Do Differences in Hospital and Surgeon Quality Explain Racial Disparities in Lower-Extremity Vascular Amputations?
Do Differences in Hospital and Surgeon Quality Explain Racial Disparities in Lower-Extremity Vascular Amputations?
复制标题
DOI：
10.1097/sla.0b013e3181b41d53
复制
发表时间：
2009-09-01
影响因子：
9
通讯作者：
Jha, Ashish K.
中科院分区：
文献类型：
--
作者：
Regenbogen, Scott E.;Gawande, Atul A.;Jha, Ashish K.
目的：为了了解是否种族差异在手术下肢动脉疾病是最小化的高品质的供应商，或者相反，其他类似的患者的差异治疗pervades所有settings.Summary背景资料：黑人患者比白人更有可能接受截肢，而不是下肢动脉疾病的血运重建。因为他们的护理是不成比例地集中在一小部分供应商，一些人认为这种差异的质量和能力，这些sites.Methods：我们评估了所有86,865白色或黑色的收费服务医疗保险受益人65岁及以上谁经历了重大下肢血管手术。使用广义线性混合模型与随机效应，我们计算了截肢的风险调整后的赔率种族整体，并通过显着的患者和供应商的特征serial substrategy后，结果：黑人更有可能接受截肢（45%比20%）。他们的手术更常由非专家进行（41% vs. 27%; P < 0.001），在低容量医院（40% vs. 32%; P < 0.001），截肢率高（5.3% vs. 29%; P < 0.001）。控制合并症、疾病严重程度、外科医生和医院表现的差异，黑人截肢的几率仍然高出1.7倍（95%置信区间：1.6-1.9）。即使是在表现最好的供应商--拥有血管成形术设施的大容量城市教学医院的血管专家--种族差距也持续存在（风险调整截肢率：黑人7%对白人4%，P < 0.001;比值比：1.8，95%可信区间：1.5-2.1）。患有严重肢体缺血的黑人患者面临着更高的大截肢风险，即使是由最有可能进行血运重建的供应商治疗。增加转诊到高性能供应商可能会增加肢体保护，但不能消除差距，直到公平的待遇可以确保在所有设置。
Objective: To understand whether racial disparities in surgery for lower-extremity arterial disease are minimized by high-quality providers, or instead, differential treatment of otherwise similar patients pervades all settings.Summary Background Data: Black patients are substantially more likely than whites to undergo amputation rather than revascularization for lower-extremity arterial disease. Because their care is disproportionately concentrated among a small share of providers, some have attributed such disparities to the quality and capacity of these sites.Methods: We evaluated all 86,865 white or black fee-for-service Medicare beneficiaries 65 and older who underwent major lower-extremity vascular procedures. Using generalized linear mixed models with random effects, we computed risk-adjusted odds of amputation by race overall, and after serial substratification by salient patient and provider characteristics.Results: Blacks were far more likely to undergo amputation (45% vs. 20%). Their procedures were performed more often by nonspecialists (41% vs. 27%; P < 0.001), in low-volume hospitals (40% vs. 32%; P < 0.001), with high amputation rates (5.3% vs. 29%; P < 0.001). Controlling for differences in comorbidity, disease severity, and surgeon and hospital performance, blacks' odds of amputation remained 1.7 times greater (95% confidence interval: 1.6-1.9). Even among highest-performing providers-vascular specialists in high-volume, urban teaching hospitals with angioplasty facilities-racial gaps persisted (risk-adjusted amputation rates: 7% for blacks vs. 4% for whites, P < 0.001; odds ratio: 1.8, 95% confidence interval: 1.5-2.1).Conclusions: Black patients with critical limb ischemia face significantly higher risk of major amputation, even when treated by providers with highest likelihoods of revascularization. Increased referral to high-performing providers might increase limb-preservation, but cannot eliminate disparities until equitable treatment can be ensured in all settings.