Article
Racial/Ethnic Disparities in Revascularization for Limb Salvage: An Analysis of the National Surgical Quality Improvement Program Database
Vascular and Endovascular Surgery 2014, Vol. 48(5-6) 402-405 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414543276 ves.sagepub.com
Kakra Hughes, MD, FACS1, Christopher Boyd, MD1, Tolulope Oyetunji, MD1, Daniel Tran, MD1, David Chang, MD2, David Rose, MD1, Suryanarayan Siram, MD1, Edward Cornwell III, MD1, and Thomas Obisesan, MD3
Abstract Introduction: Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and a lower rate of revascularization for limb salvage when compared to white patients. Objective: We undertook this study to determine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascular techniques has had an impact on this disparity. Methods: The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee amputation as well as all patients who had undergone an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among the different ethnic groups. Results: There were 1568 patients identified in the NSQIP database as having undergone a major lower extremity amputation in 2005 and 2006. Of these patients, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data. The group undergoing amputation was primarily male (61%) with a mean age of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did not have identifying ethnic data. Open surgical patients were primarily male (63%) with a mean age of 66. Median length of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a mean age of 68. Median length of stay was 5 days, and 30-day mortality was 4%. Conclusion: There remains a significant ethnic disparity in limb-salvage revascularization. Blacks comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity. Keywords limb ischemia, amputation, revascularization, racial/ethnic disparities
Introduction Ethnic differences appear to continue to play some role in the type of health care Americans receive even in contemporary times.1-3 It was reported as far back as 2 decades ago that blacks have a higher rate of major lower extremity amputation and a lower rate of limb-salvage revascularization procedures as compared to whites.4-7 Despite recent advances in health care, these disparities have continued to persist. Indeed, 1 recent study reports that blacks are 2 to 4 times less likely to have any type of limb-salvage procedure attempted 2 years
1
Department of Surgery, Howard University, Washington, DC, USA Department of Surgery, University of California, San Diego, CA, USA 3 Department of Internal Medicine, Howard University, Washington, DC, USA 2
Corresponding Author: Kakra Hughes, Department of Surgery, Howard University, 2041 Georgia Avenue NW, 4B.04. Washington, DC 20060, USA. Email: [email protected]
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
Hughes et al
403
prior to amputation as compared to whites.8 Although some have suggested that this disparity may be explained by limited access to limb-salvage revascularization for blacks,9 the demonstration that this disparity is even more pronounced in centers that have increased revascularization capabilities suggests that access alone may not explain this discrepancy.1 An underlying biologic difference in ethnicity has been suggested as a potential factor for this health care disparity.3 Blacks have been noted to have an increased risk of diabetes mellitus, a well-known risk factor for developing peripheral arterial disease.10 Even so, nondiabetic blacks are also reported to be more likely to undergo a major lower extremity amputation as compared to nondiabetic whites.1,8 Moreover, it has been observed that even when one controls for diabetes, blacks are still less likely to receive limb-salvage revascularization.6 We undertook this study in an attempt to evaluate this disparity in recent times and to determine how this may have been impacted by the widespread adoption of endovascular revascularization techniques.
Methods The National Surgery Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent an above- or below-knee amputation as well as all patients who underwent an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded. Preoperative comorbidities were defined as cardiac (history of coronary artery disease, congestive heart failure, or a history of percutaneous transluminal coronary angioplasty or coronary artery bypass graft), pulmonary (chronic obstructive pulmonary disease or active pneumonia), renal (acute renal failure or dialysisdependent renal failure), and diabetes (insulin- or noninsulindependent diabetes mellitus). Comparisons were made among the different ethnic groups, and statistical differences were identified by using standard chi-square analysis and Student t testing.
Table 1. Demographics.
