Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

BACKGROUND: Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia. METHODS: A retrospective study was conducted at a regional tertiary care centre (2008-2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed. RESULTS: In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05-3.79), p = 0.036) and rural patients (OR 1.83(1.21-2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13-24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2-3.04), p = 0.007), and rural patients (OR 1.73(1.13-2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18-4.54), p = 0.015) and rural patients (OR 1.92(1.29-2.86), p = 0.001). CONCLUSIONS: This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.