Racial disparities in the use of revascularization before leg amputation in Medicare patients
Racial disparities in the use of revascularization before leg amputation in Medicare patients
复制标题
DOI：
10.1016/j.jvs.2011.02.035
复制
发表时间：
2011-08-01
影响因子：
4.3
通讯作者：
Birkmeyer, John D.
中科院分区：
文献类型：
--
作者：
Holman, Kerianne H.;Henke, Peter K.;Birkmeyer, John D.
目的：患有外周动脉疾病的黑人患者接受截肢的比率是白人患者的两到四倍。为了确定保肢尝试的差异是否可能导致这种差异，我们研究了黑人患者与白人患者在截肢前接受的肢体护理情况。方法：利用 2003 年至 2006 年住院患者医疗保险数据，我们确定了所有接受下肢大截肢术的受益人的回顾性样本。 “保肢护理”被定义为截肢前两年内发生的与肢体相关的入院和手术。我们使用多元逻辑回归来比较黑人和白人截肢者接受血运重建和其他肢体护理的比率，并根据患者的个体特征进行调整。然后，我们控制了医院转诊区域，以评估护理差异是否可能归因于黑人和白人患者接受护理的地理区域。最后，我们检查了两个种族的血运重建相对于截肢的时间。结果：我们的样本包括 24,600 名黑人和 65,881 名白人截肢者。与白人相比，黑人截肢者更有可能是女性，而且社会经济地位较低。不同种族之间的平均年龄、糖尿病发病率和合并症水平相似。黑人截肢者接受血运重建术（23.6% vs 31.6%；P < .0001）、任何肢体相关入院（39.6% vs 44.7%；P < .0001）、脚趾截肢（12.9% vs 13.8%；P < .0005）或伤口清创（11.6% vs 11.6% vs 13.8%）的可能性明显低于白人14.2%；P < .0001) 截肢前。在调整个体患者特征的差异后，黑人截肢者仍然明显低于白人接受血运重建（比值比 [OR]，0.72 [95% 置信区间，.68-.76]）、肢体相关入院（OR，0.81 [0.78-0.84]）或截肢前伤口清创（OR，0.80 [0.75-0.85]）。不同种族之间血运重建相对于截肢的时间相似。观察到的护理差异存在于医院转诊区域内，并且不能用黑人和白人患者接受护理的地区差异来解释。结论：黑人患者在截肢前尝试保肢的可能性比白人低得多。进一步的研究应该探讨这种差异是否可能归因于动脉疾病严重程度、患者偏好或医生决策方面的种族相关差异。 （花瓶外科杂志 2011 年；54：420-6。）
Objective: Black patients with peripheral arterial disease undergo amputation at two to four times the rate of white patients. In order to determine whether differences in attempts at limb salvage might contribute to this disparity, we studied the limb care received prior to amputation by black patients compared with whites.Methods: Using inpatient Medicare data for the years 2003 through 2006, we identified a retrospective sample of all beneficiaries who underwent major lower extremity amputation. "Limb salvage care" was defined as limb-related admissions and procedures that occurred during the 2 years prior to amputation. We used multiple logistic regression to compare rates of revascularization and other limb care received by black versus white amputees, adjusting for individual patient characteristics. We then controlled for hospital referral region in order to assess whether differences in care might be attributable to the geographic regions in which black and white patients received care. Finally, we examined the timing of revascularization relative to amputation for both races.Results: Our sample included 24,600 black and 65,881 white amputees. Compared with whites, black amputees were more likely to be female and had lower socioeconomic status. Average age, rates of diabetes, and levels of comorbidity were similar between races. Black amputees were significantly less likely than whites to have undergone revascularization (23.6% vs 31.6%; P < .0001), any limb-related admission (39.6% vs 44.7%; P < .0001), toe amputation (12.9% vs 13.8%; P < .0005), or wound debridement (11.6% vs 14.2%; P < .0001) prior to amputation. After adjusting for differences in individual patient characteristics, black amputees remained significantly less likely than whites to undergo revascularization (odds ratios [OR], 0.72 [95% confidence interval,.68-.76]), limb-related admission (OR, 0.81 [0.78-0.84]), or wound debridement prior to amputation (OR, 0.80 [0.75-0.85]). Timing of revascularization relative to amputation was similar between races. Observed differences in care were shown to exist within hospital referral regions and were not accounted for by regional differences in where black and white patients received care.Conclusion: Black patients are much less likely than whites to undergo attempts at limb salvage prior to amputation. Further studies should explore whether this disparity might be attributable to race-related differences in severity of arterial disease, patient preferences, or physician decision making. (J Vase Surg 2011;54:420-6.)