Frailty is defined as a state of decreased physiologic reserve contributing to functional decline and adverse outcomes. Racial disparities in frail patients have been described sparsely in the literature. We aimed to ass...Frailty is defined as a state of decreased physiologic reserve contributing to functional decline and adverse outcomes. Racial disparities in frail patients have been described sparsely in the literature. We aimed to assess whether race influences frailty status in geriatric patients undergoing revascularization for peripheral artery disease (PAD) with chronic limb-threatening ischemia (CLTI). A 5-year analysis of the National Surgical Quality Improvement Program database included all geriatric (65 years and older) patients who underwent revascularization for lower extremity PAD with CLTI. The frailty index was calculated using a 11-variable modified frailty index and a cutoff of 0.27 indicated frail status. The primary outcome was an association of race or ethnicity with frailty status. We included 7,837 geriatric patients who underwent a surgical procedure (open: 55.2%) for PAD with CLTI. Mean age of patients was 75.4 years, 63.8% were male, 24.1% (n = 1,889) were frail, and 21.8% (n = 1,710) were African American (AA). Overall complication rate was 11.2% (n = 909) and overall mortality rate was 1.9% (n = 148). AA patients were more likely to be frail than White patients (29.6% v 23.9%; P = .03). AA and Hispanic patients were more likely to have complications (P = .03 and P = .001) and require readmission (P = .015 and P = .001) compared with White and non-Hispanic patients, respectively. Frail AA and frail Hispanic patients were more likely to have 30-day complications and readmission compared with frail White and frail non-Hispanic patients, respectively. Race and ethnicity influence frailty status in geriatric patients with PAD and CLTI. These disparities exist regardless of age, sex, comorbid conditions, and type of operative procedure. Additional studies are needed to highlight disparities by race and ethnicity to identify potentially modifiable risk factors to improve outcomes.
Lower extremity peripheral artery disease and the resultant complications disproportionately affect underrepresented racial and ethnic minority groups, as well as those with low socioeconomic status (SES). Revascularizat...Lower extremity peripheral artery disease and the resultant complications disproportionately affect underrepresented racial and ethnic minority groups, as well as those with low socioeconomic status (SES). Revascularization, including both open surgical and endovascular techniques, is a mainstay of therapy for symptomatic peripheral artery disease; it is required to maximize limb salvage in chronic limb-threatening ischemia and used to improve function and quality of life in patients with claudication. The outcomes of lower extremity revascularization in Black and Hispanic patients, as well as patients with low SES, are not widely known and this knowledge gap formed the basis for this review. The preponderance of evidence suggests that Black, Hispanic, and low-SES patients have inferior limb-related outcomes after revascularization compared with White patients. Based solely on the limited published evidence in the revascularization literature, the specific reasons for these disparities are not clear. The high prevalence of comorbidities and risks factors, as well as the advanced presentation of peripheral artery disease in Black, Hispanic, and low-SES patients, appear to contribute to the inferior limb outcomes post revascularization seen in these groups, but do not account for all of the disparities. Undoubtedly, a complex interplay of social determinants underlies these disparities in care and outcomes at individual, community, and societal levels. Additional understanding of the underpinnings and mechanisms of inferior outcomes in these populations in the specific context of lower extremity revascularization is needed, as this would allow us to identify targets for intervention to improve post-revascularization outcomes in these at-risk populations.
Peripheral artery disease (PAD) has been associated with poorer outcomes based on particular social determinants of health, including insurance status. A unique population to study treatment outcomes related to PAD is th...Peripheral artery disease (PAD) has been associated with poorer outcomes based on particular social determinants of health, including insurance status. A unique population to study treatment outcomes related to PAD is those with dual-eligible status-those who qualify for both Medicare and Medicaid-comprising more than 12 million people. We performed a systematic review of the literature surrounding dual-eligible patients and impact on PAD, with final inclusion of six articles. Dual eligibility has been associated with higher rates of comorbidities; more severe symptoms at initial presentation for PAD; and poorer treatment outcomes, including mortality. Further studies are needed to specifically look at the association between PAD and dual-eligible status, but what is clear is that patients in this population would benefit from early identification to prevent disease progression and improve equity.
Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularizatio...Peripheral artery disease (PAD) is a debilitating disease that disproportionately affects people of low socioeconomic status and racial minority individuals. These groups also tend to have lower rates of revascularization and worse outcomes, including higher rates of major amputation. In 2010, the Affordable Care Act (ACA) was signed into law, providing better opportunities for health care access to millions of uninsured Americans, although the implementation of different components started at a later date. Political issues led to uneven adaptation by states of the different ACA components. In states that adopted Medicaid expansion under the ACA, similar to that under the Massachusetts Health Care Reform Law of 2006, patients of low socioeconomic status and racial minority patients gained better access to health care. This review article will examine the disparities that exist in peripheral artery disease outcomes, as well as the effects of the ACA and Medicaid expansion on revascularization, limb salvage, and major amputation rates.
Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital...Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity.
McDermott KM, Bose S, Keegan A
… +1 more, Hicks CW
Semin Vasc Surg
· 2023 Mar · PMID 36958896
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Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (P...Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (PAD). Higher rates of major LEA in disadvantaged groups are associated with increased health care utilization and higher costs of care. Functional decline that often follows major LEA confers substantial risk of disability and premature mortality, and the burden of these outcomes is more prevalent in racial and ethnic minority groups, people with low socioeconomic status, and people in geographic regions where limited resources or distance from specialty care are barriers to access. We present a narrative review of the existing literature on estimated costs of diabetic foot disease and PAD, inequalities in care that contribute to excess costs, and disparities in outcomes that lead to a disproportionate burden of diabetes- and PAD-related LEA on systematically disadvantaged populations.
As peripheral artery disease (PAD) continues to affect many people in our population, the search continues for medical advances to improve the treatment algorithms for this debilitating disease. Prior research studies ha...As peripheral artery disease (PAD) continues to affect many people in our population, the search continues for medical advances to improve the treatment algorithms for this debilitating disease. Prior research studies have more than adequately documented the disparity that exists in the outcomes of patients with PAD based on race and ethnicity. One of the paths to clinical improvement and removal of the disparate outcomes is through application of the studied variables in a well-constructed clinical trial. Unfortunately, the groups that are known for worse outcomes are also those with limited enrollment into clinical trials, which exacerbates the problem. This article evaluates the issue of underrepresentation of racial and ethnic minority populations in clinical trials, addresses factors contributing to the problem, and provides possible pathways to a viable solution.
Brennan MB, Tan TW, Schechter MC
… +1 more, Fayfman M
Semin Vasc Surg
· 2023 Mar · PMID 36958894
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Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twic...Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.
Semin Vasc Surg
· 2023 Mar · PMID 36958893
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Chronic limb-threatening ischemia represents the morbid end stage of severe peripheral artery disease, with significant impact on patient quality of life. Early diagnosis of arterial insufficiency and referral for vascul...Chronic limb-threatening ischemia represents the morbid end stage of severe peripheral artery disease, with significant impact on patient quality of life. Early diagnosis of arterial insufficiency and referral for vascular intervention are essential for successful limb salvage. Disparate outcomes have been reported among patients residing in rural areas due to decreased access to care. Remote telemedicine outreach programs represent an opportunity to improve access to care in these rural communities. Establishment of a telehealth program requires identification of communities most in need of specialty care. After locating an ideal site, collaboration with local providers is necessary to develop a program that meets the specific needs of providers and patients. Surgeon guidance in development of screening and management algorithms ensures that patients obtain care reliably and with adjustments as needed to suit the referring provider, the patient, and the specialist. Telehealth evaluations can limit the financial burden associated with travel, while ensuring access to higher levels of care than are available in the patients' immediate area. Multiple barriers to telehealth exist. These include limited reimbursement, local provider resistance to new referral patterns, lack of in-person interaction and evaluation, and the inability to do a physical examination. Improved reimbursement models have made telehealth feasible, although care must be taken to ensure that practice patterns complement existing resources and are designed in a way that omits the need for in-person evaluation until the time of specialist intervention. Telemedicine is an underused tool in the arsenal of vascular surgeons. Targeted telehealth programs aid in increasing patient access to expert-level care, thereby improving health disparities that exist in rural populations.
