Long-term implications of racial differences in the use of revascularization procedures (the Myocardial Infarction Triage and Intervention registry)

Life Expectancy and Years of Potential Life Lost After Acute Myocardial Infarction by Sex and Race: A Cohort-Based Study of Medicare Beneficiaries

BACKGROUND

Most studies of sex and race differences after acute myocardial infarction (AMI) have not taken into account differences in life expectancy in the general population. Years of potential life lost (YPLL) is a metric that takes into account the burden of disease and can be compared by sex and race.

OBJECTIVES

This study sought to determine sex and race differences in long-term survival after AMI using life expectancy and YPLL to account for differences in population-based life expectancy.

METHODS

Using data from the Cooperative Cardiovascular Project, a prospective cohort study of Medicare beneficiaries hospitalized for AMI between 1994 and 1995 (N = 146,743), we calculated life expectancy and YPLL using Cox proportional hazards regression with extrapolation using exponential models.

RESULTS

Of the 146,743 patients with AMI, 48.1% were women and 6.4% were black; the average age was 75.9 years. Post-AMI life expectancy estimates were similar for men and women of the same race but lower for black patients than white patients. On average, women lost 10.5% (SE 0.3%) more of their expected life than men, and black patients lost 6.2% (SE 0.6%) more of their expected life than white patients. After adjustment, women still lost an average of 7.8% (0.3%) more of their expected life than men, but black race became associated with a survival advantage, suggesting that racial differences in YPLL were largely explained by differences in clinical presentation and treatment between black and white patients.

CONCLUSIONS

Women and black patients lost more years of life after AMI, on average, than men and white patients, an effect that was not explained in women by clinical or treatment differences.

The effect of race/ethnicity, sex, and social circumstances on coronary revascularization preferences: a vignette comparison

Disparities in cardiac care cannot be explained by clinical factors alone. We previously found that physicians' perceived nonclinical factors such as patient preferences influenced decisions for coronary revascularization. For this study, we mailed a questionnaire to a random sample of family medicine physicians, internists, cardiologists, and cardiothoracic surgeons to examine whether the patient's sex, race/ethnicity, and social circumstances impacted treatment preferences for different physician subgroups. All physicians were randomized to receive 1 of 4 questionnaires that contained a vignette describing certain hypothetical situations (desire for an active lifestyle, heavy career or family demands) for a 50-year patient who was a candidate for coronary revascularization who was 1) female, 2) male, 3) black male, or 4) white male. The response rate was 70% (544 of 777). The patient's race/ethnicity and sex did not significantly affect the physicians' treatment preferences. However, significant differences were found according to the social circumstance. More male physicians (78%) than female physicians (66%) recommended revascularization for patients with heavy family demands (P < 0.05). In logistic regression analyses, if the patient desired an active lifestyle, black and Hispanic physicians and fee-for-service physicians preferred revascularization less often than white and salaried physicians, respectively (odds ratio [OR] = 0.45 [0.21-0.94] for black/Hispanic; OR = 0.40 [0.18-0.86] for fee-for-service). Based on these results, certain social circumstances might influence treatment preferences among physician subgroups more than sex- or race-based patient factors. Research examining for causes of disparities in cardiac care should consider the effects of sociocultural issues on management decisions.

Racial and ethnic differences in incident myocardial infarction in end-stage renal disease patients: The USRDS

