Racial/ethnic Disparities in Lower Extremity Amputation Vs Revascularization: A Brief Review

Contemporary Outcomes of Limb-Salvage Procedures Using Vascular Quality Initiative-Medicare Linked Data: Racial and Ethnic Disparities Persist

INTRODUCTION

Several reports have shown that ethnic and racial minorities with chronic limb-threatening ischemia (CLTI) are more likely to undergo major amputation. Whether this disparity is driven by limited access to care, statistical discrimination or biological factors remains a matter of debate. We sought to study the effect of race/ethnicity on short and long-term outcomes of limb-salvage procedures among patients with new onset CLTI.

METHODS

We identified all patients who underwent first time (open or endovascular) revascularization for CLTI between January 2010 and December 2016 in the Vascular Quality Initiative-Medicare linked database. These patients were divided into non-Hispanic whites (NHW) and racial/ethnic minority (REM) groups. Early end points included length of stay and operative mortality, while 2-year outcomes included major amputation, freedom from subsequent revascularization, number of limb salvage reinterventions and all-cause mortality. A sub-analysis comparing NHWs to Hispanics and NHWs to blacks was also performed.

RESULTS

Of 16,249 presenting with CLTI, 73.9% were non-Hispanic whites. Racial/ethnic minority patients were younger (mean age, 69.9 ± 11.3 years vs 74.2 ± 10.5 years; P < .001) and more likely to be female (45.9% vs 37.7%; P < .001). Other baseline differences included a higher rate of smoking history, coronary artery disease, chronic obstructive pulmonary disease and chronic kidney disease among non-Hispanic whites, whereas racial/ethnic minority patients were more likely to have diabetes and hypertension and more likely to present with tissue loss (78% vs 76.6%; P =.04). Preoperative ankle-brachial index and procedure type (endovascular vs open) were similar between the groups. On multivariable analysis, NHW's had a 13% increase in length of stay and a 25% decrease in operative mortality. In regard to 2-year outcomes, limb salvage estimates were 86% for the NHW group versus 77.1% for the REM group; P < .001. Comparison between the two groups showed similar rates of freedom from subsequent revascularization (67.9% vs 67.1%; P =.2). REM patients achieved higher rates of overall survival (70.3% vs 68.4%; P =.01) when compared to their white counterparts. Patients in the REM group were more likely to undergo more than two limb salvage reinterventions during follow-up (14.2% vs 8.6%; P < .001). After adjusting for potential confounders, REM patients had significantly higher odds of major amputation at 2 years (adjusted hazard ratio, 1.49; 95% confidence interval, 1.36-1.63; P < .001) CONCLUSIONS: In this Vascular Quality Initiative-Medicare matched study, racial and ethnic minority patients continue to face a higher major amputation risk despite having equivalent attempts at limb salvage. Further studies identifying risk factors and evaluating intervention strategies that may be more effective in preventing amputation in this particular population are warranted.