Temporal and Geographic Trends in the Treatment of Peripheral Arterial Disease Stratified by Race among Medicare Beneficiaries

Importance: Racial disparities in the management of peripheral arterial disease (PAD) are well established. Analysis of the temporal trends and geographic variation in racial differences in the use of revascularization and major amputation may identify areas for targeted intervention. Objective: To investigate differences in the treatment of PAD between Black and White patients over time and by US state. Design, Setting, and Participants: This cohort study examined data for Medicare fee-for-service beneficiaries with a PAD diagnosis between 2018 and 2022. Data were analyzed from November 14, 2023, to February 13, 2025. Exposures: Black and White race. Main Outcomes and Measures: The proportions of Black and White patients with PAD undergoing revascularization and major amputation were compared over time and by state. Data were adjusted for age, sex, hypertension, diabetes, tobacco use, chronic kidney disease, and county-level Social Vulnerability Index (SVI). Results: The total sample size was 2376300 beneficiaries (1224537 men [51.5%]). Black patients (219338 [9.2%]) were slightly younger than White patients (2156962 [90.8%]; mean [SD] age, 75.8 [7.9] years vs 76.9 [7.8] years; P <.001) and had a higher prevalence of comorbidities. A higher proportion of Black patients (8.9%) than White patients (7.6%) underwent revascularization (odds ratio, 1.19 [95% CI, 1.18-1.21]; P <.001), and a higher proportion of Black patients (2.8%) than White patients (1.0%) underwent major amputation (odds ratio, 2.91 [95% CI, 2.83-2.99]; P <.001). Higher proportions of Black patients than White patients underwent revascularization and major amputation in the majority of states, although with marked variation in these proportional differences across states. The proportions of Black and White patients who underwent revascularization decreased over time (from 8.0% to 7.4% for Black patients and from 6.8% to 6.2% for White patients). The proportion of Black patients who underwent major amputation decreased (from 2.9% to 2.5%; P <.001), but there was no change among White patients (from 0.7% to 0.7%; P =.53). Revascularization correlated weakly (ρ = 0.10), and amputation correlated moderately with SVI (ρ = 0.46). Conclusions and Relevance: These findings suggest that higher proportions of Black patients than White patients undergo invasive procedures for PAD, with considerable variation across states. Although the proportional difference in major amputations has narrowed over time, the persistent proportional excess of major amputations among Black patients requires further study to investigate whether this difference reflects remediable disparities in care.