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 age. With the current demographic changes and an increasingly elderly society, age-based inequalities are becoming particularly important. If age-based inequalities in diagnosis and treatment of cardiovascular diseases are present has not been elucidated on a nation-wide cohort so far. Knowledge of treatment structures in the outpatient setting are essential to identify and solve inequalities in this high-risk population.

Patients and methods

We analyzed age-related differences in prevalence, 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. 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 28% were older than 80 years. 

PAD prevalence increased across all age groups between 2008 and 2019 (1,85% vs 3,14%). Of note, the proportion of the elderly population above 80 years increased by a third in that time frame (24,4 % vs 31,2%).

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, elderly patients were less likely to present to a vascular specialist and less likely to receive guideline recommended medical therapy. 

The age gap between patients above 80 years and younger patients presenting to a vascular specialist, however, narrowed in the observed time frame (angiology in 2009 3,4% vs 2018 2,6%; vascular surgery 2009 3,6% vs 2018 3,5%, p<0,05).

Pharmacotherapy also significantly differed between older and younger patients over the course of time. Patients older than 80 years continuously had lower prescription rates for statins and antiplatelets than younger patients (statins 2009 80,5% vs 19,5%, 2016 73,4% vs 26,6%; antiplatelets 2009 74,03% vs 25,97%, 2016 70,09% vs 29,9%). In the elderly population, however, prescription rates increased over the observed time-frame (p<0,05). 

Conclusions

Our results demonstrate that age-related 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, elderly patients are even less likely to receive both. Adherence to guideline recommended therapy is increasing, but the age-gap still poses a challenge.