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. Despite clear guideline recommendations regarding medical treatment of patients, implementation of those guideline recommendations is still incomplete and significantly depends on social status and race. If gender-based inequalities in diagnosis and treatment of cardiovascular diseases are present has not been elucidated so far. Knowledge of treatment structures in the outpatient setting are essential to identify and solve gender-based inequalities in this high-risk population. 

Patients and methods

We analyzed gender-based differences in pharmacotherapy (statins, antiplatelets) and treatment by specialized outpatient care (angiology, vascular surgery, internal medicine, cardiology) in 17,633,970 patients with PAD and statutorily insurance 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, comprising 70.1 million patients per year. 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 and 53% were female. Only a minority of 37,1% presented to a vascular specialist (8,5% angiology, 10,2% vascular surgery, 24,6% cardiology) with no significant change over the course between 2009 and 2018. Interestingly, female patients were less likely to present to a vascular specialist and less likely to receive guideline recommended medical therapy. 

The gender gap between male and female patients presenting to a vascular specialist, however, narrowed in the observed time frame (angiology in 2009 1,8% vs 2018 1,0%; vascular surgery 2009 3,2% vs 2018 1,5%, p<0,0001).

Pharmacotherapy also significantly differed between female and male patients over the course of time. While prescription rates of statins and antiplatelet drugs increased (statins 42,8% vs 55,7% (male), 35,1% vs 45% (female); antiplatelets 29,2% vs 34,4% (male), 20,2 vs 24,3% (female)), the gender gap also increased between 2009 and 2018 (7,7% vs 10,7% (statins); 8,9% vs 10% (antiplatelets), p<0,0001).

Conclusions

Our results demonstrate that gender-based differences in pharmacotherapy and specialized outpatient care of patients with PAD are evident in Germany. While overall outpatient treatment by a vascular specialist and guideline recommended medical therapy of PAD are remarkably low, female patients are even less likely to receive both. Adherence to guideline recommended therapy is increasing, but the gender-gap continues to widen.