Received: 23 June 2017
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Revised: 25 July 2017
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Accepted: 25 July 2017
DOI: 10.1111/joic.12431
ORIGINAL INVESTIGATION
Gender disparities among patients with peripheral arterial disease treated via endovascular approach: A propensity score matched analysis Rajkumar Doshi MD, MPH1
Priyank Shah MD, MPH, FACC2 |
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Perwaiz Meraj MD, FACC, FSCAI1 1 Department
of Cardiology, North Shore University Hospital, Northwell Health, Manhasset, New York
2 Department
of Cardiology, Medical College of Georgia-Southwest Clinical Campus, Albany, Georgia Correspondence Perwaiz M. Meraj, MD, FACC, Assistant Professor of Cardiology, Director of Fellowship Research, CHIP, Complex Structural Heart Disease, Associate Program Director, Cardiovascular Disease Fellowship Program, Department of Cardiology, Northwell Health, Hofstra − Northwell School of Medicine, Manhasset, NY. Email:
[email protected]
Background: Remarkable improvement in the treatment of Peripheral Arterial Disease (PAD) has led to changes in revascularization strategies from traditional open surgery to less invasive endovascular management. However, few studies are available on gender disparities in patients with PAD treated via an endovascular approach. This study was designed to analyze gender related differences with respect to in-hospital outcomes in PAD patients. Methods: Our data was obtained from National Inpatient Sample (NIS) 2012 through 2014. We used International Classification of Diseases, 9th Revision, Clinical Modification diagnostic and procedural codes appropriate for PAD and endovascular treatment. Endovascular treatment included drug eluting stent, bare metal stent, atherectomy or angioplasty of lower extremity arteries. A propensity score matching was performed to adjust for imbalances between variables. Results: Females presented late with more comorbidities and underwent more emergent/urgent procedures. After performing propensity score matched analysis, 25 758 patients were included in each group. There was no difference in in-hospital mortality between males and females in matched cohorts (2.3% vs 2.4%, P = 0.25). Acute renal failure, gangrene, infection, and composite of all complications were higher in males. Only blood transfusion was noted higher in females. Conclusion: This study revealed no difference in in-hospital mortality between males and females undergoing endovascular peripheral intervention. Males have a higher rate of complications compared to females which explains the higher cost of care in males. Further research with long-term follow up is needed to see if there is any difference with regards to long-term outcomes and re-admission. KEYWORDS
gender disparities, in-hospital outcomes, peripheral artery disease
Abbreviations: ALI, Acute Limb Ischemia; BMS, Bare Metal Stent; CAD, Coronary Artery Disease; CLI, Chronic Limb Ischemia; DES, Drug Eluting Stent; ICD 9 CM, International Classification of Diseases, Ninth Revision, Clinical Modification; NIS, National Inpatient Sample; PAD, peripheral Arterial Disease; PVI, Peripheral Vascular Intervention.
J Interven Cardiol. 2017;1–8.
wileyonlinelibrary.com/journal/joic
© 2017, Wiley Periodicals, Inc.
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DOSHI
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1 | INTRODUCTIO N
ET AL.
therapies using a large-scale inpatient sample from discharges in the United States.
Peripheral arterial disease (PAD) affects about 8-12 million individuals in the United States.1–4 The prevalence of PAD increases with age and it significantly increases after the age of 65.5 It is a considerable public burden as it impairs quality of life and is associated with significant morbidity and mortality.6 At the time of diagnosis of PAD, more than 60% patients are either asymptomatic or present with atypical symptoms.7 Compared to patients with coronary artery disease, patients with PAD are less likely to be adequately managed for
2 | METH ODS This study was exempted from Institutional review by Institutional review board as National Inpatient Sample (NIS) has de-identified data available from NIS database, collected by the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project (AHRQ HCUP).
hyperlipidemia, hypertension, and antiplatelet therapy.6,8 Most patients do not present with sensation of weakness in legs or claudication that occurs with exertion or cramping leg pain or discomfort. The management of PAD depends on the clinical presentation as it is highly variable. In the initial stage of the disease, supervised exercise is recommended for symptom improvement.9 Compared to patients with coronary artery disease, patients with PAD are less likely to be adequately managed for hyperlipidemia, hypertension, and antiplatelet therapy.6,8 Revascularization for improvement in symptoms for patients with lifestyle limiting claudication and inadequate response to goal directed medical therapy is reasonable.9 Patients with acute limb ischemia (ALI) should be treated immediately with either invasive or surgical procedure. As only a small patient population progresses to chronic limb ischemia (CLI), revascularization should be considered when there is life-style limiting symptoms such as claudication or rest pain. The ERASE trial randomized patients with claudication and aortoiliac (as well as femoropopliteal) disease to endovascular revascularization plus supervised exercise or supervised exercise alone. Although both groups had significant improvements in walking distance at 1 year, combined therapy had greater improvement.10 The 2017 PAD guidelines recommend endovascular procedures9 as: i) effective revascularization option for patients with lifestylelimiting claudication and hemodynamically significant aortoiliac occlusive disease (class 1), and ii) reasonable revascularization option for patients with lifestyle-limiting claudication and hemodynamically significant femoropopliteal disease (class 2a). There is a perception that women are less prone to develop PAD and this has led to under-diagnosis and late and advanced presentation in women.11–14 A study by Diehm et al demonstrated that among patients
