

“That is huge that we did not see racial disparities in how dedicated VA vascular surgeons are when it comes to saving the legs of our veterans,” she said. “This also means that we need to understand what happens to our patients with end-stage PAD before they meet a vascular surgeon.”

Regarding the management of PAD, all patients diagnosed with the condition “should be on guideline-directed medical therapy (these are published by the American Heart Association every 3 to 4 years),” Alabi said.

“Some patients with relatively mild manifestations of peripheral artery disease benefit from exercise therapy,” she explained. “Others with more severe manifestations of peripheral artery disease should be considered for surgery. This means all patients, veterans included.”

Alabi pointed out that while racial disparities were not present, geographic and socioeconomic factors may still play a role in research moving forward.

“We know race is a proxy for something ... likely other social and political determinants of health that remain understudied to date,” she said. “We found that there are regional differences in receipt of vascular assessment, perhaps there are best practices that we can learn from the regions that do well in that regard compared to the regions that do not do as well.”

References:

• Alabi O, et al. JAMA Surg. 2023;doi:10.1001/jamasurg.2023.0479.
• Emory-led study examines quality of care for veterans with serious artery disease. https://news.emory.edu/stories/2023/04/hs-veterans-peripheral-artery-disease-study/story.html. Published April 19, 2023. Accessed April 21, 2023.