Predictive Modeling for One-Year Lower Extremity Endovascular Revascularization Failure in Black Persons

INTRODUCTION

Black persons bear a disproportionate burden of peripheral artery disease (PAD) and experience higher rates of endovascular revascularization failure (ERF) when compared with non-Hispanic White persons. We aimed to identify predictors of ERF in Black persons using predictive modeling.

METHODS

This retrospective study included all persons identifying as Black who underwent an initial endovascular revascularization procedure for PAD between 2011 and 2018 at a midwestern tertiary care center. Three predictive models were developed using (1) logistic regression, (2) penalized logistic regression (least absolute shrinkage and selection operator [LASSO]), and (3) random forest (RF). Predictive performance was evaluated under repeated cross-validation.

RESULTS

Of the 163 individuals included in the study, 113 (63.1%) experienced ERF at 1 y. Those with ERF had significant differences in symptom status (P < 0.001), lesion location (P < 0.001), diabetes status (P = 0.037), and annual procedural volume of the attending surgeon (P < 0.001). Logistic regression and LASSO models identified tissue loss, smoking, femoro-popliteal lesion location, and diabetes control as risk factors for ERF. The RF model identified annual procedural volume, age, PAD symptoms, number of comorbidities, and lesion location as most predictive variables. LASSO and RF models were more sensitive than logistic regression but less specific, although all three methods had an overall accuracy of ≥75%.

CONCLUSIONS

Black persons undergoing endovascular revascularization for PAD are at high risk of ERF, necessitating need for targeted intervention. Predictive models may be clinically useful for identifying high-risk patients, although individual predictors of ERF varied by model. Further exploration into these models may improve limb salvage for this population.

Impact of Regional Differences and Neighborhood Socioeconomic Deprivation on the Outcomes of Patients with Lower Extremity Wounds Evaluated by a Limb-Preservation Service

INTRODUCTION

Management of lower extremity (LE) wounds has evolved with the establishment of specialized limb preservation services. While clinical factors contribute to limb outcomes, socioeconomic status and community factors also influence the risk for limb loss. The Distressed Community Index (DCI) score is a validated index of social deprivation created to provide an objective measure of economic well-being in U.S communities. Few studies have examined the influence of geographic deprivation on outcomes in patients with LE wounds. We examined relationships between socioeconomic deprivation and outcomes of inpatients evaluated by a dedicated limb preservation service (FLEX).

METHODS

Inpatients referred to FLEX over a 5-year period were included. Wound, Ischemia, foot Infection (WIfI) staging was collected. DCI scores were determined using 7 indices based on ZIP Code. Outcomes included any minor or major amputations, any endovascular or open LE revascularization, or wound care procedures. Disease etiology, demographic, and anthropometric data were collected. Associations between neighborhood deprivation and limb-specific outcomes were evaluated in models for the DCI and each of its components separately.

RESULTS

677 patients were included. Thirty-eight percent were female, with a mean age of 64 years. Sixty percent had WIfI stage 3 or 4 risk of amputation, and 43% had WIfI stage 3 or 4 risk of revascularization. Mean (SD) ABI and toe pressure were 0.96 (0.43) and 80 (57) mmhg. Thirty-five percent were non-white. Amputation was performed in 31% of patients while 17% underwent revascularization. The mean (SD) distress score was 64 (24). Mean DCI scores did not differ across WIfI scores. Likewise, overall DCI distress score was not related to any of the outcomes in univariable or multivariable LR models. In univariable LR models for amputation, higher poverty rate (odds ratio (OR) for SD increase 1.20, 95% confidence limits (CL) 1.02-1.42, P=0.025) was significantly associated with the outcome. In multivariable models, neither DCI distress score nor any of its components remained significantly associated with the outcome.

CONCLUSIONS

Despite known racial disparities in limb-specific outcomes, an aggregate measure of community level distress was not found to be related to outcomes. While poverty rate demonstrated a significant relationship with amputation in univariable analysis, this association was not found in multivariable models. Notably, non-white race emerged as a predictor of amputation, underscoring the importance of addressing racial disparities in LE outcomes. Further investigation of potential determinants of LE outcomes is needed, particularly the interaction of such factors with race.

Direct and Indirect Effects of Race and Socioeconomic Deprivation on Outcomes After Lower Extremity Bypass

OBJECTIVE

To evaluate the potential pathway, through which race and socioeconomic status, as measured by the social deprivation index (SDI), affect outcomes after lower extremity bypass chronic limb-threatening ischemia (CLTI), a marker for delayed presentation.

BACKGROUND

Racial and socioeconomic disparities persist in outcomes after lower extremity bypass; however, limited studies have evaluated the role of disease severity as a mediator to potentially explain these outcomes using clinical registry data.

METHODS

We captured patients who underwent lower extremity bypass using a statewide quality registry from 2015 to 2021. We used mediation analysis to assess the direct effects of race and high values of SDI (fifth quintile) on our outcome measures: 30-day major adverse cardiac event defined by new myocardial infarction, transient ischemic attack/stroke, or death, and 30-day and 1-year surgical site infection (SSI), amputation and bypass graft occlusion.

