Procedural trends in the treatment of peripheral arterial disease by insurer status in New York State.

BACKGROUND: Type or lack of insurance may affect access to care, treatment, and outcomes. We evaluated trends for surgical management of all peripheral arterial disease (PAD) in-hospital admissions by insurer status in New York State.

STUDY DESIGN: Statewide Planning and Research Cooperative System (SPARCS) data were obtained and cross-referenced for diagnostic and procedure codes. Data from 2001 to 2002 were averaged and used as a baseline. Change in indication, volume of admissions, procedures, and amputations were calculated for the years 2003 to 2008 and were analyzed by insurer status.

RESULTS: There were 83,949 admissions. Endovascular intervention (EVI) increased tremendously for all indications and was used equally in the insured and uninsured. Among critical limb ischemia admissions, patients with private insurance were significantly more likely to be admitted for rest pain and significantly less likely to be admitted for gangrene (p < 0.001). Admission for gangrene declined for all. As EVI increased, amputation decreased and was significantly lowest in patients with private insurance (p < 0.001). Amputation was significantly higher in Medicaid than other insured (Medicaid vs private, p < 0.001; Medicaid vs Medicare, p = 0.003), but comparable to the uninsured (p = 0.08). Age greater than 65 years and low socioeconomic class or minority status were significant risks for gangrene (p = 0.014; p < 0.001) and ultimate amputation (p = 0.05; p < 0.001). Lack of insurance may pose a similar risk.

CONCLUSIONS: EVI increased tremendously and was used without disparity across insurer status. Amputation declined steadily and may have been related to increased EVI or to decreased admission for gangrene. Advanced age, low socioeconomic class or minority status, and lack of insurance negatively affect presentation and limb salvage. Universal health care may be beneficial in improving outcomes but must address root causes for delayed presentation.