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Annals of Surgery:
doi: 10.1097/SLA.0b013e3181b41d53
Original Articles

Do Differences in Hospital and Surgeon Quality Explain Racial Disparities in Lower-Extremity Vascular Amputations?

Regenbogen, Scott E. MD, MPH*†; Gawande, Atul A. MD, MPH*‡; Lipsitz, Stuart R. ScD‡§; Greenberg, Caprice C. MD, MPH‡; Jha, Ashish K. MD, MPH*§¶

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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.

© 2009 Lippincott Williams & Wilkins, Inc.

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