Percent male Mean age, years Median length of stay, days 30-Day mortality, %
Amputation
Open Surgery
Endovascular
61 65 11
63 66 6
61 68 5
9
3
4
Table 2. Comorbidities: Open Surgery.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Cardiac
Pulmonary
Renal
Diabetes
41 36 39 60 .018
15 10 6 7 .009
5 16 12 13 .000
33 46 62 40 .000
Cardiac
Pulmonary
Renal
Diabetes
43 33 39 40 .160
16 11 0 0 .259
3 16 8 20 .000
27 42 46 20 .018
Cardiac
Pulmonary
Renal
Diabetes
45 31 48 55 .000
17 10 11 27 .001
22 31 28 27 .000
59 60 80 55 .663
Table 3. Comorbidities: Endovascular.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Table 4. Comorbidities: Amputation.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Results There were 1568 patients identified in the NSQIP database as having undergone a major limb amputation (defined as an above- or below-knee amputation) in 2005 and 2006. Of these, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data and 0.8% were listed as other. Patients undergoing amputation were primarily male (61%) with a mean age of 65. Median length of stay was 11 days and 30-day mortality was 9% following a major amputation. During this same time interval, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage (ie, preoperative diagnosis was either ischemic rest pain or tissue loss). Of those patients undergoing an open limb-salvage procedure, 74% were white, 12% black, 4% Hispanic, and 0.4% Asian. Identifying ethnic data were not available for 10% of these patients. Open surgical patients were primarily male (63%) with a mean age of 66. Median length
of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. Endovascular patients were mostly male (61%) with a mean age of 68. Median length of stay was 5 days and 30-day mortality was 4%, Table 1. When comorbidities were compared across ethnicities, blacks undergoing open or endovascular revascularization were significantly more likely to have renal comorbidities and diabetes mellitus as compared to whites, whereas whites undergoing open surgery were more likely to have pulmonary comorbidities. For patients undergoing amputation, there was no statistically significant difference in cardiac comorbidity among ethnic groups. Blacks, however, were more likely to have renal comorbidities as compared to whites, while whites were more likely to have pulmonary comorbidities as compared to blacks, Tables 2 to 4.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
404
Vascular and Endovascular Surgery 48(5-6)
Figure 1. Distribution of surgical procedure by race.
Discussion Employing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a multiinstitutional surgical outcomes database incorporating over 100 hospitals nationwide, we were able to describe the practice of amputation and limb-salvage revascularization across the United States.11 Although peripheral arterial disease affects 8 to 10 million Americans every year,12 it is a minority with critical limb ischemia (ie, ischemic rest pain and/or tissue loss) who are in danger of limb loss and, therefore, require prompt revascularization, that is, limb-salvage revascularization.12 Blacks, who make up approximately 13% of the US population,8 appear to be overrepresented among patients receiving amputations (29% of all amputation patients) and underrepresented among limb-salvage revascularization patients (12% of all patients undergoing open limb-salvage revascularization and 10% of all patients undergoing limb-salvage endovascular revascularization), Figure 1. This finding is concordant with the study by Feinglas et al demonstrating that postal codes that were primarily populated by blacks were associated with a higher rate of amputation as compared to postal codes primarily populated by whites.2,4 Our study is also in agreement with the report by Holman et al, indicating that blacks have a significantly less likelihood of having any type of attempt at revascularization or minor amputation prior to above- or below-knee amputation.8 Other more recent reports also corroborate our findings.2,13 The fact that blacks undergoing open revascularization were less likely to have cardiac and pulmonary comorbidities suggests that these patients were not offered limb-salvage surgery less frequently because they were less likely to be physiologically able to tolerate these operations. Instead, the higher incidence of renal failure and diabetes in blacks might suggest a potential explanation for the higher selection for amputation in this ethnic group. Unfortunately, there continues to be an existing bias in the medical community against limb revascularization for patients with diabetes due to an erroneous concept of ‘‘small vessel disease.’’14 Despite repeated refutations by anatomic, physiologic, and clinical studies,15-18 this archaic notion persists and may be responsible for potentially unnecessary amputations being undertaken in patients with diabetes mellitus.19,21 As has already been discussed (in Introduction), diabetes mellitus, alone, however, does not adequately explain this disparity.