African Americans have a greater risk of cardiovascular disease (CVD) than Caucasians in early chronic kidney disease; however, limited data describe racial and ethnic differences in the risk of incident myocardial infarction (MI) among patients with end-stage renal disease (ESRD). We conducted a prospective, observational cohort study among 271 102 incident dialysis patients receiving renal replacement therapy enrolled in the United States Renal Data System (USRDS) for whom Medicare was the primary insurer between 1995 and 2000. The incidence and risk of any MI (non-fatal or fatal) estimated by Cox proportional hazards models was the primary outcome of interest. Of those with prevalent CVD at baseline (118 708), 14 849 had an incident non-fatal MI compared with 9926 events for those without prevalent CVD (152 394). Patients with prevalent CVD had higher crude rates of combined fatal and non-fatal MI (99.3/1000 person-years vs 42.9/1000 person-years) compared with those without prevalent CVD. Among those with prevalent CVD, African Americans (adjusted relative risk (aRR)=0.65, 95% confidence interval (CI):0.62-0.68), Asian Americans (aRR=0.74, 95% CI: 0.66-0.83), and Hispanics (aRR=0.72, 95% CI: 0.68-0.77) were 26-35% less likely to have an incident MI compared to Caucasians. Similarly, among those without prevalent CVD, racial/ethnic minorities were 26-42% less likely to have an incident MI compared to Caucasians. We conclude that in a national setting where comparable access to dialysis and associated medical care, exist, racial/ethnic minorities were found to have a lower risk of non-fatal and fatal MI than Caucasians.

Apparent racial disparity in the utilization of invasive testing for risk assessment of cardiac patients undergoing noncardiac surgery

BACKGROUND

Studies on racial disparity in the use of cardiac diagnostic procedures are limited because they were conducted in the acute clinical setting without control for patient knowledge and emotional state or used models not controlling for racism. Using the setting (model) of elective evaluation of known, stable, cardiac patients undergoing noncardiac surgery, where the surgeon/anesthesiologist's personal interest precludes expression of potential racial bias, we assessed for racial differences in the utilization of diverse cardiac diagnostic procedures for risk assessment and optimization.

METHODS

This is a secondary analysis of data from 314 consecutive patients [92 (29%) African-American, 222 (71%) Caucasian] with coronary artery disease (CAD), cardiomyopathy (ejection fraction <45%), or treatment-requiring arrhythmias, who underwent noncardiac surgery.

RESULTS

The incidence of angina, prior myocardial infarction, and ischemic cardiomyopathy was higher in Caucasians (75%, 68%, and 164%, P<.0001, respectively), while nonischemic cardiomyopathy was more prevalent among African-Americans (84%, P<.0001). While, multivariately, African race predicted underuse of coronary angiography (odds ratio: 0.10, 95% confidence interval: 0.04-0.26, P<.0001), this predictor was eliminated when presence of CAD plus cardiomyopathy was factored in as a surrogate of severity. The use of noninvasive cardiac procedures and the 30-day mortality and morbidity did not differ by race.

CONCLUSION

In a racism-proof model of preoperative evaluation of stable cardiac veterans, the racial disparity in the use of invasive procedures was related to epidemiologic differences. In addition, the parity in mortality and morbidity corroborates no underuse of diagnostic procedures among African-Americans.

Influence of racial disparities in procedure use on functional status outcomes among patients with coronary artery disease

BACKGROUND

Although black cardiac patients receive fewer revascularization procedures than whites, it is unclear whether this has a detrimental impact on outcomes. The objective of our study was to compare 6-month functional status and angina outcomes among blacks and whites with documented coronary disease and to assess whether differential use of revascularization procedures affects these outcomes.

METHODS AND RESULTS

We identified a prospective cohort of 1534 white and 337 black patients undergoing cardiac catheterization between August 1998 and April 2001. Health status was assessed at baseline and 6 months with the Short-Form 36 (SF-36) Health Survey and the Seattle Angina Questionnaire (SAQ) Angina Frequency Scale. Compared with whites, blacks received fewer coronary revascularization procedures (52.5% versus 66.0%; P<0.01). By 6 months, blacks had similar mortality (odds ratio, 1.03; 95% CI, 0.57 to 1.9) but worse scores in 5 SF-36 domains (physical, social, role physical, role emotional, and mental health function). Blacks also reported higher rates of angina at 6 months than whites (34.2% versus 24.6%; P<0.01). After adjustment for baseline functional status and clinical and demographic variables, blacks had significantly worse summary physical component scores, summary mental component scores, and SAQ Angina Frequency Scale scores. However, differences in physical component summary scores and SAQ scores between blacks and whites were no longer significant after adjustment for revascularization status.

