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The Impact of Neighborhood Deprivation on Acute Limb Ischemia Presentation, Progression, and Outcomes
Khushie Matharoo
1, Jeffrey Gaskins
2, Nicholas Bandy
2, Hosam F El Sayed
3, Animesh Rathore
3, Matthew J Rossi
3, David J Dexter, III
3 1Eastern Virginia Medical School, Norfolk, VA;
2Sentara Norfolk General Hospital, Norfolk, VA;
3Sentara Vascular Specialists, Norfolk, VA
BACKGROUND: The Area Deprivation Index (ADI) is a composite measure of neighborhood disadvantage. It ranks geographic areas by 17 socioeconomic factors such as income, education, employment, and housing quality. It is reported in national or state percentiles and local deciles. Higher ADI scores indicate greater deprivation. ADI has been a validated tool used in numerous studies to evaluate poor health outcomes, hospital readmission, and barriers to care in several vascular disease states, however it has not been used to assess outcomes in acute limb ischemia (ALI). Our objective is to explore the relationship between geographic deprivation, as measured by the ADI, and the demographics and outcomes of patients receiving vascular surgery care in Virginia and North Carolina for ALI, with a focused analysis on the Hampton Roads region.
METHODS: A retrospective analysis was conducted on patients aged 18-89 years receiving vascular surgical care within a single regional health system from 2018-2022. Patients were identified using ICD-10 codes for thrombosis of the arteries of the lower extremity, and chart review confirming acute limb ischemia. Demographic variables include age, sex, race, ethnicity, body mass index (BMI), and insurance status. Comorbidity burden is assessed using the Charlson Comorbidity Index. ADI is used as a geographic measure of neighborhood socioeconomic disadvantage and recorded as both state decile and national percentile, based on each patient's primary residence at the time of presentation. The association between ADI and patient demographic characteristics is examined to identify regions of neighborhood deprivation across population subgroups. Geographic data are linked at the census block group level using publicly available ADI rankings. Patients are stratified by ADI for descriptive analysis and examined for associations with presentation severity, management strategies, and outcomes. Key outcomes include Rutherford classification at presentation, index procedure type (revascularization vs. amputation), reintervention within 30 days and 1 year, rehospitalization for recurrent ischemia within 1 year, length of stay, and major adverse limb events (MALE)-free survival.
Descriptive statistics were performed to summarize patient demographics and baseline characteristics in the 2022 cohort, with categorical variables reported as frequencies and percentages and continuous variables as means with standard deviations. The 2022 cohort was used for the analysis described herein. Associations between ADI and categorical outcomes such as Rutherford classification at presentation, index amputation, and reintervention were evaluated using Chi-square tests or Fisher's exact test where appropriate. Continuous outcomes, including hospital length of stay, were assessed using linear regression models and visualized with scatterplots and fitted regression lines. The relationship between ADI and probability of clinical events was further evaluated using logistic regression modeling. Major adverse limb event (MALE)-free survival was compared across ADI tertiles using Kaplan-Meier survival analysis with log-rank testing for group differences. All analyses were performed using JMP software (SAS Institute, Cary, NC).
RESULTS: From 2018-2022, 401 patients were identified with arterial thrombosis of the lower extremity, and 83 patients in 2022 were confirmed with ALI and treated within the healthcare system. The mean age was 63 years (range 34-89), with 59% male and 41% female. The racial distribution was 53% White, 45% African American, and 2% other. The mean ADI state decile was 6.38, and the mean ADI national percentile was 50.8, indicating moderate to high deprivation within the cohort.
Severity at presentation. A stepwise relationship is observed between ADI and Rutherford classification at presentation. Patients from higher ADI neighborhoods are less likely to present with Class I ischemia (p = 0.1183), and significantly more likely to present with Class IIa ischemia (p = 0.0439,
Figure 1). This suggests a trend toward delayed care and greater ischemic burden among patients residing in more deprived neighborhoods.
Reinterventions and rehospitalizations. Patients in higher ADI groups are equally likely to undergo reintervention within 30 days of their index procedure (p = 0.7343). Higher ADI groups have a higher frequency of revascularization in the 30-day to 1-year interval, trending towards significance (p = 0.2125). Within one year of index presentation, higher ADI is also associated with greater likelihood of rehospitalization for recurrent ischemia in the same limb or arterial segment, although not significantly.
Length of stay. Hospital length of stay demonstrates an association with neighborhood deprivation. Patients from high-ADI neighborhoods trend towards having longer hospitalizations compared with those from lower-ADI neighborhoods, reflecting either more advanced disease at presentation, greater perioperative morbidity, or challenges in discharge planning linked to social determinants of health (F = 1.3394; p = 0.2506).
Survival analysis. Kaplan-Meier analysis of MALE-free survival was performed across ADI tertiles. Patients in the lowest ADI tertile (least deprived) showed improved MALE-free survival compared to those in the second and third, highlighting a prognostic impact of neighborhood deprivation for long-term limb outcomes, although not significantly (p = 0.6019).
Geographic disparities. Mapping of the Hampton Roads region demonstrated clusters of high deprivation in urban areas such as Norfolk, Portsmouth, and Newport News. This geospatial alignment underscores the potential value of ADI for identifying communities at disproportionate risk (
Figure 2).
CONCLUSION: Neighborhood deprivation, as measured by the Area Deprivation Index, is associated with the presentation, treatment, and outcomes of acute limb ischemia. Patients from high-ADI neighborhoods presented with more advanced Rutherford classifications, as well as trended towards experiencing higher rates of late reintervention and facing prolonged hospital stays.
These findings establish ADI as a meaningful and practical tool for incorporating social determinants of health into vascular outcomes research. To our knowledge, this is the first study to use ADI to correlate neighborhood deprivation with disease severity, management strategy, and prognosis in ALI, extending its utility beyond chronic vascular conditions into the domain of vascular emergencies.
For clinicians and health care systems, these results highlight the importance of identifying disease earlier in areas where there are high levels of ADI. This can be done at the outreach and prevention level as well as when treating acute decompensation. Geospatial analysis of ADI may guide resource allocation toward high-risk communities, potentially reducing delays in presentation and improving limb salvage rates.
Data collection is ongoing to encompass all patients presenting from 2018-2022, with which we will conduct multivariable modeling to isolate the independent effect of ADI and analyze long-term endpoints outlined previously. We expect the trends seen in the 2022 cohort to become significant and robust with the inclusion of patients presenting from 2018-2021. Incorporating ADI into predictive models for ALI could improve risk adjustment and inform both patient counseling and healthcare policy. Ultimately, this study lays the groundwork for a new paradigm in vascular surgery that integrates geographic and socioeconomic context with clinical decision-making, advancing equity in limb salvage and vascular health.
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