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Blacks More Likely Than Whites to Undergo Leg Amputation
Blacks More Likely Than Whites to Undergo Leg Amputation
Laurie Barclay, MD
Mar 20, 2013
Black patients have greater odds than white patients of undergoing lower-extremity amputation rather than revascularization for ischemia, according to a hospital database study reported online March 20 in JAMA Surgery. These disparities persisted after correction for a range of confounding parameters and were greater in wealthier neighborhoods and in hospitals with greater resources.
"Among patients presenting with critical lower extremity ischemia, it has been previously documented that white individuals are more likely to undergo revascularization than nonwhite individuals, with the disparity largely attributed to differences in resources and access to care," write Tyler S. Durazzo, MD, from the Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
The study goal was to assess the disparity between white and nonwhite patients in use of amputation for critical lower-extremity ischemia. This study expanded on previous research by using a larger data set and by examining the role of confounding factors, including access and hospital resources.
Using multiple logistic regression, the investigators analyzed all hospital discharge records from the Nationwide Inpatient Sample of adults diagnosed with critical lower-extremity ischemia from 2002 to 2008 (n = 774,399).
Compared with white patients, black patients had 1.77 times (95% confidence interval [CI], 1.72 - 1.84; P < .001) the odds of undergoing amputation, after controlling for a range of confounding factors.
Paradoxically, the black-to-white odds ratio increased along with increasing revascularization capacity of the presenting hospital (range, 1.43 [95% CI, 1.23 - 1.65] to 1.98 [95% CI, 1.83 - 2.24]). And the black-to-white disparity in amputation increased for patients residing in wealthier ZIP codes.
"Contrary to current beliefs that the disparity is mainly secondary to differences in access, this study found that the disparity was magnified in settings where resources were greatest," the study authors write. "Whether the explanation lies primarily in patient-specific, physician-specific, or institutional-specific factors remains to be determined but is critical to better understanding our health care system and maintaining approaches that are consistently fair and equitable."
The amputation rate of Hispanic patients was intermediate: higher than in white patients but lower than in black patients.
Limitations of this study include retrospective design, unmeasured confounders, and little information regarding primary vs repeat amputation or ethnicity of Hispanic patients.
null
In an accompanying editorial, Karl A. Illig, MD, Division of Vascular Surgery, University of South Florida Health, Morsani College of Medicine, Tampa, notes that either healthcare provider bias or genetic differences in the disease process itself could explain the disparities.
"It may be the former, but we must investigate the latter to provide the best possible care for all our patients," Dr. Illig writes. "It is politically dangerous to raise the issue of consistent biologic variability between groups, but such variability unequivocally exists for certain genetically determined entities. If we ignore this issue, we run the risk of doing just what we are trying to avoid — giving one group of patients inferior care because we have not recognized the true cause of the problem."
The study authors and Dr. Illig have disclosed no relevant financial relationships.
JAMA Surg. Published online March 20, 2013.
http://www.medscape.com/viewarticle/781109?nlid=29465_1049&src=wnl_edit_dail
Laurie Barclay, MD
Mar 20, 2013
Black patients have greater odds than white patients of undergoing lower-extremity amputation rather than revascularization for ischemia, according to a hospital database study reported online March 20 in JAMA Surgery. These disparities persisted after correction for a range of confounding parameters and were greater in wealthier neighborhoods and in hospitals with greater resources.
"Among patients presenting with critical lower extremity ischemia, it has been previously documented that white individuals are more likely to undergo revascularization than nonwhite individuals, with the disparity largely attributed to differences in resources and access to care," write Tyler S. Durazzo, MD, from the Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
The study goal was to assess the disparity between white and nonwhite patients in use of amputation for critical lower-extremity ischemia. This study expanded on previous research by using a larger data set and by examining the role of confounding factors, including access and hospital resources.
Using multiple logistic regression, the investigators analyzed all hospital discharge records from the Nationwide Inpatient Sample of adults diagnosed with critical lower-extremity ischemia from 2002 to 2008 (n = 774,399).