CONCLUSIONS

Our study is among the first to document greater symptoms and functional impairment among black cardiac patients relative to whites. Differential use of coronary revascularization may contribute to the poorer functional outcomes observed among black patients with documented coronary disease.

Socioeconomic inequities in invasive cardiac procedures after first myocardial infarction in Finland in 1995

OBJECTIVE

We examined socioeconomic disparities in coronary procedure rates after first events among hospitalized myocardial infarction (MI) patients.

STUDY DESIGN AND SETTING

Information on MI patients in 1995 in Finland was obtained from the Finnish Cardiovascular Disease Register Project. Data on comorbidity, invasive treatments, hospitalizations, mortality, and socioeconomic status were obtained by linking data from the Finnish Hospital Discharge Register, cause of death register, population census, and the health insurance register using personal identity numbers.

RESULTS

In 1995, 5172 patients aged 40 to 74 years were hospitalized for first MI. This corresponds to age-standardized event rates of 354/100,000 for men and 152/100,000 for women. Within 2 years, 33% of men and 21% of women underwent an invasive coronary procedure. Men in the lowest income third underwent 25% (95% confidence interval [CI] 12-36) fewer procedures than men in the highest third. Among women, the corresponding difference was 43% (95% CI 24-57). These disparities persisted throughout the 2-year follow-up, and they were not reduced by adjustment for comorbidity or hospital district.

CONCLUSION

Socioeconomic disparities were observed in receipt of invasive cardiac procedures. More attention should be paid to equitable distribution of scarce health care resources.

Ethnic differences in utilization of invasive cardiac procedures and in long-term survival following acute myocardial infarction

BACKGROUND

Ethnic differences in coronary mortality have been documented, and South Asians from the Indian subcontinent are particularly vulnerable.

HYPOTHESIS

This study sought to determine whether there was a difference in the utilization of invasive cardiac procedures and long-term mortality in survivors of myocardial infarction (MI) among Chinese, Malays, and South Asians in Singapore.

METHODS

All MI events in the country were identified and defined by the Singapore Myocardial Infarction Register, which uses modified procedures of the World Health Organization MONICA Project. Information on utilization of coronary angiography, coronary angioplasty, coronary artery bypass graft, and survival was obtained by data linkage with national billing and death registries. Hazard ratios (HR) were calculated using the Cox proportional hazards model with adjustment for baseline characteristics.

RESULTS

From 1991 to 1999, there were 10,294 patients who survived > or = 3 days of MI. Of these, 40.6% underwent coronary angiography and 16.5% a revascularization procedure < or = 28 days. Malays received substantially less angiography (34.0%) and revascularization (11.4%) than Chinese (41.9%, 17.9%) and South Asians (40.0%, 16.3%). The ethnic disparity increased during the 1990s, particularly in the performance of coronary angiography (p = 0.038). While fatality declined during the study period for Chinese and South Asians, the rate remained stable for Malays. After a median follow-up period of 4.1 years, survival was lowest among Malays (adjusted HR, 1.28; 95% confidence interval, 1.15-1.42, compared with Chinese).

CONCLUSION

Ethnic inequalities in invasive cardiac procedures exist in Singapore and were exacerbated in the 1990s. Inequalities in medical care may contribute to the poorer longterm survival among Malays.

Universal health insurance coverage does not eliminate inequities in access to cardiac procedures after acute myocardial infarction

BACKGROUND

It remains unclear whether socioeconomic status (SES) influences access to invasive cardiac procedures after acute myocardial infarction (AMI) in a universal health care system. The objective of this study was to evaluate the effect of SES on access to cardiac procedure after AMI in a universal health care system.

