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


BACKGROUND
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.
Regenbogen
Scott E
SE
Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA. sregenbogen@partners.org
Gawande
Atul A
AA
Lipsitz
Stuart R
SR
Greenberg
Caprice C
CC
Jha
Ashish K
AK
D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D001157:Arterial Occlusive Diseases / Q000601:surgery*; D016009:Chi-Square Distribution; D002983:Clinical Competence; D005260:Female; D013502:General Surgery / Q000592:standards*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D007866:Leg / Q000601:surgery*; D016014:Linear Models; D008297:Male; D006278:Medicare; D016491:Peripheral Vascular Diseases / Q000601:surgery*; D018570:Risk Assessment; D012307:Risk Factors; D014481:United States; D014656:Vascular Surgical Procedures / Q000706:statistics & numerical data*; D044465:White People / Q000706:statistics & numerical data*