Socioeconomic Status Not Associated With Worse Outcomes After Open Lower Extremity Revascularization

Prior research has shown that socioeconomic status (SES) is correlated with higher rates of diabetes, peripheral vascular disease, and amputation. We sought to determine whether socioeconomic status or insurance type increases the risk of mortality, major adverse limb event (MALE), or hospital length of stay following open lower extremity revascularization. We conducted a retrospective analysis of a prospectively maintained database of patients who underwent open lower extremity revascularization at a single tertiary care center from January 2011 to March 2017 (n = 542). Socioeconomic status was determined using state area deprivation index (ADI), a validated metric determined by income, education, employment, and housing quality by census block group. In patients undergoing revascularization procedures on both limbs, each limb was treated individually for analysis. We performed a multivariate analysis of the association between ADI and insurance type with mortality, MALE, and hospital length of stay using Cox proportional hazard models, including confounding variables such as age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes. The cohort with an ADI of 1, meaning least deprived, and the Medicare cohort were used for reference. P values of <.05 were considered statistically significant. Of 542 patients reviewed, 245 patients undergoing surgery had complete data and were included. Controlling for age, gender, smoking status, body mass index, hyperlipidemia, hypertension, and diabetes, SES was not an independent predictor of mortality (Table I) (P = .974), MALE (P = .989), or hospital length of stay (P = .325). Controlling for the same confounders, insurance type was not independently correlated with mortality (Table II) (P = .164) or MALE (P = .743). Private insurance was associated with significantly longer hospital stays (P = .004). This study suggests that SES does not correlate with increased risk of mortality or MALE in patients undergoing open lower extremity revascularization. While insurance type did not impact risk of mortality or MALE, those with private insurance may have longer hospital stays following surgery. These findings suggest that individuals undergoing open lower extremity revascularization at this single tertiary care center received similar care, regardless of their SES or insurance type. Further study is warranted to determine the factors that led to these findings, including whether individuals with lower SES may be presenting too late for revascularization and instead undergo primary amputation.Table IMultivariate analysis of the association between socioeconomic status and postoperative outcomes using an area deprivation index (ADI) of 1 as the reference groupMultivariate hazard ratio [95% CI]P valueMortality ADI 20.97 [0.32-2.92].952 ADI 31.02 [0.36-2.89].969 ADI 40.91 [0.28-2.96].871 ADI 50.48 [0.17-1.33].159 ADI 60.51 [0.18-1.47].212 ADI 70.71 [0.24-2.10].541 ADI 81.04 [0.34-3.12].950 ADI 91.33 [0.30-5.97].707 ADI 100.98 [0.32-3.03].974 Age1.05 [1.03-1.08]<.001 Gender (male)1.28 [0.76-2.15].361 Smoking (yes vs no)0.79 [0.50-1.24].307 BMI0.99 [0.95-1.02].437 Hyperlipidemia (yes vs no)1.06 [0.57-1.98].844 Hypertension (yes vs no)1.39 [0.53-3.64].509 Diabetes (yes vs no)1.34 [0.86-2.11].201MALE ADI 20.56 [0.12-2.62].462 ADI 31.67 [0.43-6.46].459 ADI 41.12 [0.28-4.53].872 ADI 51.33 [0.35-5.04].677 ADI 61.16 [0.32-4.21].825 ADI 71.30 [0.36-4.75].690 ADI 82.33 [0.62-8.77].212 ADI 92.79 [0.67-11.59].159 ADI 101.01 [0.25-4.08].989 Age0.98 [0.96-1.00].097 Gender (male)0.89 [0.55-1.43].640 Smoking (yes vs no)1.13 [0.71-1.81].607 BMI1.00 [0.96-1.04].943 Hyperlipidemia (yes vs no)0.56 [0.33-0.95].033 Hypertension (yes vs no)2.99 [1.23-7.27].016 Diabetes (yes vs no)1.09 [0.69-1.72].711Hospital length of stay, days ADI 20.66 [0.23-1.91].444 ADI 30.67 [0.24-1.88].446 ADI 40.63 [0.21-1.91].411 ADI 50.73 [0.26-2.01].543 ADI 60.73 [0.27-1.99].532 ADI 70.55 [0.20-1.53].252 ADI 80.48 [0.16-1.41].183 ADI 90.57 [0.14-2.36].434 ADI 100.58 [0.19-1.73].325 Age1.03 [1.01-1.05].014 Gender (male)1.06 [0.66-1.70].821 Smoking (yes vs no)1.47 [0.91-2.35].113 BMI0.99 [0.96-1.03].674 Hyperlipidemia (yes vs no)1.28 [0.68-2.42].446 Hypertension (yes vs no)1.45 [0.53-3.92].469 Diabetes (yes vs no)1.07 [0.69-1.65].773BMI, Body mass index; CI, confidence interval; MALE, major adverse limb events. Open table in a new tab Table IIMultivariate analysis of the association between insurance type and postoperative outcomes using Medicare as the reference groupMultivariate hazard ratio [95% CI]P valueMortality Private1.55 [0.84-2.87].164 Medicaid1.60 [0.68-3.77].283 Self-pay2.46 [0.74-8.25].144 Age1.06 [1.03-1.08]<.0001 Gender (male)1.40 [ 0.88-2.22].150 Smoking (yes vs no)0.83 [0.53-1.30].404 BMI0.98 [0.94-1.01].186 Hyperlipidemia (yes vs no)1.06 [0.57-1.96].862 Hypertension (yes vs no)1.22 [0.47-3.17].679 Diabetes (yes vs no)1.37 [0.89-2.11].157MALE Private1.10 [0.61-1.99].743 Medicaid1.57 [0.75-3.28].236 Self-pay2.16 [0.83-5.61].114 Age0.99 [0.96-1.01].211 Gender (male)0.94 [0.60-1.47].775 Smoking (yes vs no)1.12 [0.71-1.75].625 BMI1.00 [0.96-1.04].914 Hyperlipidemia (yes vs no)0.62 [0.37-1.03].067 Hypertension (yes vs no)2.85 [1.18-6.91].020 Diabetes (yes vs no)1.04 [0.67-1.62].850Hospital length of stay, days Private1.79 [0.91-3.53].090 Medicaid1.28 [0.56-2.93].563 Self-pay1.84 [0.53-6.42].340 Age1.04 [1.02-1.06].001 Gender (male)1.07 [0.68-1.71].765 Smoking (yes vs no)1.56 [0.97-2.51].067 BMI0.99 [0.96-1.03].750 Hyperlipidemia (yes vs no)1.31 [0.69-2.50].415 Hypertension (yes vs no)1.40 [0.54-3.67].488 Diabetes (yes vs no)1.07 [0.69-1.65].757BMI, Body mass index; CI, confidence interval; MALE, major adverse limb events.Boldface entries indicate statistical significance. Open table in a new tab