METHODS

This was an observational cohort study of all patients with a first AMI in the province of Quebec, Canada, between 1985 to 1995. Information on treatment was obtained from the discharge and physicians' claims databases. SES was obtained from census data by linking postal codes. SES-independent predictors of use were identified, then incorporated in hierarchical models to predict use in low, medium, and high SES areas. The main outcome measures were rates of cardiac catheterization, percutaneous coronary intervention (PCI), and coronary artery bypass graft surgery (CABG) as a function of SES.

RESULTS

SES data were available for 62,364 individuals with a first AMI. Of these, 65% were men and the mean age was 64 +/- 13 years. Rates of cardiac procedures rose with an increase in several SES measures. After adjustment for individual-level predictors of use of cardiac catheterization, average rent, (odds ratio per $100 difference: 1.57, 95% credible interval: 1.36 to 1.80) and proportion of renters, (odds ratio, 2.2; 95% CI: 1.21 to 3.73) in the area were independent SES predictors. Patients in low SES areas (median family income: $ 30,809 CDN) were less likely to undergo cardiac catheterization than patients in high SES areas ($92,169 CDN) (men: 33%; compared with 47%; women: 18%; compared with 47%). However, among patients with cardiac catheterization, SES was not associated with the use of revascularization procedures. For example, PCI rates for men within 90 days after AMI were 26%, compared with 25% in low and high SES areas, respectively. CABG rates were 15%, compared with 19%.

CONCLUSIONS

We found that in the universal health care system of Canada, access to cardiac catheterization after AMI varied according to SES. Among those with cardiac catheterization, SES did not appear to influence further use of revascularization procedures.

Cardiac surgery in African Americans

Retrospective and prospective randomized studies that provide information on the influence of race on the morbidity and mortality of cardiac surgical procedures are reviewed. We intentionally focus our attention on the specific outcomes of these procedures in African Americans because African Americans have a high incidence of all-cause cardiovascular mortality and a high prevalence of a number of risk factors associated with cardiovascular mortality. Furthermore, numerous studies have confirmed that blacks, as a function of race, lack equal access to diagnostic and therapeutic invasive cardiac procedures. Here we use the terms "black" and "African American" interchangeably. In this context we interpret both terms to refer to Americans of African descent. Similarly, we use the term "white" or "Caucasian" interchangeably to refer to Americans of European descent.

The impact of ethnicity on outcomes following coronary artery bypass graft surgery in the Veterans Health Administration

OBJECTIVES

We evaluated the effect of African American (AA) and Hispanic American (HA) ethnicity on mortality and complications following coronary artery bypass graft (CABG) surgery in the Veterans Health Administration (VHA).

BACKGROUND

Few studies have examined the impact of ethnicity on outcomes following cardiovascular procedures.

METHODS

This study included all 29,333 Caucasian, 2,570 AA, and 1,525 HA patients who underwent CABG surgery at any one of the 43 VHA cardiac surgery centers from January 1995 through March 2001. We evaluated the relationship between ethnicity (AA vs. Caucasian and HA vs. Caucasian) and 30-day mortality, 6-month mortality, and 30-day complications, adjusting for a wide array of demographic, cardiac, and noncardiac variables.

RESULTS

After adjustment for baseline characteristics, AA and Caucasian patients had similar 30-day (AA/Caucasian odds ratio [OR] 1.07; 95% confidence interval [CI] 0.84 to 1.35; p = 0.59) and 6-month mortality risk (AA/Caucasian OR 1.10; 95% CI 0.91 to 1.34; p = 0.31). However, among patients with low surgical risk, AA ethnicity was associated with higher mortality (OR 1.52, CI 1.10 to 2.11, p = 0.01), and AA patients were more likely to experience complications following surgery (OR 1.28; 95% CI 1.14 to 1.45; p < 0.01). In contrast, HA patients had lower 30-day (HA/Caucasian OR 0.70; 95% CI 0.49 to 0.98; p = 0.04) and 6-month mortality risk (HA/Caucasian OR 0.66; 95% CI 0.50 to 0.88; p < 0.01) than Caucasian patients.

