目的:虽然多学科诊所可改善慢性威胁肢体缺血(CLTI)的预后,他们在解决社会经济差距方面的作用是未知的。我们的机构在传统的普通血管诊所和多学科的肢体保护计划(LPP)治疗CLTI患者。LPP位于少数民族社区,由一致的团队在单一设施提供快速护理。我们将LPP内的结果与我们机构的传统诊所进行了比较,并探讨了患者对护理障碍的看法,以评估LPP是否可以解决这些问题。
方法:2014-2023年在我们机构接受CLTI指数血运重建的所有患者均按临床类型(LPP或传统)进行分层。我们收集了临床和社会经济变量,包括区域剥夺指数(ADI)。使用卡方比较患者特征,学生t,或情绪中位数测试。使用对数秩和多变量Cox分析比较结果。我们还进行了半结构化访谈,以了解患者感知的障碍。
结果:从2014年至2023年,对871例患者的983条肢体进行了血运重建;在LPP内治疗了19.5%的肢体。与传统的门诊患者相比,更多的LPP患者是非白人(43.75%vs27.43%,p<0.0001),糖尿病(82.29%vs61.19%,p<0.0001),透析依赖性(29.17%和13.40%,p<0.0001),ADI处于最贫困的十分位数(29.38%对19.54%,p=0.0061),居住在靠近诊所的地方(中位数为6.73英里vs28.84英里,p=0.0120),WIfI分期更差(p<0.001)。免于死亡的自由没有区别,主要不良肢体事件(男性),或通畅性损失。在最贫困的亚组(ADI>90)中,与LPP患者相比,传统临床患者的通畅性丧失较早(p=0.0108).对整个队列的多变量分析表明,随着年龄的增长,心力衰竭,透析,慢性阻塞性肺疾病,WIfI分期的增加与早期死亡独立相关,男性与早期男性相关。通过便利抽样采访了10名传统临床患者。新出现的主题包括难以理解他们的疾病,访问频率高,交通障碍,对医疗系统的不信任,和病人-医生种族不一致。
结论:LPP患者的合并症和社会经济剥夺更严重,但与健康患者的结果相似,较少剥夺非LPP患者。多学科诊所的结构解决了几个患者感知的障碍。它靠近弱势患者,并且能够在一次访问中进行多次预约,可以解决交通和访问频率障碍,和一致的团队可以促进病人的教育和提高信任。在多学科诊所中包括这些元素并将其定位在需要的区域中可能会减轻社会经济剥夺对CLTI结果的一些负面影响。
OBJECTIVE: Although
multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a
multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution\'s traditional clinics and explored patients\' perspectives on barriers to care to evaluate if the LPP might address them.
METHODS: All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers.
RESULTS: From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance.
CONCLUSIONS: LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The
multidisciplinary clinic\'s structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a
multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.