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Original Investigation |

Influence of Race on the Management of Lower Extremity Ischemia:  Revascularization vs Amputation

Tyler S. Durazzo, MD1; Stanley Frencher, MD1; Richard Gusberg, MD1
[+] Author Affiliations
1Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
JAMA Surg. 2013;148(7):617-623. doi:10.1001/jamasurg.2013.1436.
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Importance  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.

Objective  To investigate the amputation disparity between white and nonwhite patients with critical lower extremity ischemia in more detail using a larger data set than previous studies, with a focus on the role of confounding factors such as access and hospital resources.

Design, Setting, and Patients  All hospital discharge records from the Nationwide Inpatient Sample of adult patients with the primary diagnosis of critical lower extremity ischemia from 2002-2008 were examined in detail using multiple logistic regression (n = 774 399).

Main Outcomes and Measures  Rates of amputation and revascularization for peripheral vascular disease across race/ethnicity.

Results  Controlling for confounding factors, black patients were found to have 1.77 times the odds of receiving an amputation compared with white patients (95% CI, 1.72-1.84; P < .001). Further analysis revealed the black to white odds ratio paradoxically increased with increasing revascularization capacity of the presenting hospital, from a low of 1.43 (95% CI, 1.23-1.65) to a high of 1.98 (95% CI, 1.83-2.24). The amputation disparity also paradoxically increased for patients living in wealthier zip codes.

Conclusions and Relevance  Black patients have greater odds of undergoing amputation than white patients, even after correcting for an array of confounding parameters. 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. 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.

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Figures

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Figure 1.
Proportion of Patients With Critical Lower Extremity Ischemia Presenting to Hospitals of Different Revascularization Capacities

No statistical differences existed between hospital types to which black and white patients presented. Categories on the x-axis reflect the capacity of the hospital for performing lower extremity revascularization. Amputation-only hospitals did not perform a revascularization procedure during the study period. Hospitals in quartiles 1-4 performed an increasing volume of revascularizations.

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Figure 2.
Amputation Odds Ratio vs Revascularization Capacity of Hospitals

The x-axis indicates the capacity of a hospital to perform revascularization. The y-axis indicates the odds ratio of receiving amputation to receiving revascularization. Overall odds for receiving an amputation decreases when presenting to hospitals with greater revascularization capacity. However, the disparity between black and white patients was higher at hospitals with the greatest revascularization capacity, as reflected by the black to white odds ratio for amputation. All odds ratios were calculated using multiple logistic regression, correcting for confounding variables.

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Figure 3.
Amputation Odds Ratio vs Wealth of Residing Zip Code

The x-axis indicates the mean income of patients’ residing zip code, divided into quartiles. The y-axis indicates the odds ratio of receiving amputation to receiving revascularization. Overall odds for receiving an amputation were lower for patients residing in wealthier zip codes. However, the disparity between black and white patients increased as the wealth of zip code increased, as reflected by the black to white odds ratio for amputation. All odds ratios were calculated using multiple logistic regression, correcting for confounding variables.

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Odds Ratios and Relative Risks
Posted on March 21, 2013
Angela Sauaia, MD
University of Colorado Denver
Conflict of Interest: None Declared
Odds ratios offer a good approximation of the relative risk when the incidence of the outcome is low. Since the proportion of amputation was higher than 30%, this equivalence is no longer valid. (1) Could the authors please add a correction of the odds ratios or expand on how odds ratios should be interpreted? References1. Zhang J, Yu KF. What's the relative risk?: A method of correcting the odds ratio in cohort studies of common outcomes. JAMA: The Journal of the American Medical Association. 1998;280(19):1690-1.
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