Hypertension has aptly been described as a well-known adverse cardiovascular risk factor, especially in the black population.20-23 In our study, whites presented with significantly more cardiac comorbidities as compared to blacks potentially leading one to conclude that hypertension may not play a significant role in this disparity. It is, nonetheless, important to consider that some of these patients who do ‘‘not have’’ a comorbidity may simply be ‘‘not yet diagnosed.’’24 Although our study focused on the ethnic disparities in the black population, a similar disparity has also been reported for the Hispanic/Latino community. Hispanics have been reported to have proportionally more amputations associated with diabetes than non-Hispanic whites and even blacks.25 Of note, it has been suggested that improperly treated diabetes has a disproportionate effect on Hispanics.26,27 In a recent triumvirate health care system analysis of public, private, and Veterans Administration hospitals, Blumberg et al reported that Hispanics were significantly more likely to develop advanced diabetic foot ulcers and eventual amputation due to poor treatment as compared to whites.28 Although the Hispanic population is estimated to be 17%,29 Hispanics comprised 8% of those undergoing amputation while accounting for only 4% of all patients receiving open revascularization and 2% of all patients undergoing endovascular revascularization in our study. Clearly additional studies focusing on the Hispanic population are needed. There are several limitations to this study. The established pitfalls of NSQIP have been abundantly described,30 as having specific challenges of using this database in vascular research.31 The difficulty in drawing conclusions from NSQIP specifically for our study is due to the fact that only a snapshot of patient care is provided, and many treatment biases are not taken into account. Furthermore, the lack of long-term longitudinal data did not allow us to assess potential previous efforts at limb salvage in a particular patient prior to the current admission for amputation. Hopefully, this shortcoming is somewhat mitigated by our performance of simultaneous queries for amputation and limb-salvage revascularization. Moreover, data regarding adequacy of medical treatment such as statin use and antiplatelet regimens were not available to us. In conclusion, there remains a significant ethnic disparity in amputation and limb-salvage revascularization in the United States. Blacks comprise 29% of patients undergoing a major lower extremity amputation but only 12% of those undergoing an open revascularization operation and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular limb-salvage techniques does not seem to have had much impact on this disparity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
Hughes et al
405
References
16. Strandness DE Jr, Priest RE, Gibbons GE. Combined clinical and pathologic study of diabetic and nondiabetic peripheral arterial disease. Diabetes. 1964;13:366-372. 17. Irwin ST, Gilmore J, McGrann S, Hood J, Allen JA. Blood flow in diabetics with foot lesions due to ‘small vessel disease’. Br J Surg. 1988;75(12):1201-1206. 18. Pomposelli FB, Kansal N, Hamdan AD, et al. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg. 2003;37(2):307-315. 19. Hughes K, Padilla L, Al-Zubeidy B, et al. Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction. Am J Surg. 2014;207(4):573-577. 20. Vasan RS, Massaro JM, Wilson PW, et al. Antecedent blood pressure and risk of cardiovascular disease: the Framingham heart study. Circulation. 2002;105(1):48-53. 21. Sipahi I, Tuzcu EM, Schoenhagen P, et al. Effects of normal, prehypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis. J Am Coll Cardiol. 2006;48(4): 833-838. 22. Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet. 2008;371(9623): 1513-1518. doi:1510.1016/S0140-6736(1508)60655-60658. 23. Howard G, Lackland DT, Kleindorfer DO, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med. 2013;173(1):46-51. doi:10.1001/2013. jamainternmed.1857. 24. Peters RM, Aroian KJ, Flack JM. African American culture and hypertension prevention. West J Nurs Res. 2006;28(7):831-854; discussion 855-863. 25. Lavery LA, Ashry HR, van Houtum W, Pugh JA, Harkless LB, Basu S. Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care. 1996;19(1):48-52. 26. Chuckweke I, Cordero-MacIntyre Z. Overview of type 2 diabetes in Hispanic Americans. Int J Body Compos Res. 2010;8(supp):77-81. 27. Pugh JA, Medina RA, Cornell JC, Basu S. NIDDM is the major cause of diabetic end-stage renal disease. More evidence from a tri-ethnic community. Diabetes. 1995;44(12):1375-1380. 28. Blumberg SN, Warren SM. Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration Hospital. J Diabetes. 2014;6(1):68-75. doi:10.1111/1753-0407.12050. 29. Bureau USC. Quick Facts. State and County QuickFacts; June 11, 2014. http://quickfacts.census.gov/qfd/states/00000.html. Accessed June 11, 2014. 30. Farmer DL. NSQIP lite: a potential tool for global comparative effectiveness evaluations. Arch Surg. 2012;147(9):803-804. 31. Nguyen LL, Barshes NR. Analysis of large databases in vascular surgery. J Vasc Surg. 2010;52(3):768-774.
