Defining the Burden of Indigent Vascular Care: The Impact of Socioeconomic Factors on Lower Extremity Revascularization

BACKGROUND: Within the context of healthcare system reform, the cost efficacy of lower extremity revascularization remains a timely topic. The impact of an individual patient’s socioeconomic status represents an under-studied aspect of vascular care, especially with respect to longitudinal costs and outcomes. The purpose of this study is to examine the relationship between socioeconomic status and these factors.
METHODS: A retrospective femoropopliteal revascularization database, which included socioeconomic factors (household income, education level and payor status), in addition to standard demographic, clinical, anatomical and procedural variables was analyzed over a three-year period. Patients were stratified by income level (low income [LI] < 200% federal poverty level [$42,400 for a household of 4], and higher income [HI] > 200% federal poverty level) and revascularization technique (open versus endovascular) and analyzed for the endpoints of primary assisted patency, amortized cost-per-day of patency and limb salvage. Data were analyzed with univariate and multivariate techniques.
RESULTS: A total of 187 cases were identified with complete data for analysis, 145 in the LI and 41 in the HI cohorts. LI patients differed from HI patients by mean age (66.2 ± 1.0 versus 61.8 ± 1.5 years, P = 0.04), high school graduate rate (51.4% versus 85.4%, P < 0.001), presence of tissue loss (30.1% versus 14.6%, P = 0.05), female gender (43.7% versus 22.0%, P = 0.01) and preoperative statin use (45.8% versus 75.6%, P < 0.001). There were no differences with respect other co-morbidities including smoking status, presence of diabetes, renal insufficiency, anatomic factors or treatment modality (open versus endovascular). Ninety seven patients underwent endovascular revascularization. The following outcomes were noted in the endovascular subset of LI and HI patients respectively: primary assisted patency (71% versus 66%, P = NS) and 12 month cost-per-day of patency ($166.30 ± 77.40 versus $22.45 ± 12.45, P = 0.05). Ninety-eight patients underwent open revascularization, with the following outcomes in LI and HI patients respectively: primary assisted patency (78% versus 86%, P = NS) and 12 month cost-per-day of patency ($319.43 ± 225.44 versus $40.47 ± 4.63, P = 0.07). Of the 77 patients with critical limb ischemia, 19 underwent eventual amputation. Multivariate analysis demonstrated that HI was protective against limb loss (odds ratio 0.06, 95% confidence interval 0.01 - 0.51, P < 0.001).
CONCLUSION: In patients undergoing femoropopliteal revascularization, income level correlates with advanced disease state presentation, advanced age (possibly a proxy for delayed presentation) and lack of statin use. While the primary assisted patency rate is not effected by income status, lower income patients demonstrate an increased cost-per-day of patency and inferior limb salvage compared to higher income patients. These data are the first to establish a relationship between income and metrics of lower extremity revascularization success, and demonstrate the financial and clinical burden associated with caring for these patients.