Robert Wood Johnson Foundation, The University of Michigan, Ann Arbor, MI,
J Vasc Surg. 2011 Aug;54(2):420-6, 426.e1. doi: 10.1016/j.jvs.2011.02.035. Epub 2011 May 14.
Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared with whites.
Using inpatient Medicare data for the years 2003 through 2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. "Limb salvage care" was defined as limb-related admissions and procedures that occurred during the 2 years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races.
Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6% vs 31.6%; P < .0001), any limb-related admission (39.6% vs 44.7%; P < .0001), toe amputation (12.9% vs 13.8%; P < .0005), or wound debridement (11.6% vs 14.2%; P < .0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (odds ratios [OR], 0.72 [95% confidence interval, .68-.76]), limb-related admission (OR, 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR, 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions and were not accounted for by regional differences in where black and white patients received care.
Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making.
外周动脉疾病的黑人患者截肢率是白人患者的两到四倍。为了确定在保肢尝试方面的差异是否是造成这种差异的原因，我们研究了黑人患者截肢前的肢体护理情况，并将其与白人患者进行了比较。
我们使用 2003 年至 2006 年的医疗保险住院数据，确定了所有接受大下肢截肢手术的受益人的回顾性样本。“保肢护理”被定义为截肢前两年内发生的与肢体相关的入院和手术。我们使用多变量逻辑回归比较了黑人和白人截肢患者的血运重建率和其他肢体护理的接受率，并调整了个体患者特征。然后，我们控制了医院转诊区域，以评估护理方面的差异是否归因于黑人患者和白人患者接受护理的地理区域。最后，我们检查了两种种族的血运重建与截肢的时间关系。
我们的样本包括 24600 名黑人截肢患者和 65881 名白人截肢患者。与白人患者相比，黑人截肢患者更可能是女性，社会经济地位较低。种族之间的平均年龄、糖尿病发生率和合并症水平相似。黑人截肢患者接受血运重建的可能性明显低于白人患者（23.6%比 31.6%；P <.0001），接受任何与肢体相关的入院治疗的可能性也明显低于白人患者（39.6%比 44.7%；P <.0001），接受脚趾截肢的可能性也明显低于白人患者（12.9%比 13.8%；P <.0005），接受伤口清创术的可能性也明显低于白人患者（11.6%比 14.2%；P <.0001）。在调整了个体患者特征的差异后，黑人截肢患者接受血运重建的可能性仍明显低于白人患者（比值比[OR]，0.72 [95%置信区间，0.68-0.76]），接受与肢体相关的入院治疗的可能性（OR，0.81 [0.78-0.84]），或在截肢前接受伤口清创术的可能性（OR，0.80 [0.75-0.85]）。种族之间血运重建的时间关系相似。在医院转诊区域内观察到的护理差异确实存在，并且不能用黑人和白人患者接受护理的区域差异来解释。
黑人患者在截肢前接受保肢尝试的可能性远低于白人患者。进一步的研究应该探讨这种差异是否归因于与种族相关的动脉疾病严重程度、患者偏好或医生决策方面的差异。