1. Durazzo TS, Frencher S, Gusberg R. Influence of race on the management of lower extremity ischemia: revascularization vs amputation. JAMA Surgery. 2013;148(7):1-6. 2. Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010; 51(4):S21-S26. 3. Nguyen LL, Henry AJ. Disparities in vascular surgery: is it biology or environment? J Vasc Surg. 2010;51(4 suppl):36S-41S. 4. Feinglass J, Abadin S, Thompson J, Pearce WH. A census-based analysis of racial disparities in lower extremity amputation rates in Northern Illinois, 1987-2004. J Vasc Surg. May 2008;47(5): 1001-1007; discussion 1007. 5. Feinglass J, Kaushik S, Handel D, Kosifas A, Martin GJ, Pearce WH. Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997. Arch Surg. 2000;135(1):75-80. 6. Guadagnoli E, Ayanian JZ, Gibbons G, McNeil BJ, LoGerfo FW. The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities. Arch Surg. 1995;130(4):381-386. 7. Huber TS, Wang JG, Wheeler KG, et al. Impact of race on the treatment for peripheral arterial occlusive disease. J Vasc Surg. 1999;30(3):417-425. 8. Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54(2):420-426, 426.e421. 9. McBean AM, Gornick M. Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. Health Care Financing Review. 1994;15(4):77-90. 10. CDC. 2011 National Diabetes Fact Sheet; 2011. http://www.cdc. gov/diabetes/pubs/figuretext11.htm#fig4. Accessed March 11, 2014. 11. Ingraham AM RK, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251-267. 12. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vas Endovas Surg. 2007; 33(1):S1-S75. 13. Hughes K, Seetahal S, Oyetunji T, et al. Racial/ethnic disparities in amputation and revascularization: a nationwide inpatient sample study. Vasc Endovasc Surg. 2014 2014;48(1):34-37. 14. Goldenberg S, Alex M, Joshi RA, Blumenthal HT. Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. Diabetes. 1959;8(4):261-273. 15. Conrad MC. Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease. Circulation. 1967; 36(1):83-91.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
Racial/Ethnic Disparities in Revascularization for Limb Salvage: An Analysis of the National Surgical Quality Improvement Program Database
Vascular and Endovascular Surgery 2014, Vol. 48(5-6) 402-405 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/1538574414543276 ves.sagepub.com
Kakra Hughes, MD, FACS1, Christopher Boyd, MD1, Tolulope Oyetunji, MD1, Daniel Tran, MD1, David Chang, MD2, David Rose, MD1, Suryanarayan Siram, MD1, Edward Cornwell III, MD1, and Thomas Obisesan, MD3
Abstract Introduction: Previous reports have suggested that black patients have a higher rate of major lower extremity amputation and a lower rate of revascularization for limb salvage when compared to white patients. Objective: We undertook this study to determine the extent of this ethnic disparity in recent years and to evaluate whether the widespread adoption of endovascular techniques has had an impact on this disparity. Methods: The American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP) database was queried to identify all patients who had undergone an above- or below-knee amputation as well as all patients who had undergone an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded, and comparisons were made among the different ethnic groups. Results: There were 1568 patients identified in the NSQIP database as having undergone a major lower extremity amputation in 2005 and 2006. Of these patients, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data. The group undergoing amputation was primarily male (61%) with a mean age of 65. Median length of stay was 11 days, and 30-day mortality was 9% following amputation. During this same time period, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage. Of those patients undergoing an open procedure, 74% were white, 12% black, 4% Hispanic, 0.4% Asian, and 10% did not have identifying ethnic data. Open surgical patients were primarily male (63%) with a mean age of 66. Median length of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. The endovascular group was also primarily male (61%) with a mean age of 68. Median length of stay was 5 days, and 30-day mortality was 4%. Conclusion: There remains a significant ethnic disparity in limb-salvage revascularization. Blacks comprise 29% of patients undergoing a major lower extremity amputation, but only 12% of those undergoing an open surgical procedure and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular revascularization techniques appears not to have had much impact on this disparity. Keywords limb ischemia, amputation, revascularization, racial/ethnic disparities
