Income-based differences in outpatient care of peripheral artery diseases in Germany

Background Peripheral artery disease (PAD) is a major manifestation of atherosclerosis and a risk factor for morbidity and mortality. Guideline-recommended therapy and specialized outpatient care are essential for optimal treatment. Income-based inequalities in diagnosis and treatment of cardiovascular diseases are present, while differences for PAD are scarse. Knowledge of the treatment structures in the outpatient setting are essential to identify and solve income-based inequalities in this high-risk population. Purpose Aim of the study was to identify income-based inequalities in outpatient treatment care and pharmacotherapy in PAD patients. Methods We analyzed income-based differences in PAD prevalence, pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, cardiology) in all statutorily insured patients with PAD presenting to outpatient care facilities in Germany between 2009 and 2018. The study is based on ambulatory claims data of the panel doctors' services according to §295 SGB V and drug prescription data according to §300 SGB V. Diagnosis of PAD was defined upon medical diagnoses of PAD ICD I70.2-9. Statistical analysis was performed with chi-squared test for trend and two-way Anova. Results Overall, 17,633,970 patients were included in the study. Prevalence of PAD was higher in low-income states. This income-driven gap widened between 2009 (2.3% vs 1.7%) and 2018 (4.4% vs 2.8%). Angiology outpatient care density was higher in low-income states, whereas vascular surgery and cardiology outpatient care density was higher in high-income states (p<0.05). While overall specialised outpatient care was underutilized, patients in low-income states were more likely to present to angiologists, while patients in high-income states more frequently presented to vascular surgeons. Patients with more progressed PAD stages were less likely to present to a specialist and to receive guideline recommended medical therapy, irrespective of the ...