title: Influence of race on the management of lower extremity ischemia: revascularization vs amputation.
abstract: OBJECTIVE
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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).
  
  
  METHODS
  Rates of amputation and revascularization for peripheral vascular disease across race/ethnicity.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Surgery, Yale University School of Medicine, New Haven, Connecticut 06511, USA. tyler.durazzo@yale.edu
authors.forename: Tyler S
authors.initials: TS
authors.lastname: Durazzo
authors.forename: Stanley
authors.initials: S
authors.lastname: Frencher
authors.forename: Richard
authors.initials: R
authors.lastname: Gusberg
mesh_terms: D001741:Black or African American; D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D015986:Confounding Factors, Epidemiologic; D005260:Female; D054625:Healthcare Disparities / Q000208:ethnology; D006801:Humans; D007511:Ischemia / Q000208:ethnology* / Q000601:surgery*; D016015:Logistic Models; D035002:Lower Extremity / Q000098:blood supply*; D008297:Male; D012189:Retrospective Studies; D014656:Vascular Surgical Procedures / Q000706:statistics & numerical data*