Introduction Ethnic differences appear to continue to play some role in the type of health care Americans receive even in contemporary times.1-3 It was reported as far back as 2 decades ago that blacks have a higher rate of major lower extremity amputation and a lower rate of limb-salvage revascularization procedures as compared to whites.4-7 Despite recent advances in health care, these disparities have continued to persist. Indeed, 1 recent study reports that blacks are 2 to 4 times less likely to have any type of limb-salvage procedure attempted 2 years
1
Department of Surgery, Howard University, Washington, DC, USA Department of Surgery, University of California, San Diego, CA, USA 3 Department of Internal Medicine, Howard University, Washington, DC, USA 2
Corresponding Author: Kakra Hughes, Department of Surgery, Howard University, 2041 Georgia Avenue NW, 4B.04. Washington, DC 20060, USA. Email: [email protected]
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
Hughes et al
403
prior to amputation as compared to whites.8 Although some have suggested that this disparity may be explained by limited access to limb-salvage revascularization for blacks,9 the demonstration that this disparity is even more pronounced in centers that have increased revascularization capabilities suggests that access alone may not explain this discrepancy.1 An underlying biologic difference in ethnicity has been suggested as a potential factor for this health care disparity.3 Blacks have been noted to have an increased risk of diabetes mellitus, a well-known risk factor for developing peripheral arterial disease.10 Even so, nondiabetic blacks are also reported to be more likely to undergo a major lower extremity amputation as compared to nondiabetic whites.1,8 Moreover, it has been observed that even when one controls for diabetes, blacks are still less likely to receive limb-salvage revascularization.6 We undertook this study in an attempt to evaluate this disparity in recent times and to determine how this may have been impacted by the widespread adoption of endovascular revascularization techniques.
Methods The National Surgery Quality Improvement Program (NSQIP) database was queried to identify all patients who underwent an above- or below-knee amputation as well as all patients who underwent an open or endovascular revascularization procedure for critical limb ischemia for the years 2005 to 2006. Patient demographics and 30-day outcomes were recorded. Preoperative comorbidities were defined as cardiac (history of coronary artery disease, congestive heart failure, or a history of percutaneous transluminal coronary angioplasty or coronary artery bypass graft), pulmonary (chronic obstructive pulmonary disease or active pneumonia), renal (acute renal failure or dialysisdependent renal failure), and diabetes (insulin- or noninsulindependent diabetes mellitus). Comparisons were made among the different ethnic groups, and statistical differences were identified by using standard chi-square analysis and Student t testing.
Table 1. Demographics.
Percent male Mean age, years Median length of stay, days 30-Day mortality, %
Amputation
Open Surgery
Endovascular
61 65 11
63 66 6
61 68 5
9
3
4
Table 2. Comorbidities: Open Surgery.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Cardiac
Pulmonary
Renal
Diabetes
41 36 39 60 .018
15 10 6 7 .009
5 16 12 13 .000
33 46 62 40 .000
Cardiac
Pulmonary
Renal
Diabetes
43 33 39 40 .160
16 11 0 0 .259
3 16 8 20 .000
27 42 46 20 .018
Cardiac
Pulmonary
Renal
Diabetes
45 31 48 55 .000
17 10 11 27 .001
22 31 28 27 .000
59 60 80 55 .663
Table 3. Comorbidities: Endovascular.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Table 4. Comorbidities: Amputation.
