title: Smoking cessation is the least successful outcome of risk factor modification in uninsured patients with symptomatic peripheral arterial disease.
abstract: BACKGROUND
  Patients with peripheral arterial disease (PAD) have multiple atherosclerotic risk factors. Risk factor modification can reduce severity of disease at presentation and improve treatment outcomes. The Trans-Atlantic Inter-Society Consensus II (TASC II) has issued several recommendations that are widely adopted by specialists. However, the ability to provide proper services to patients may depend on the specific patient's access to care, which is primarily determined by the presence of health insurance. The purpose of our study was to determine whether insurance status impairs the ability of patients with symptomatic PAD to meet select TASC II recommendations.
  
  
  METHODS
  A retrospective review of patients with symptomatic PAD from August 2011 to May 2013 was conducted; demographic, preoperative, procedural, and standard outcome variables were collected. Patients were divided into the insured group (private insurance, Medicare, Medicaid) or the uninsured group (self-pay). Insurance status was analyzed for its association to select TASC II recommendations: smoking cessation, referral to smoking cessation program, low-density lipoprotein cholesterol <2.59 mmol/L (<100 mg/dL), low-density lipoprotein cholesterol <1.81 mmol/L (<70 mg/dL), patients with coexisting hyperlipidemia and diabetes, glycated hemoglobin <7%, systolic blood pressure <140 mm Hg, prescription of aspirin, and prescription of a statin.
  
  
  RESULTS
  One hundred and forty-four patients with symptomatic PAD were identified. Insured patients were more likely to be African American, older at presentation, or have a diagnosis of congestive heart failure. There was no significant difference between insured and uninsured patients in success rates of low-density lipoprotein cholesterol targets (65.1% vs. 51.1% for <2.59 mmol/L; 24.3% vs. 19.1% for <1.81 mmol/L), glycated hemoglobin targets (61.9% vs. 61.1% for <7%), blood pressure control (51.1% vs. 50.0% for systolic blood pressure <140), aspirin use (72.8% vs. 59.6%), or statin use (77.2% vs. 63.5%). However, insured patients were more likely to quit smoking than uninsured patients (35.1% vs. 17.7%, P = 0.023). Furthermore, there was no difference in patterns of referral to a multidisciplinary smoking cessation program between the 2 groups (31.5% vs. 38.5%).
  
  
  CONCLUSIONS
  Insurance status does not impair patients' ability to meet most TASC II guidelines to modify cardiovascular risk factors in patients who have access to health care. Uninsured patients are, however, less likely to cease smoking compared with insured patients, despite no significant difference in referral patterns between the 2 groups for multidisciplinary smoking cessation counseling. Future efforts to assist patients with symptomatic PAD with atherosclerotic risk factor modification should focus on aiding uninsured patients in smoking cessation efforts.
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Kathy H
authors.initials: KH
authors.lastname: Huen
authors.affiliation: Department of Epidemiology, Emory University School of Public Health, Atlanta, GA.
authors.forename: Ritam
authors.initials: R
authors.lastname: Chowdhury
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Susan M
authors.initials: SM
authors.lastname: Shafii
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Luke P
authors.initials: LP
authors.lastname: Brewster
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Shipra
authors.initials: S
authors.lastname: Arya
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Yazan
authors.initials: Y
authors.lastname: Duwayri
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Ravi K
authors.initials: RK
authors.lastname: Veeraswamy
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA.
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Dodson
authors.affiliation: Division of Vascular Surgery, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA. Electronic address: r.rajani@emory.edu.
authors.forename: Ravi R
authors.initials: RR
authors.lastname: Rajani
mesh_terms: D000328:Adult; D001741:Black or African American; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000959:Antihypertensive Agents / Q000627:therapeutic use; D015897:Comorbidity; D005260:Female; D006297:Health Services Accessibility; D054625:Healthcare Disparities / Q000208:ethnology; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D000960:Hypolipidemic Agents / Q000627:therapeutic use; D008297:Male; D008484:Medicaid; D017057:Medically Uninsured / Q000208:ethnology; D006278:Medicare; D008875:Middle Aged; D058729:Peripheral Arterial Disease / Q000175:diagnosis / Q000208:ethnology / Q000628:therapy*; D012042:Registries; D012189:Retrospective Studies; D012307:Risk Factors; D040242:Risk Reduction Behavior; D012907:Smoking / Q000009:adverse effects / Q000208:ethnology; D016540:Smoking Cessation; D000074606:Smoking Prevention; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000959:Antihypertensive Agents; D007004:Hypoglycemic Agents; D000960:Hypolipidemic Agents