CONCLUSIONS

Ethnicity does not appear to be a strong risk factor for adverse outcomes following CABG surgery in the VHA. Future studies are needed to determine why AA patients have more complications, but ethnicity should not affect the decision to offer the operation.

Association between abciximab and length of stay in intensive care for patients undergoing percutaneous coronary intervention. A 2-stage econometric model in a naturalistic setting

OBJECTIVE

To examine the effect of abciximab treatment on intensive care length of stay for patients undergoing percutaneous coronary intervention (PCI).

DESIGN AND SETTING

A retrospective study conducted in a naturalistic setting.

METHODS

A 2-stage econometric model was used to control for the influence of possible selection bias across categories of patients and for both observable and unobservable factors correlated with each patient's treatment selection and length of stay in intensive care. Multivariate analysis was applied to control for a wide range of factors (patient demographics, insurance provider, health conditions, admission and discharge information, and hospital characteristics) that may influence intensive care length of stay. Retrospective data were obtained from HCIA's Clinical Pathways Database.

PARTICIPANTS

Patients (n = 13,364) who were hospitalised in any of 87 hospitals across the US over the period from October 1, 1995 to December 1, 1996.

RESULTS

After controlling for high-risk indications and selection bias, results indicated that administration of abciximab was associated with a significantly shorter length of stay in intensive care compared with not administering a GPIIb/IIIa inhibitor (0.45 fewer days; p < or = 0.0001). In a subgroup analysis of patients having an acute myocardial infarction (n = 4793), administration of abciximab was also associated with a significantly shorter intensive care stay (0.27 fewer days; p < 0.0001).

CONCLUSION

Results of this study indicate that the administration of abciximab is associated with a reduction in the length of stay in intensive care. This reduction implies potential cost offsets for patients undergoing PCI who receive abciximab.

The effect of race on coronary bypass operative mortality

OBJECTIVES

The study was done to determine whether race is an independent predictor of operative mortality after coronary artery bypass graft (CABG) surgery.

BACKGROUND

Blacks are less frequently referred for cardiac catheterization and CABG than are whites. Few reports have investigated the relative fate of patients who undergo CABG as a function of race.

METHODS

The Society of Thoracic Surgeons National Database was used to retrospectively review 25,850 black and 555,939 white patients who underwent CABG-alone from 1994 through 1997. A multivariate logistic regression model was developed to determine whether race affected risk-adjusted operative mortality.

RESULTS

Operative mortality was 3.83% for blacks versus 3.14% for whites (unadjusted black/white odds ratio [OR] 1.23 [1.15-1.31]). Blacks were younger, more likely female, hypertensive, diabetic and in heart failure. Nonetheless, the influence of these and other preoperative risk factors on procedural mortality was quite similar in black and white patients. After controlling for all risk factors, race remained a significant independent predictor of mortality in the multivariate logistic model (adjusted black/white OR 1.29 [1.21, 1.38]). Proportionately, these differences were greatest among lower-risk patients. The race-by-gender interaction was significant (p<0.05). The unadjusted mortality for black men, 3.30% and white men, 2.64% differed significantly (p<0.05), whereas for women there was no difference (black, 4.49%; white 4.41%).

CONCLUSIONS

Black race is an independent predictor of operative mortality after CABG except for very high-risk patients. The difference in mortality is greatest for male patients and, though statistically significant, is small in absolute terms. Therefore, patients should be referred for CABG based on clinical characteristics irrespective of race.

Racial and ethnic differences in the use of cardiovascular procedures: findings from the California Cooperative Cardiovascular Project

OBJECTIVES

This study used data from the California Cooperative Cardiovascular Project to examine the use of invasive and noninvasive cardiovascular procedures among Whites, African Americans, and Hispanics.