White, % Black, % Hispanic, % Asian, % P values (black vs white)
Results There were 1568 patients identified in the NSQIP database as having undergone a major limb amputation (defined as an above- or below-knee amputation) in 2005 and 2006. Of these, 54% were white, 29% black, 8% Hispanic, and 0.7% Asian. Eight percent of patients did not have identifying ethnic data and 0.8% were listed as other. Patients undergoing amputation were primarily male (61%) with a mean age of 65. Median length of stay was 11 days and 30-day mortality was 9% following a major amputation. During this same time interval, 4191 patients underwent an open surgical procedure and 569 patients underwent an endovascular procedure for the purposes of limb salvage (ie, preoperative diagnosis was either ischemic rest pain or tissue loss). Of those patients undergoing an open limb-salvage procedure, 74% were white, 12% black, 4% Hispanic, and 0.4% Asian. Identifying ethnic data were not available for 10% of these patients. Open surgical patients were primarily male (63%) with a mean age of 66. Median length
of stay was 6 days, and 30-day mortality was 3.3%. Of those patients undergoing an endovascular procedure, 79% were white, 10% black, 2% Hispanic, 1% Asian, and 8% did not have identifying ethnic data. Endovascular patients were mostly male (61%) with a mean age of 68. Median length of stay was 5 days and 30-day mortality was 4%, Table 1. When comorbidities were compared across ethnicities, blacks undergoing open or endovascular revascularization were significantly more likely to have renal comorbidities and diabetes mellitus as compared to whites, whereas whites undergoing open surgery were more likely to have pulmonary comorbidities. For patients undergoing amputation, there was no statistically significant difference in cardiac comorbidity among ethnic groups. Blacks, however, were more likely to have renal comorbidities as compared to whites, while whites were more likely to have pulmonary comorbidities as compared to blacks, Tables 2 to 4.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
404
Vascular and Endovascular Surgery 48(5-6)
Figure 1. Distribution of surgical procedure by race.
Discussion Employing the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP), a multiinstitutional surgical outcomes database incorporating over 100 hospitals nationwide, we were able to describe the practice of amputation and limb-salvage revascularization across the United States.11 Although peripheral arterial disease affects 8 to 10 million Americans every year,12 it is a minority with critical limb ischemia (ie, ischemic rest pain and/or tissue loss) who are in danger of limb loss and, therefore, require prompt revascularization, that is, limb-salvage revascularization.12 Blacks, who make up approximately 13% of the US population,8 appear to be overrepresented among patients receiving amputations (29% of all amputation patients) and underrepresented among limb-salvage revascularization patients (12% of all patients undergoing open limb-salvage revascularization and 10% of all patients undergoing limb-salvage endovascular revascularization), Figure 1. This finding is concordant with the study by Feinglas et al demonstrating that postal codes that were primarily populated by blacks were associated with a higher rate of amputation as compared to postal codes primarily populated by whites.2,4 Our study is also in agreement with the report by Holman et al, indicating that blacks have a significantly less likelihood of having any type of attempt at revascularization or minor amputation prior to above- or below-knee amputation.8 Other more recent reports also corroborate our findings.2,13 The fact that blacks undergoing open revascularization were less likely to have cardiac and pulmonary comorbidities suggests that these patients were not offered limb-salvage surgery less frequently because they were less likely to be physiologically able to tolerate these operations. Instead, the higher incidence of renal failure and diabetes in blacks might suggest a potential explanation for the higher selection for amputation in this ethnic group. Unfortunately, there continues to be an existing bias in the medical community against limb revascularization for patients with diabetes due to an erroneous concept of ‘‘small vessel disease.’’14 Despite repeated refutations by anatomic, physiologic, and clinical studies,15-18 this archaic notion persists and may be responsible for potentially unnecessary amputations being undertaken in patients with diabetes mellitus.19,21 As has already been discussed (in Introduction), diabetes mellitus, alone, however, does not adequately explain this disparity.
