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Food Insecurity Is Associated With Poor Outcomes After Revascularization For Chronic Limb Threatening Ischemia
Thomas McNamara, B.S., Max Zhu, B.S., Diana Rodriguez, Nikiruka Arinze, M.D., Thomas W. Cheng, M.D., Alik Farber, M.D., M.B.A., Elizabeth G. King, M.D., Andrea Alonso, M.D., Jeffrey J. Siracuse, M.D., M.B.A.
Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
OBJECTIVES: Social determinants of health (SDH) challenges have been associated with poor surgical outcomes. One aspect which has been poorly characterized is food insecurity. Our goal was to assess the association of food insecurity with outcomes after lower extremity revascularization for chronic limb threatening ischemia (CLTI) as this condition has been associated with higher rates of SDH challenges and malnutrition.
METHODS: A retrospective, single center review of patients presenting for a lower extremity revascularization (2018-2022) at a safety-net, tertiary hospital was conducted. Patients were classified as experiencing food insecurity, if self-reported on a SDH screen, or had a food pantry referral within one year. Outcomes included were ED visits, readmission, reintervention, amputation, and death up to 1 year. Univariable and multivariable analyses were performed.
RESULTS: There were 299 patients analyzed with 83% having tissue loss. Wound, ischemia and foot infection (WIfI) stages were 1 (10%), 2 (23%), 3 (31%), and 4 (36%). Interventions were 28% bypass (23% suprainguinal, 30% popliteal target, 57% tibial target), 3% endarterectomy, 8% hybrid, and 61% endovascular revascularization (14% iliac, 68% femoral-popliteal, and 47% tibial). Food insecurity was reported in 17% of patients. On multivariable analysis, younger age (OR .96, 95% CI .92-.99, P=.02) and African American race (OR 3.8, 95% CI 1.4-10.3, P=.01) were associated with food insecurity. Overall, patients with food insecurity had higher 30-day (54% vs. 29%) and 90-day (71% vs. 48%) ED visits as well as 30-day (38% vs. 22%) and 90-day (62% vs. 46%) readmissions (P<.05 for all). On unadjusted Kaplan-Meier analysis at 1-year, patients with food insecurity had similar amputation/death (32% vs. 27%, P=.38), reintervention/amputation/death (57% vs. 44%, P=.059), and mortality (14% vs. 17%, P=.7). Food insecurity was independently associated with 90-day readmission (OR 2.1, 95% CI 1.05-4.04, P=.04). For 1-year outcomes, food insecurity was independently associated with increased ED visits (OR 6.4, 95% CI 1.8-22.6, P=.004), readmissions (OR 4.2, 95% CI 1.5-11.6, P=.005), and increased amputation/death (HR 1.9, 95% CI 1.1-3.1, P=.013).
CONCLUSIONS: Food insecurity was common in our population of CLTI patients undergoing revascularization and was associated with higher readmissions and major amputations. Addressing this is in these high-risk patients is an area for targeted improvement.
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