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Limb Salvage Surgery for CLTI: Comparing Measures of Neighborhood Health Disparity
Joseph P Hart, Mark G Davies
Ascension Health, Waco, TX

Background: Health disparities influence the outcomes of vascular surgery interventions. Several composite measures of neighborhood social vulnerability exist, and this study compares and contrasts the performance of the three health disparity measures (Area Deprivation Index - ADI), Distressed Communities Index - DCI, and the Social Vulnerability Index - SVI) on the outcomes of patients undergoing a lower extremity intervention for chronic limb-threatening ischemia (CLTI).
Methods: Between 2018 and 2023, all patients undergoing a primary intervention for CLTI (bypass, BYP; endovascular interventions, EV; or major amputation, AMP) were analyzed. Patient addresses were geocoded, and estimated ADI, DCI, and SVI scores were assigned. The cutoff for high risk was an ADI (≥7th decile): a DCI (absolute score ≥50) and (≥70th percentile). Short-term objective performance goals and Amputation-free survival (AFS; survival without major amputation) were analyzed
Results: 1974 patients (55% male, age 64±12years, mean ± SD) underwent either EV (57%), a BYP (29%), or AMP (14%) for CLTI. The incidence of presenting disease severity, diabetes, obesity, and ESRD was significantly greater in each high-risk group (P=0.02). Documented access to primary care was significantly diminished for each high-risk group. High-risk patients underwent more complex procedures and underwent the majority of primary amputations compared to their equivalent low-risk group. Perioperative events, as measured by 30-day MACE (P=0.04), 30-day MALE (P=0.03), and 30-day major amputation(P=0.001), were significantly elevated in each high-risk group compared to the equivalent low-risk groups and exceeded the SVS objective performance goal thresholds. On multivariable modeling, patients with high social disparity as determined by SVI (OR 3.24, P < 0.001), ADI (OR 3.2, P < 0.001), and DCI (OR 2.01, P = 0.03) were more likely to have poor amputation-free survival compared with those with low social vulnerability. During follow-up, the designation of high risk of health disparity was associated with a significant increase in contralateral CLTI requiring intervention by SVI (OR 2.6, P=0.03), ADI (OR 2.8, P=0.03), and DCI (OR 22.3, P = 0.02).
Conclusions: Each neighborhood vulnerability index has an equivalent predictive value for adverse short-term and long-term outcomes after CLTI intervention. Assessing and addressing domains in social disparity risk using any of the three measures will identify higher-risk patients undergoing major lower extremity intervention for CLTI.
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