Hypertension has aptly been described as a well-known adverse cardiovascular risk factor, especially in the black population.20-23 In our study, whites presented with significantly more cardiac comorbidities as compared to blacks potentially leading one to conclude that hypertension may not play a significant role in this disparity. It is, nonetheless, important to consider that some of these patients who do ‘‘not have’’ a comorbidity may simply be ‘‘not yet diagnosed.’’24 Although our study focused on the ethnic disparities in the black population, a similar disparity has also been reported for the Hispanic/Latino community. Hispanics have been reported to have proportionally more amputations associated with diabetes than non-Hispanic whites and even blacks.25 Of note, it has been suggested that improperly treated diabetes has a disproportionate effect on Hispanics.26,27 In a recent triumvirate health care system analysis of public, private, and Veterans Administration hospitals, Blumberg et al reported that Hispanics were significantly more likely to develop advanced diabetic foot ulcers and eventual amputation due to poor treatment as compared to whites.28 Although the Hispanic population is estimated to be 17%,29 Hispanics comprised 8% of those undergoing amputation while accounting for only 4% of all patients receiving open revascularization and 2% of all patients undergoing endovascular revascularization in our study. Clearly additional studies focusing on the Hispanic population are needed. There are several limitations to this study. The established pitfalls of NSQIP have been abundantly described,30 as having specific challenges of using this database in vascular research.31 The difficulty in drawing conclusions from NSQIP specifically for our study is due to the fact that only a snapshot of patient care is provided, and many treatment biases are not taken into account. Furthermore, the lack of long-term longitudinal data did not allow us to assess potential previous efforts at limb salvage in a particular patient prior to the current admission for amputation. Hopefully, this shortcoming is somewhat mitigated by our performance of simultaneous queries for amputation and limb-salvage revascularization. Moreover, data regarding adequacy of medical treatment such as statin use and antiplatelet regimens were not available to us. In conclusion, there remains a significant ethnic disparity in amputation and limb-salvage revascularization in the United States. Blacks comprise 29% of patients undergoing a major lower extremity amputation but only 12% of those undergoing an open revascularization operation and 10% of those undergoing an endovascular procedure for limb salvage. The widespread adoption of endovascular limb-salvage techniques does not seem to have had much impact on this disparity. Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
Hughes et al
405
References
16. Strandness DE Jr, Priest RE, Gibbons GE. Combined clinical and pathologic study of diabetic and nondiabetic peripheral arterial disease. Diabetes. 1964;13:366-372. 17. Irwin ST, Gilmore J, McGrann S, Hood J, Allen JA. Blood flow in diabetics with foot lesions due to ‘small vessel disease’. Br J Surg. 1988;75(12):1201-1206. 18. Pomposelli FB, Kansal N, Hamdan AD, et al. A decade of experience with dorsalis pedis artery bypass: analysis of outcome in more than 1000 cases. J Vasc Surg. 2003;37(2):307-315. 19. Hughes K, Padilla L, Al-Zubeidy B, et al. Diabetes is not associated with an increased peri-operative mortality or non-infectious morbidity following lower extremity arterial reconstruction. Am J Surg. 2014;207(4):573-577. 20. Vasan RS, Massaro JM, Wilson PW, et al. Antecedent blood pressure and risk of cardiovascular disease: the Framingham heart study. Circulation. 2002;105(1):48-53. 21. Sipahi I, Tuzcu EM, Schoenhagen P, et al. Effects of normal, prehypertensive, and hypertensive blood pressure levels on progression of coronary atherosclerosis. J Am Coll Cardiol. 