Semin Vasc Surg
· 2023 Mar · PMID 36958892
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Major nontraumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease. Incidence of major LEAs consistently declined during...Major nontraumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease. Incidence of major LEAs consistently declined during the 1990s and 2000s, but rates have plateaued or increased in many regions during the past decade. Marked racial, ethnic, socioeconomic, and geographic disparities in risk of LEA persist and are related to inequalities in access to care and differential rates of attempted limb preservation. Multidisciplinary diabetic foot care (MDFC) is increasingly recognized as a necessary model for optimal management of patients with diabetic foot and vascular disease. This article reviews the role of MDFC in reducing major LEAs and the specific ways in which MDFC can mitigate disparities in care delivery and limb preservation outcomes. Access to MDFC among vulnerable populations remains a significant barrier to systematic reduction in major LEAs.
Minc SD, Powell C, Drudi LM
… +5 more, Young L, Kempe K, Ochoa L, Peek M, Dino G
Semin Vasc Surg
· 2023 Mar · PMID 36958891
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Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including th...Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.
Weaver ML, Sundland R, Adams AM
… +18 more, Faria I, Feldman HA, Gudmundsdottir H, Marmor H, Miles V, Ochoa B, Ruff SM, Tonelli C, Altieri MS, Cannada L, Dewan K, Etkin Y, Marmor R, Plichta JK, Reyna C, Tatebe L, Drudi LM, Hicks CW
Semin Vasc Surg
· 2022 Dec · PMID 36414364
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Peer review is a learned skill set that requires knowledge of study design, review construct, ethical considerations, and general expertise in a field of study. Participating in peer review is a rewarding and valuable ex...Peer review is a learned skill set that requires knowledge of study design, review construct, ethical considerations, and general expertise in a field of study. Participating in peer review is a rewarding and valuable experience in which all academic physicians are encouraged to partake. However, formal training opportunities in peer review are limited. In 2021, the Association of Women Surgeons and the journal Surgery collaborated to develop a Peer Review Academy. This academy is a 1-year longitudinal course that offers a select group of young women surgical trainees across all specialties a curriculum of monthly lectures and multiple formal mentored peer review opportunities to assist them in developing the foundation necessary to transition to independent peer review. The trainees and faculty mentors participating in the Association of Women Surgeons-Surgery Peer Review Academy compiled a summary of best peer review practices, which is intended to outline the elements of the skill set necessary to become a proficient peer reviewer.
In this article, we compare and contrast methods of reviewing, summarizing, and synthesizing the literature, including systematic reviews, scoping reviews, and narrative reviews. Review articles are essential to help inv...In this article, we compare and contrast methods of reviewing, summarizing, and synthesizing the literature, including systematic reviews, scoping reviews, and narrative reviews. Review articles are essential to help investigators wade through the plethora of exponentially growing medical literature. In the era of evidence-based medicine, a systematic approach is required. A systematic review is a formalized method to address a specific clinical question by analyzing the breadth of published literature while minimizing bias. Systematic reviews are designed to answer narrow clinical questions in the PICO (population, intervention, comparison, and outcome) format. Alternatively, scoping reviews use a similar systematic approach to a literature search in order to determine the breadth and depth of knowledge on a topic; to clarify definitions, concepts, and themes; or sometimes as a precursor to a systematic review or hypothesis generator to guide future research. However, scoping reviews are less constrained by a priori decisions about which interventions, controls, and outcomes may be of interest. Traditional narrative reviews still have a role in informing practice and guiding research, particularly when there is a paucity of high-quality evidence on a topic.
A statistic often quoted is that <15% of research is translated into practice and routine adoption of novel research findings can take up to 17 years. Dissemination and implementation science is a field of research focus...A statistic often quoted is that <15% of research is translated into practice and routine adoption of novel research findings can take up to 17 years. Dissemination and implementation science is a field of research focused on studying and developing approaches that can increase the uptake of such innovations, thereby reducing the significant time lag between scientific discovery and widespread adoption. As such, it can have a major clinical impact by increasing the utilization of proven innovations in routine clinical practice using systematic frameworks to implement, disseminate, and evaluate the successful application of evidence-based practices. Herein, we discuss the background and theory of implementation science, major frameworks and considerations for study design, and current examples of its application in surgical research.
