Racial Disparities in Outcomes of Endovascular Procedures for Peripheral Arterial Disease: An Evaluation of California Hospitals, 2005–2009

Abstract

Background Racial/ethnic disparities in treatment outcomes of peripheral arterial disease (PAD) are well documented. Compared to non-Hispanic (NH) whites, blacks and Hispanics are more likely to undergo amputation and less likely to undergo bypass surgery for limb salvage. Endovascular procedures are being increasingly performed as first line of therapy for PAD. In this study, we examined the outcomes of endovascular PAD treatments based on race/ethnicity in a contemporary large population-based study. Methods We used Patient Discharge Data (PDD) from California’s Office of Statewide Health Planning and Development (OSHPD) to identify all patients over the age of 35 who underwent a lower extremity arterial intervention from 2005 to 2009. A look-back period of five years was used to exclude all patients with prior lower extremity arterial revascularization procedures or major amputation. Cox proportional hazards regression was used to compare amputation-free survival and time to death within 365 days. Logistic regression was used for comparison of 1-month myocardial infarction (MI), 1-month major amputation, 1-month all-cause mortality, 12-month major amputation, 12-month reintervention, and 12-month all-cause mortality rates among NH white, black, and Hispanic patients. These analyses were adjusted for age, gender, insurance status, severity of PAD, comorbidities, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. Results Between 2005 and 2009, a total of 41,507 individuals underwent PAD interventions, 25,635 (61.7%) of whom underwent endovascular procedures. There were 17,433 (68%) NH whites, 4,417 (17.2%) Hispanics, 1,979 (7.7%) blacks, 1,163 (4.5%) Asian/Native Hawaiians, and 643 (2.5%) others in this group. There was a statistically significant difference in the amputation-free survival within 365 days among the NH white, Hispanic and black groups (P < 0.0001); the hazard ratio for amputation within 365 days was 1.69 in Hispanics (95% CI 1.51–1.90; P <0.0001) and 1.68 in blacks (95% CI 1.44–1.96; P <0.001) compared to NH whites following endovascular procedures after adjusting for age, gender, insurance status, comorbidities, severity of PAD, history of coronary artery angioplasty or bypass surgery, or history of carotid endarterectomy. After adjusting for the aforementioned confounders, the first reintervention within 12 months was also significantly associated with race/ethnicity (P=0.002). Odds ratio for reintervention was 1.17 in blacks (95% CI 1.06–1.30, P=0.002) and 1.084 in Hispanics (95% CI 1.00–1.16, P=0.04) compared to NH whites. Conclusions In this contemporary large population-based study, we demonstrated that even among matched cohorts Hispanics and blacks have worse amputation-free survival than NH whites following endovascular therapy. Our study also found that Hispanics and blacks are more likely to undergo lower extremity arterial reinterventions than NH whites. Further research is crucial in understanding if higher reintervention rates in ...

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

“…7,22,23 Despite revascularization, black race has been shown to affect patency of open and endovascular procedures. 4,8,9,28 The predilection for more aggressive atherosclerotic disease burden is further supported by our findings of the higher predicted 3-year amputation risk (5%) seen in black patients with DM and CKD/ESRD living in low-SES neighborhoods despite presenting early with claudication. In contrast, white patients with CLI and without the other risk factors have only a 7% predicted risk of limb loss over the same time.…”

“…Involvement of distal tibial vessels in PAD may preclude successful attempts at revascularization and increase the need for primary amputation 7, 22, 23. Despite revascularization, black race has been shown to affect patency of open and endovascular procedures 4, 8, 9, 28. The predilection for more aggressive atherosclerotic disease burden is further supported by our findings of the higher predicted 3‐year amputation risk (5%) seen in black patients with DM and CKD/ESRD living in low‐SES neighborhoods despite presenting early with claudication.…”

“…Advanced clinical stage, presence of comorbid diabetes mellitus (DM) and chronic kidney disease (CKD), and higher anatomic complexity of disease not amenable to revascularization have been put forth as reasons for poor limb salvage in black patients 7. Poorer patency of lower extremity bypasses and endovascular interventions in black patients suggest biological pathways affecting higher risk of amputation 4, 8, 9. Racial differences in endothelial oxidative stress and inflammation may be mechanisms for poorer outcomes in PAD patients 10…”

“…7 Poorer patency of lower extremity bypasses and endovascular interventions in black patients suggest biological pathways affecting higher risk of amputation. 4,8,9 Racial differences in endothelial oxidative stress and inflammation may be mechanisms for poorer outcomes in PAD patients. 10 Some authors have argued that race could be a marker for socioeconomic status (SES) and thus for healthcare access, as the reason for racial disparity in vascular outcomes.…”

Hospital cost impact of orbital atherectomy with angioplasty for critical limb ischemia treatment: a modeling approach

“…Despite the initiation of limb salvage programs, race and/or ethnic origins appear to drive some of the ongoing inadequate vascular medicine practices. Multiple studies have demonstrated that African-Americans, Hispanics and Asians comprise a disproportionately higher proportion of patients admitted for CLI and undergoing amputation, with a lower proportion undergoing revascularization [47,48]. With the overall minority population growth rate projected to be in the double digits in the coming decades [38], finding ways to deliver quality and cost-effective care especially to those currently predisposed to poorer outcomes is critical.…”