Compared with white patients, black patients had 1.77 times (95% confidence interval [CI], 1.72 - 1.84; P < .001) the odds of undergoing amputation, after controlling for a range of confounding factors.
Paradoxically, the black-to-white odds ratio increased along with increasing revascularization capacity of the presenting hospital (range, 1.43 [95% CI, 1.23 - 1.65] to 1.98 [95% CI, 1.83 - 2.24]). And the black-to-white disparity in amputation increased for patients residing in wealthier ZIP codes.
"Contrary to current beliefs that the disparity is mainly secondary to differences in access, this study found that the disparity was magnified in settings where resources were greatest," the study authors write. "Whether the explanation lies primarily in patient-specific, physician-specific, or institutional-specific factors remains to be determined but is critical to better understanding our health care system and maintaining approaches that are consistently fair and equitable."
The amputation rate of Hispanic patients was intermediate: higher than in white patients but lower than in black patients.
Limitations of this study include retrospective design, unmeasured confounders, and little information regarding primary vs repeat amputation or ethnicity of Hispanic patients.
null
In an accompanying editorial, Karl A. Illig, MD, Division of Vascular Surgery, University of South Florida Health, Morsani College of Medicine, Tampa, notes that either healthcare provider bias or genetic differences in the disease process itself could explain the disparities.
"It may be the former, but we must investigate the latter to provide the best possible care for all our patients," Dr. Illig writes. "It is politically dangerous to raise the issue of consistent biologic variability between groups, but such variability unequivocally exists for certain genetically determined entities. If we ignore this issue, we run the risk of doing just what we are trying to avoid — giving one group of patients inferior care because we have not recognized the true cause of the problem."
The study authors and Dr. Illig have disclosed no relevant financial relationships.
JAMA Surg. Published online March 20, 2013.
http://www.medscape.com/viewarticle/781109?nlid=29465_1049&src=wnl_edit_dail
Barb: Registration to medscape.com is free and easy and well worth the time. I posted the entire article and cited my source so I didn't see a problem.
"......I had a brother-in-law that had to undergo amputation; he was treated by VA. He passed away last fall. He was white...."
Well, I guess that trumps the article which only "analyzed all hospital discharge records from the Nationwide Inpatient Sample of adults diagnosed with critical lower-extremity ischemia from 2002 to 2008 (n = 774,399)."
rivll: "The point is that "the disparity is *magnified* in settings where resources were greatest."
*That* really is scary."
Yes indeed, that is what troubled me.
"......I had a brother-in-law that had to undergo amputation; he was treated by VA. He passed away last fall. He was white...."
Well, I guess that trumps the article which only "analyzed all hospital discharge records from the Nationwide Inpatient Sample of adults diagnosed with critical lower-extremity ischemia from 2002 to 2008 (n = 774,399)."
rivll: "The point is that "the disparity is *magnified* in settings where resources were greatest."
*That* really is scary."
Yes indeed, that is what troubled me.
Paradoxically, the black-to-white odds ratio increased along with increasing revascularization capacity of the presenting hospital (range, 1.43 [95% CI, 1.23 - 1.65] to 1.98 [95% CI, 1.83 - 2.24]). And the black-to-white disparity in amputation increased for patients residing in wealthier ZIP codes.
"Contrary to current beliefs that the disparity is mainly secondary to differences in access, this study found that the disparity was magnified in settings where resources were greatest," the study authors write. "Whether the explanation lies primarily in patient-specific, physician-specific, or institutional-specific factors remains to be determined but is critical to better understanding our health care system and maintaining approaches that are consistently fair and equitable."
The point is that "the disparity is *magnified* in settings where resources were greatest."
*That* really is scary.
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"with the disparity largely attributed to differences in resources and access to care"
I had a brother-in-law that had to undergo amputation; he was treated by VA. He passed away last fall. He was white.
"with the disparity largely attributed to differences in resources and access to care"
I had a brother-in-law that had to undergo amputation; he was treated by VA. He passed away last fall. He was white.
And this scares me too.
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