Clinician Specialty, Access to Care, and Outcomes Among Patients with Peripheral Artery Disease

Published:October 07, 2021DOI:



      Understanding the relationship between patterns of peripheral artery disease and outcomes is an essential step toward improving care and outcomes. We hypothesized that clinician specialty would be associated with occurrence of major adverse vascular events (MAVE).


      Patients with at least 1 peripheral artery disease-related encounter in our health system and fee-for-service Medicare were divided into groups based on the specialty of the clinician (ie, cardiologist, surgeon, podiatrist, primary care, or other) providing a plurality of peripheral artery disease-coded care in the year prior to index encounter. The primary outcome was MAVE (a composite of all-cause mortality, myocardial infarction, stroke, lower extremity revascularization, and lower extremity amputation).


      The cohort included 1768 patients, of whom 30.0% were Black, 23.9% were Medicaid dual-enrollment eligible, and 31.1% lived in rural areas. Patients receiving a plurality of their care from podiatrists had the highest 1-year rates of MAVE (34.4%, P <.001), hospitalization (65.9%, P <.001), and amputations (22.6%, P <.001). Clinician specialty was not associated with outcomes after adjustment. Patients who were Medicaid dual-eligible had higher adjusted risks of mortality (adjusted hazard ratio [HRadj] 1.54, 95% confidence interval [CI] 1.11-2.14) and all-cause hospitalization (HRadj 1.20, 95% CI 1.03-1.40) and patients who were Black had a higher adjusted risk of amputation (HRadj 1.49, 95% CI 1.03-2.15).


      Clinician specialty was not associated with worse outcomes after adjustment, but certain socioeconomic factors were. The effects of clinician specialty and socioeconomic status were likely attenuated by the fact that all patients in this study had health insurance; these analyses require confirmation in a more representative cohort.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Allison MA
        • Ho E
        • Denenberg JO
        • et al.
        Ethnic-specific prevalence of peripheral arterial disease in the United States.
        Am J Prev Med. 2007; 32: 328-333
        • Zafar AM
        • Dhangana R
        • Murphy TP
        • et al.
        Lower-extremity endovascular interventions for Medicare beneficiaries: comparative effectiveness as a function of provider specialty.
        J Vasc Interv Radiol. 2012; 23: 3-9.e1-14
        • Wallace JR
        • Yuo T
        • Marone L
        • Chaer RA
        • Makaroun MS
        Outcomes of endovascular lower extremity interventions depend more on indication than physician specialty.
        J Vasc Surg. 2014; 59: 376-383.e3
        • Kalbaugh CA
        • Loehr L
        • Wruck L
        • et al.
        Frequency of care and mortality following an incident diagnosis of peripheral artery disease in the inpatient or outpatient setting: the ARIC (Atherosclerosis Risk in Communities) study.
        J Am Heart Assoc. 2018; 7e007332
        • Regenbogen SE
        • Gawande AA
        • Lipsitz SR
        • Greenberg CC
        • Jha AK
        Do differences in hospital and surgeon quality explain racial disparities in lower-extremity vascular amputations?.
        Ann Surg. 2009; 250: 424-431
        • Lasota AN
        • Overvad K
        • Eriksen HH
        • Tjonneland A
        • Schmidt EB
        • Gronholdt MM
        Validity of peripheral arterial disease diagnoses in the Danish National Patient Registry.
        Eur J Vasc Endovasc Surg. 2017; 53: 679-685
        • Hong Y
        • Sebastianski M
        • Makowsky M
        • Tsuyuki R
        • McMurtry MS
        Administrative data are not sensitive for the detection of peripheral artery disease in the community.
        Vasc Med. 2016; 21: 331-336
        • Weissler EH
        • Lippmann SJ
        • Smerek MM
        • et al.
        Model-based algorithms for detecting peripheral artery disease using administrative data from an electronic health record data system: algorithm development study.
        JMIR Med Inform. 2020; 8: e18542
        • Birman-Deych E
        • Waterman AD
        • Yan Y
        • Nilasena DS
        • Radford MJ
        • Gage BF
        Accuracy of ICD-9-CM codes for identifying cardiovascular and stroke risk factors.
        Med Care. 2005; 43: 480-485
        • Quan H
        • Sundararajan V
        • Halfon P
        • et al.
        Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data.
        Med Care. 2005; 43: 1130-1139
        • Saely CH
        • Sternbauer S
        • Vonbank A
        • et al.
        Type 2 diabetes mellitus is a strong predictor of LDL cholesterol target achievement in patients with peripheral artery disease.
        J Diabetes Complications. 2020; 34107692
      1. Agency for Healthcare Research and Quality. Chartbook on Access to Health Care. Available at: Accessed November 17, 2020.