METHODS

The use of catheterization, percutaneous transluminal coronary angioplasty (PTCA), coronary artery bypass graft (CABG) surgery, and several noninvasive tests among all patients 65 years or older with a confirmed acute myocardial infarction in nonfederal hospitals from 1994 to 1995 was studied.

RESULTS

African Americans (n = 527) were less likely than Whites (n = 9489) to have received catheterization (adjusted odds ratio [OR] = 0.62, 95% confidence interval [CI] = 0.50, 0.76), PTCA (OR = 0.64, 95% CI = 0.49, 0.85), or CABG surgery (OR = 0.42, 95% CI = 0.27, 0.64); somewhat more likely to have received a stress test or an echocardiogram; and equally likely to have received a multiple-gated acquisition scan. Hispanics (n = 689) also were less likely than Whites to have received catheterization (OR = 0.82, 95% CI = 0.68, 0.98) or PTCA (OR = 0.58, 95% CI = 0.45, 0.75).

CONCLUSIONS

African Americans were less likely than Whites to undergo costly invasive cardiovascular procedures. In addition, Hispanics were less likely than Whites to have received catheterization and PTCA.

Race and sex differences in the management of coronary artery disease

Although numerous studies have documented race and sex differences in the treatment of coronary artery disease, the available analyses have not been comprehensively evaluated. In this review, we summarize prior estimates of race and sex disparities in the utilization of standard tests and therapies, and we evaluate studies of factors that may contribute to gaps in care. The studies presented consistently demonstrate that blacks and women with coronary artery disease, compared with whites and men, are substantially less likely to receive standard interventions. Studies also indicate that racial differences relate in part to socioeconomic factors, process-of-care variables, and patient preferences, whereas sex differences relate in part to clinical factors. In both cases, however, our understanding is limited by deficiencies in currently available datasets. Moreover, factors that have been shown to contribute to race and sex disparities in medical care fail to explain them fully. In both cases, physician decision-making appears to contribute as well, suggesting that subconscious biases may contribute to treatment disparities. We conclude by proposing initiatives to remedy race and sex disparities in medical care. Efforts should focus on increasing physician awareness of this problem. Studies should gather data that are currently unavailable for analysis, including detailed clinical variables and patient-level socioeconomic information. Finally, novel quality assurance programs, designed to evaluate and improve the care of blacks and women with coronary artery disease, should be promptly undertaken.

Myocardial infarction in treated hypertensive patients: the paradox of lower incidence but higher mortality in young blacks compared with whites

BACKGROUND

Despite the impressive decline in coronary heart disease death rates, a mortality differential between blacks and whites persists. Our study objective was to determine whether excess mortality among well-controlled hypertensive black men compared with whites is due to differences in disease incidence or in case fatality.

METHODS AND RESULTS

Of 3382 male subjects (1266 blacks and 2116 whites) enrolled between 1973 and 1996 and followed up through 1997 in a work-site hypertension control program, 2343 were followed up until 60 years of age, and 1884 were followed up until >60 years of age (either continuing after 60 years [n=845] or beginning treatment at >/=60 years [n=1039]), with a mean follow-up of 5.2 and 5.5 years, respectively. During follow-up, 186 myocardial infarction (MI) events (including 31 revascularizations) occurred, with 63 in patients <60 years and 123 in patients >/=60 years of age. Age-adjusted MI incidence was nearly twice as high for whites as blacks in younger (6.3 versus 3.4/1000 person-years) and older (14.1 versus 7.5 person-years) subjects. In contrast, the age-adjusted case fatality rate was 3-fold higher for younger blacks than for whites (37.8% versus 12.2%). In older patients, case fatality did not differ significantly between blacks and whites (37.6% versus 50. 3%). In separate Cox regression analyses, among younger blacks but not younger whites, history of diabetes and smoking were significantly associated with both incidence and fatality.

