The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease

Witrick, Brian; Shi, Lu; Mayo, Rachel; Hendricks, Brian; Kalbaugh, Corey A.

doi:10.3389/fcvm.2022.1021692

Cited by 5 publications

(6 citation statements)

References 52 publications

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“…Those from distressed or the most disadvanta ged neighborhoods had the highest risk. This study confirms the utility of the Distressed Communities Index in predicting important health outcomes because it has successfully predicted mortality after cardiac surgery, 12 COVID-19, 13 limb amputation rates, 14 emergency department visits for firearm injuries, 15 and HIV prevalence among hospital admissions. 16 Although other ophthalmic studies have evaluated state and national emergency department databases, 17 to our knowledge this is the first study to present detailed data on emergency department presentation primarily for DR. As seen in outpatient and survey-based studies, [2][3][4]18 we found race to be predictive of a more advanced presentation of DR, with minority groups being more likely to present to the emergency department for PDR than Whites.…”

Section: Discussionsupporting

confidence: 73%

Section: Discussionsupporting

confidence: 72%

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Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Akinyemi,

Jones MD,

Ochoa

et al. 2024

Journal of VitreoRetinal Diseases

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Purpose: To investigate the association between neighborhood-level socioeconomic factors, quantified by the Distressed Communities Index, and emergency department visits for diabetic retinopathy (DR). Methods: All patients who presented to the emergency department for DR in California were analyzed using the State Emergency Department Database (2018–2020). Patients were stratified by Distressed Communities Index score and DR severity. Logistic regression was applied to explore the independent correlation between Distressed Communities Index scores and proliferative DR (PDR). Results: Of 2 725 195 emergency department visits for diabetic patients, Distressed Communities Index data were available for 2 459 577 (90.3%); 39 693 were for DR, including 13 617 (34.3%) for PDR. Hispanics (44.2%) were the largest racial/ethnic group to present for PDR, followed by non-Hispanic Whites (19.6%) and non-Hispanic Blacks (19.3%). A significant association was observed between the Distressed Communities Index and emergency department visits for PDR, with distressed neighborhoods having the highest incidence (adjusted odds ratio [aOR], 1.63; 95% CI, 1.20-2.23; P = .001). Other predictors included Hispanic ethnicity (aOR, 2.21; 95% CI, 1.97-2.48; P < .001) and Black race (aOR, 1.46; 95% CI, 1.28-1.67; P < .001) compared with White race and having Medicaid (aOR, 1.37; 95% CI, 1.13-1.65; P = .001) compared with private insurance. Conclusions: The Distressed Communities Index identified patients residing in the most distressed neighborhoods as being at the highest risk for presenting to the emergency department for PDR based on 7 socioeconomic factors. Policymakers may consider the Distressed Communities Index as a tool for targeting DR prevention strategies and improving healthcare accessibility.

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Section: Discussionsupporting

confidence: 73%

Section: Discussionsupporting

confidence: 72%

Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Akinyemi,

Jones MD,

Ochoa

et al. 2024

Journal of VitreoRetinal Diseases

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“…Black individuals with PAD in non-distressed communities have a higher lifetime incidence of amputation compared to White individuals in distressed communities. 10 A better understanding of the mechanisms that underlie these racial inequities in both potentially harmful revascularizations and limb loss is necessary to ultimately provide better care and improved outcomes. So why do Black patients receive different and suboptimal care compared to White patients even when controlling for location, insurance, socioeconomic status (SES), and risk factor profiles?…”

