Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06511, USA.
JAMA Surg. 2013 Jul;148(7):617-23. doi: 10.1001/jamasurg.2013.1436.
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.
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).
Rates of amputation and revascularization for peripheral vascular disease across race/ethnicity.
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.
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.
在出现严重下肢缺血的患者中，先前的研究已经证实，白人患者比非白人患者更有可能接受血运重建治疗，这种差异主要归因于资源和获得医疗护理的差异。
利用比以往研究更大的数据集，更详细地研究白人患者和非白人患者之间在严重下肢缺血方面的截肢差异，并重点关注资源获取和医院资源等混杂因素的作用。
设计、地点和患者：详细检查了 2002-2008 年期间来自全国住院患者样本的患有严重下肢缺血的成年患者的所有住院记录，使用多项逻辑回归（n=774399）。
不同种族/族裔的外周血管疾病的截肢率和血运重建率。
在控制混杂因素后，黑人患者接受截肢的几率是白人患者的 1.77 倍（95%CI，1.72-1.84；P<0.001）。进一步分析显示，黑人与白人的比值比随着就诊医院的血运重建能力的增加而增加，从低值 1.43（95%CI，1.23-1.65）增加到高值 1.98（95%CI，1.83-2.24）。收入较高的邮政编码的患者的截肢差异也同样增加。
即使在纠正了一系列混杂参数后，黑人患者接受截肢的几率仍大于白人患者。与目前认为这种差异主要是由于资源获取的差异造成的观点相反，本研究发现，在资源最丰富的环境中，这种差异更大。这种差异的解释主要是基于患者个体、医生个体还是机构个体因素，仍有待确定，但这对于更好地了解我们的医疗体系和保持公平公正的方法至关重要。