CONCLUSIONS

In these treated male hypertensive patients with good blood pressure control (139.6/85.7 mm Hg), young blacks, despite a lower MI incidence, had higher MI mortality than did their white counterparts. Their higher case fatality rate was associated with fewer coronary artery revascularizations and a higher prevalence of diabetes and smoking.

Racial differences in the management of unstable angina: results from the multicenter GUARANTEE registry

BACKGROUND

Prior studies, usually conducted with the use of insurance databases, have shown differences in the use of cardiac procedures between black patients and white patients hospitalized with various types of coronary artery disease. However, few data are available in prospectively collected cohorts of patients with unstable angina or on the use of appropriate medications or interventions.

METHODS AND RESULTS

We evaluated 2948 consecutive patients with unstable angina admitted to 35 hospitals across the United States in 1996, comparing nonwhite and white patients. Seventy-seven percent of patients were white, 14% were black, 4% were Hispanic, 1% were Asian, and 3% were other or unknown race. Differences were seen in coronary risk profile, with a higher incidence of hypertension and diabetes mellitus in nonwhites. Cardiac catheterization was performed less often in nonwhites compared with whites (36% vs 53%, P =.001). Even in patients meeting the criteria for appropriate catheterization in the Agency for Health Care Policy Research unstable angina guidelines, fewer nonwhites underwent catheterization (44% vs 61%, P =.001), but among these, fewer nonwhites had significant coronary stenosis (72% vs 90%, P =.001). However, among patients catheterized who had indications for revascularization, angioplasty and coronary artery bypass grafting were performed equally often in nonwhites and whites.

CONCLUSIONS

Current guidelines would recommend more aggressive use of cardiac catheterization for nonwhite patients. However, our findings suggest that racial differences may need to be included in the diagnostic and interventional algorithms.

Impact of race on the treatment for peripheral arterial occlusive disease

PURPOSE

The purpose of this study was to determine the impact of race on the treatment of peripheral artery occlusive disease (PAOD) and to examine the role of access to care and disease distribution on the observed racial disparity.

METHODS

The study was performed as a retrospective analysis of hospital discharge abstracts from 1992 to 1995 in 202 non-federal, acute-care hospitals in the state of Florida. The subjects were patients older than 44 years of age who underwent major lower extremity amputation or revascularization (bypass grafting or angioplasty) for PAOD. The main outcome measures were incidence of intervention, incidence per demographic group, multivariate predictors of amputation versus revascularization, multivariate predictors of amputation versus revascularization among those patients with access to sophisticated care (hospital with arteriographic capabilities), and multivariate predictors of surgical bypass graft type (aortoiliac vs infrainguinal).

RESULTS

A total of 51,819 procedures (9.1 per 10,000 population) were performed for PAOD during the study period and included 15,579 major lower extremity amputations (30.1%) and 36,240 revascularizations (69.9%). Although the incidence of a procedure for PAOD was comparable between African Americans and whites (9.0 vs 9.6 per 10, 000 demographic group), the incidence of amputation (5.0 vs 2.5 per 10,000 demographic group) was higher and the incidence of revascularization (4.0 vs 7.1 per 10,000 demographic group) was lower among African Americans. Furthermore, multivariate analysis results showed that African Americans (odds ratio, 3.79; 95% confidence interval [CI], 3.34 to 4.30) were significantly more likely than whites to undergo amputation as opposed to revascularization. The secondary multivariate analyses results revealed that African Americans (odds ratio, 2.29; 95% CI, 1.58 to 3. 33) were more likely to undergo amputation among those patients (n = 9193) who underwent arteriography during the procedural admission and to undergo infrainguinal bypass grafting (odds ratio, 2.00; 95% CI, 1.48 to 2.71) among those patients (n = 27,796) who underwent surgical bypass grafting.

CONCLUSION

There is a marked racial disparity in the treatment of patients with PAOD that may be caused in part by differences in the severity of disease or disease distribution.