Do differences in hospital and surgeon quality explain racial disparities in lower-extremity vascular amputations?

Full Abstract

OBJECTIVE: To understand whether racial disparities in surgery for lower-extremity arterial disease are minimized by high-quality providers, or instead, differential treatment of otherwise similar patients pervades all settings. SUMMARY BACKGROUND DATA: Black patients are substantially more likely than whites to undergo amputation rather than revascularization for lower-extremity arterial disease. Because their care is disproportionately concentrated among a small share of providers, some have attributed such disparities to the quality and capacity of these sites. METHODS: We evaluated all 86,865 white or black fee-for-service Medicare beneficiaries 65 and older who underwent major lower-extremity vascular procedures. Using generalized linear mixed models with random effects, we computed risk-adjusted odds of amputation by race overall, and after serial substratification by salient patient and provider characteristics. RESULTS: Blacks were far more likely to undergo amputation (45% vs. 20%). Their procedures were performed more often by nonspecialists (41% vs. 27%; P < 0.001), in low-volume hospitals (40% vs. 32%; P < 0.001), with high amputation rates (53% vs. 29%; P < 0.001). Controlling for differences in comorbidity, disease severity, and surgeon and hospital performance, blacks' odds of amputation remained 1.7 times greater (95% confidence interval: 1.6-1.9). Even among highest-performing providers-vascular specialists in high-volume, urban teaching hospitals with angioplasty facilities-racial gaps persisted (risk-adjusted amputation rates: 7% for blacks vs. 4% for whites, P < 0.001; odds ratio: 1.8, 95% confidence interval: 1.5-2.1). CONCLUSIONS: Black patients with critical limb ischemia face significantly higher risk of major amputation, even when treated by providers with highest likelihoods of revascularization. Increased referral to high-performing providers might increase limb-preservation, but cannot eliminate disparities until equitable treatment can be ensured in all settings.

Author information

Author/s: Regenbogen, Scott E (SE); Gawande, Atul A (AA); Lipsitz, Stuart R (SR); Greenberg, Caprice C (CC); Jha, Ashish K (AK);

Affiliation: Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA. sregenbogen(-atsign-)partners.org

Journal and publication information

Publication Type: Journal Article; Research Support, Non-U.S. Gov't

Journal: Annals of surgery (Ann Surg), published in United States. (Language: eng)

Reference: 2009-Sep; vol 250 (issue 3) : pp 424-31

Dates: Created 2009/09/09; Completed 2009/10/08;

PMID: 19652590, status: MEDLINE (last retrieval date: 10/8/2009, IMS Date: )

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