2006;48(4): 833-838. 22. Lawes CM, Vander Hoorn S, Rodgers A. Global burden of blood-pressure-related disease, 2001. Lancet. 2008;371(9623): 1513-1518. doi:1510.1016/S0140-6736(1508)60655-60658. 23. Howard G, Lackland DT, Kleindorfer DO, et al. Racial differences in the impact of elevated systolic blood pressure on stroke risk. JAMA Intern Med. 2013;173(1):46-51. doi:10.1001/2013. jamainternmed.1857. 24. Peters RM, Aroian KJ, Flack JM. African American culture and hypertension prevention. West J Nurs Res. 2006;28(7):831-854; discussion 855-863. 25. Lavery LA, Ashry HR, van Houtum W, Pugh JA, Harkless LB, Basu S. Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care. 1996;19(1):48-52. 26. Chuckweke I, Cordero-MacIntyre Z. Overview of type 2 diabetes in Hispanic Americans. Int J Body Compos Res. 2010;8(supp):77-81. 27. Pugh JA, Medina RA, Cornell JC, Basu S. NIDDM is the major cause of diabetic end-stage renal disease. More evidence from a tri-ethnic community. Diabetes. 1995;44(12):1375-1380. 28. Blumberg SN, Warren SM. Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration Hospital. J Diabetes. 2014;6(1):68-75. doi:10.1111/1753-0407.12050. 29. Bureau USC. Quick Facts. State and County QuickFacts; June 11, 2014. http://quickfacts.census.gov/qfd/states/00000.html. Accessed June 11, 2014. 30. Farmer DL. NSQIP lite: a potential tool for global comparative effectiveness evaluations. Arch Surg. 2012;147(9):803-804. 31. Nguyen LL, Barshes NR. Analysis of large databases in vascular surgery. J Vasc Surg. 2010;52(3):768-774.
1. Durazzo TS, Frencher S, Gusberg R. Influence of race on the management of lower extremity ischemia: revascularization vs amputation. JAMA Surgery. 2013;148(7):1-6. 2. Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010; 51(4):S21-S26. 3. Nguyen LL, Henry AJ. Disparities in vascular surgery: is it biology or environment? J Vasc Surg. 2010;51(4 suppl):36S-41S. 4. Feinglass J, Abadin S, Thompson J, Pearce WH. A census-based analysis of racial disparities in lower extremity amputation rates in Northern Illinois, 1987-2004. J Vasc Surg. May 2008;47(5): 1001-1007; discussion 1007. 5. Feinglass J, Kaushik S, Handel D, Kosifas A, Martin GJ, Pearce WH. Peripheral bypass surgery and amputation: northern Illinois demographics, 1993 to 1997. Arch Surg. 2000;135(1):75-80. 6. Guadagnoli E, Ayanian JZ, Gibbons G, McNeil BJ, LoGerfo FW. The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities. Arch Surg. 1995;130(4):381-386. 7. Huber TS, Wang JG, Wheeler KG, et al. Impact of race on the treatment for peripheral arterial occlusive disease. J Vasc Surg. 1999;30(3):417-425. 8. Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54(2):420-426, 426.e421. 9. McBean AM, Gornick M. Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. Health Care Financing Review. 1994;15(4):77-90. 10. CDC. 2011 National Diabetes Fact Sheet; 2011. http://www.cdc. gov/diabetes/pubs/figuretext11.htm#fig4. Accessed March 11, 2014. 11. Ingraham AM RK, Hall BL, Ko CY. Quality improvement in surgery: the American College of Surgeons National Surgical Quality Improvement Program approach. Adv Surg. 2010;44:251-267. 12. Norgren L, Hiatt WR, Dormandy JA, Nehler MR, Harris KA, Fowkes FGR. Inter-society consensus for the management of peripheral arterial disease (TASC II). Eur J Vas Endovas Surg. 2007; 33(1):S1-S75. 13. Hughes K, Seetahal S, Oyetunji T, et al. Racial/ethnic disparities in amputation and revascularization: a nationwide inpatient sample study. Vasc Endovasc Surg. 2014 2014;48(1):34-37. 14. Goldenberg S, Alex M, Joshi RA, Blumenthal HT. Nonatheromatous peripheral vascular disease of the lower extremity in diabetes mellitus. Diabetes. 1959;8(4):261-273. 15. Conrad MC. Large and small artery occlusion in diabetics and nondiabetics with severe vascular disease. Circulation. 1967; 36(1):83-91.
Downloaded from ves.sagepub.com at East Tennessee State University on May 31, 2015
