Association of food and housing insecurity with outcomes after revascularization for chronic limb-threatening ischemia.

Abstract

Adverse social determinants of health (SDH) have been associated with unfavorable surgical outcomes. However, food and housing insecurity have been underexplored, especially in the context of peripheral artery disease. Our goal was to evaluate food and housing insecurity and associated outcomes in patients undergoing lower extremity revascularization for chronic limb-threatening ischemia (CLTI). A single-center, retrospective chart review was conducted at a safety-net hospital for patients undergoing lower extremity revascularization for CLTI who completed a SDH survey between 2017 and 2022 for housing insecurity and between 2018 and 2022 for food insecurity. Patients were classified as experiencing food insecurity if they self-reported on a SDH screen or if they had a food pantry referral within 1 year. Patients were categorized as housing insecure if they indicated unstable housing within 1 year of their procedure. Univariable and multivariable analyses were performed. For food insecurity, 299 patients were analyzed, with 17% reporting food insecurity. On multivariable analysis, younger age (odds ratio [OR], 0.96; 95% confidence interval [CI], 0.92-0.99; P = .02) and Black race (OR, 3.8; 95% CI, 1.4-10.3; P = .01) were associated with food insecurity. On unadjusted Kaplan-Meier analysis at 1 year, patients with food insecurity had similar major amputation, reintervention, or death rates (57% vs 44%; P = .06), major amputation or death (32% vs 27%; P = .38), and mortality (14% vs 17%; P = .7). On adjusted analysis, food insecurity was associated with increased emergency department visits (OR, 6.4; 95% CI, 1.8-22.6; P < .01), readmissions (OR, 4.2; 95% CI, 1.5-11.6; P < .01), and increased risk of amputation/death (hazard ratio [HR], 1.88; 95% CI, 1.14-3.06; P = .01) at 1 year. For housing insecurity, 314 patients were analyzed, with 13% reporting housing insecurity. On multivariable analysis, current tobacco use (OR, 15.3; 95% CI, 5.2-45; P < .01) and coronary artery disease (OR, 3; 95% CI, 1.1-8.1; P = .03) were associated with housing insecurity. Kaplan-Meier unadjusted analysis at 1 year indicated similar rates of survival in patients with and without housing insecurity (90% vs 82%; P = .27), but patients with housing insecurity had lower rates of any medical follow-up at 1 year (69% vs 88%; P < .01), which remained significant on risk adjusted analysis (HR, 4.8; 95% CI, 1.9-12.7; P < .01). Food and housing insecurity were reported in 17% and 13% of patients undergoing revascularization for CLTI, respectively. Postoperatively, food insecurity was associated with increased emergency department visits, readmissions, and major amputations/death. Housing insecurity was associated with loss to medical follow-up within 1 year of revascularization. SDH challenges should be screened and addressed in patients with CLTI undergoing surgery to potentially limit these adverse outcomes.