Semin Vasc Surg
· 2022 Dec · PMID 36414361
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Mixed methods research is an approach that intentionally integrates both quantitative and qualitative research methods to answer a research question. The hallmark of mixed methods research is a focus on designing studies...Mixed methods research is an approach that intentionally integrates both quantitative and qualitative research methods to answer a research question. The hallmark of mixed methods research is a focus on designing studies that integrate both quantitative and qualitative data, yielding greater results than either method could yield on its own. There are a number of fundamental concepts that are essential to conducting mixed methods research. These include a methodological approach that employs one of the three core study designs, involvement of a multidisciplinary team that includes both methodological and subject matter experts, and meticulous planning to ensure that the data collected can ultimately be integrated to yield findings that answer the original research question to the investigators' (and funders') satisfaction. In this article, we will discuss mixed methods research designs, data sources typically used in mixed methods research, and common data analysis and integration strategies. We will also provide examples of mixed methods research projects that have been used in vascular surgery. The intent of this article was to provide an overview of the field of mixed methods research, enabling the reader to critically assess mixed methods research studies in the literature and consider how this methodology might benefit their own research endeavors.
Qualitative research aims to understand and describe subjective experiences and perceptions. Qualitative and mixed-methods research, in which quantitative and qualitative research methods are combined, is playing an incr...Qualitative research aims to understand and describe subjective experiences and perceptions. Qualitative and mixed-methods research, in which quantitative and qualitative research methods are combined, is playing an increasingly bigger role in vascular surgery research. The aim of this review was to describe the fundamentals of qualitative research methods and its application in vascular surgery.
Survey methodologies seek to answer questions regarding a set population's perceptions, attitudes, behaviors, or knowledge base, often pertaining to matters dealing with human behavior, social and psychological factors,...Survey methodologies seek to answer questions regarding a set population's perceptions, attitudes, behaviors, or knowledge base, often pertaining to matters dealing with human behavior, social and psychological factors, or educational research. However, they can also provide information on patient perceptions regarding disease processes or therapies. As such, questionnaires are valuable tools that researchers can use to answer specific questions. Despite this value, there is often little guidance provided to investigators or reviewers on how to use or interpret findings from these instruments. This article reviews survey terminology and provides a context from which to operate when deciding to use surveys in vascular surgery research.
Randomized controlled trials (RCTs) are widely considered to provide the highest-quality evidence for the comparative efficacy and safety of competing clinical strategies. The strength of using RCTs for causal inference...Randomized controlled trials (RCTs) are widely considered to provide the highest-quality evidence for the comparative efficacy and safety of competing clinical strategies. The strength of using RCTs for causal inference is derived from random treatment assignment and prospective data collection. Randomization eliminates confounding at the time of treatment group assignment, achieving exchangeability of the baseline study groups, such that they are the same, on average, except for the study intervention. Prospective data collection helps ensure that eligibility assessment, treatment assignment, and the start of follow-up are aligned temporally. Temporal alignment prevents biases that are common in observational research (eg, immortal time bias). In ideal settings, the results of an RCT provide the average causal effect of the intervention on the selected outcomes in the study population. Although observational research can estimate similar causal effects, observational designs require more assumptions and more advanced analytic frameworks than an RCT designed to answer the same question. Emerging trial designs, also discussed here, seek to address certain limitations of traditional RCT designs. The purpose of this review was to provide a broad overview of the central concepts in RCT design, implementation, conduct, and data analysis.
The field of vascular surgery is in constant evolution. Administrative data and registries can provide important contemporary evidence to inform clinical decision making and delivery of health services. This review outli...The field of vascular surgery is in constant evolution. Administrative data and registries can provide important contemporary evidence to inform clinical decision making and delivery of health services. This review outlines some important considerations for retrospective studies using administrative health databases and registries. First, these data sources have advantages (e.g., real-world applicability, timely data access, and relatively lower research cost) and disadvantages (e.g., potential missing data, selection bias, and confounding bias) that may be more or less relevant to different administrative databases or registries. Second, a framework to guide data source selection and provide a summary of frequently used data sources in vascular surgery research is discussed. Third, a retrospective study design warrants planned exposure, outcome, and covariate definitions and, when studying an exposure-outcome association, careful consideration of confounders through direct acyclic graphs. Finally, investigators must plan the most appropriate analytic approach, and we distinguish descriptive, explanatory, and predictive analyses.