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Kalbaugh,

Beidelman,

Howard

et al. 2024

Preprint

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Introduction. Implicit (or unconscious) bias may influence physician treatment decisions and contribute to Black-White health disparities. While implicit bias has been linked with low quality care via clinical vignettes, some worry that these studies are not representative of the 'real world.' There is limited data that has attempted to link implicit bias with actual care delivery and outcomes. We sought to understand if implicit bias is associated with potentially harmful surgical treatment selection in a cohort of patients with peripheral artery disease (PAD)-related claudication undergoing below-knee lower extremity revascularization as captured in a 'real world' procedural registry. Methods. We invited vascular specialists from the Vascular Quality Initiative (VQI) to take the race Implicit Association Test (IAT). The IAT asks participants to associate images of Black and White Americans with either positive or negative attributes. Based on reaction time differences across sequential tests, participants were grouped into race-based implicit bias categories: pro-White bias, no bias, or pro-Black bias. Our provider-level implicit bias results were linked to patient-level registry data of peripheral revascularization procedures performed for claudication. We measured the adjusted odds of performance of below knee procedures by specialist implicit bias and patient race via mixed effects logistic regression models. We assessed implicit bias as a moderator of the association of below-knee procedures and patient race with 1-yr amputation. Results. 218 vascular specialists in the United States completed the IAT and 157 (72%) had a pro-White bias. Black patients treated by a physician with pro-White bias had a 74% increase in the odds of receiving a below-knee procedure compared to the total sample (aOR: 1.74, 95% CI: 1.33-2.15). When treated by a specialist with pro-White bias, Black patients had 3 times the odds of 1-yr amputation – regardless of anatomic location treated – compared to White patients (aOR: 3.04, 95% CI: 1.68-5.51). Conversely, Black patients treated by a specialist with no bias had similar odds of a below-knee procedure (aOR: 0.99, 95% CI: 0.67-1.30) and 1-year amputation (aOR: 1.31, 95% CI: 0.35-4.96) as the full patient sample. Conclusions. Implicit bias is associated with potentially harmful below-knee procedures for Black patients and contributes to Black-White outcome disparities in the United States. These results suggest the need for system-level interventions that transparently identify and warn of procedures not aligned with best practices to reduce the negative effect of implicit bias.

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“…1 Patients with PAD represent a vulnerable cohort of patients with high comorbidity burden, management that requires a complex interplay of medical and interventional specialties and decision-making, and high risk for amputation and early mortality. [2][3][4][5][6][7][8] Studies focused on PAD-related care delivered to Black and White patients have shown that Black patients are offered different procedures than White patients, including a lower incidence of limb-sparing revascularizations and a higher incidence of primary limb amputations (i.e., amputation without attempt at revascularization). 5 Therefore, while all patients with PAD have some degree of risk for limb loss, Black patients with PAD have a 2-5 times greater lifetime risk of lower extremity amputation than White patients.…”

Section: Introductionmentioning

confidence: 99%

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons

Howard,

Witrick,

Clark

et al. 2024

Preprint

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BackgroundImplicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD).MethodsThe sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias.ResultsThere were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making.ConclusionsMost people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.CLINICAL PERSPECTIVEWhat is new?This is the first study to examine unconscious and conscious bias in vascular surgeons, an important population for treating peripheral artery disease which disproportionately affects structurally vulnerable groups.We found that the majority of vascular surgeons show a pro-White bias, there is a lack of association between unconscious bias and conscious awareness of bias, and those who do not report conscious awareness of bias may also show greater magnitude of unconscious bias.What are the clinical implications?These findings offer important considerations for attentiveness to both unconscious biases and enhancement of awareness of the existence of biases among a surgery community that provides care to a diverse population of patients with PAD and disparities in health outcomes.Incorporating information on the awareness of biases and structural changes to facilitate behavior change based on these findings may be helpful within training programs for vascular surgeons.With awareness as an important first step in mitigation, cognizance of the existence of biases, as identified by this study, can aid in efforts to minimize racial disparities in health care.

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The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease

Cited by 5 publications

References 52 publications

Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Socioeconomic Disparities and Emergency Department Visits for Diabetic Retinopathy in California

Implicit Bias And Unintentional Harm In Vascular Care: The Case For Intervention

Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons

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