RESULTS

A total of 7077 patients underwent a lower extremity bypass procedure. Black patients had a higher prevalence of CLTI (80.63% vs 66.37%, P < 0.001). In mediation analysis, there were significant indirect effects where Black patients were more likely to present with CLTI, and thus had increased odds of 30-day amputation [odds ratio (OR): 1.11, 95% CI: 1.068-1.153], 1-year amputation (OR: 1.083, 95% CI: 1.045-1.123) and SSI (OR: 1.052, 95% CI: 1.016-1.089). There were significant indirect effects where patients in the fifth quintile for SDI were more likely to present with CLTI and thus had increased odds of 30-day amputation (OR: 1.065, 95% CI: 1.034-1.098) and SSI (OR: 1.026, 95% CI: 1.006-1.046), and 1-year amputation (OR: 1.068, 95% CI: 1.036-1.101) and SSI (OR: 1.026, 95% CI: 1.006-1.046).

CONCLUSIONS

Black patients and socioeconomically disadvantaged patients tended to present with a more advanced disease, CLTI, which in mediation analysis was associated with increased odds of amputation and other complications after lower extremity bypass compared with White patients and those that were not socioeconomically disadvantaged.

Differential impact of missed initial wound clinic visit on 6-month wound healing by race/ethnicity among patients with chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimise vascular outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association between successful wound care initiation and 6-month wound healing, with specific attention to differences by race/ethnicity. This retrospective study included 398 patients with CLTI and at least one ischaemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the completion status of patients' first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. We used Aalen-Johansen estimators to produce cumulative incidence curves and calculated risk ratios within strata of race/ethnicity. The final adjustment set included age, revascularization, and initial wound size. Patients had a mean age of 67 ± 14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit and 34% of wounds healed within 6-months. There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals (RR [95% CI] = 1.18 [0.91, 1.45]; p-value = 0.130), while non-White individuals were roughly 3 times more likely to heal their wounds if they completed their first appointment (RR [95% CI] = 2.89 [2.66, 3.11]; p-value < 0.001). In conclusion, non-White patients were approximately three times more likely to heal their wound in 6 months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals' risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups with wounds have the support they need to access and successfully initiate wound care.

Black or African American patients undergo great saphenous vein ablation procedures for advanced venous disease and have the least improvement in their symptoms after these procedures

OBJECTIVE

Chronic venous insufficiency is an increasingly prevalent problem in the United States, with >25 million individuals currently affected. Previous work has shown that racial minorities and low socioeconomic status are associated with a worse clinical presentation and response to treatment. The present study aimed to determine the relationship between race, patient variables, hospital outcomes, and response to treatment for patients presenting for chronic venous insufficiency intervention.

METHODS

We performed a retrospective analysis of all patients who underwent endovenous ablation (radiofrequency or laser) of the great saphenous vein to treat symptomatic, chronic venous insufficiency using Vascular Quality Initiative data from 2014 to 2020. Patient characteristics and outcomes were analyzed stratified by patient race. The χ2 test and the Kruskal-Wallis equality-of-populations rank test were used to measure the study outcomes. The primary outcomes were an improved venous clinical severity score and improvement in patient-reported outcomes. Patient characteristics, CEAP (clinical, etiologic, anatomic, pathophysiologic) classification, prior venous interventions, length of stay, and time to follow-up were compared between races.

RESULTS

The database consisted of 9009 predominantly female patients (n = 6041; 67.1%), with a mean age distribution of 56 years. Of the 9009 patients, 7892 are White (87.6%), 627 Hispanic (6.9%), and 490 Black or African American (18.3%). The Hispanic cohort was younger than their White and Black/African American counterparts. Black/African American patients presented with more advanced clinical stages than did the White and Hispanic groups. The clinical stage according to race was as follows: C3-Black/African American, 32.9%; Hispanic, 38.9%; White, 46%; C5-Black/African American, 4.7%; Hispanic, 2.1%; White, 2.3%; and C6-Black/African American, 12.7%; Hispanic, 3.2%; White, 6.2%. Black/African American patients were more likely to present as overweight or obese (66%; P < .001) and less likely to be taking anticoagulation medication preoperatively (11%; P < .001). Non-White race was associated with a higher probability of treatment in the hospital setting (Black/African American, 63.6%; Hispanic, 87.5%; P < .001). Black/African American patients (3.25 ± 4.4; P < .001) demonstrated lower mean improvement postoperatively in both the venous clinical severity score and patient-reported outcomes than their White (4.25 ± 4.13, P <.001) and Hispanic (4.42 ± 3.78; P < .001) counterparts.

CONCLUSIONS

Differences exist in the clinical severity and symptom presentation based on race. Black/African American patients present with more advanced chronic venous insufficiency than do their White and Hispanic counterparts. Furthermore, the postprocedural analysis showed inferior clinical and self-reported improvement in chronic venous insufficiency for the Black/African American patients. Although the Hispanic population was younger, the White and Hispanic patients experienced similar responses to treatment.

Racial Disparities in Spine Surgery: A Systematic Review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To synthesize previous studies evaluating racial disparities in spine surgery.

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on racial disparities in spine surgery. Our review was constructed in accordance with Preferred Reporting Items and Meta-analyses guidelines and protocol. The main outcome measures were the occurrence of racial disparities in postoperative outcomes, mortality, surgical management, readmissions, and length of stay.

RESULTS

A total of 1753 publications were assessed. Twenty-two articles met inclusion criteria. Seventeen studies compared Whites (Ws) and African Americans (AAs) groups; 14 studies reported adverse outcomes for AAs. When compared with Ws, AA patients had higher odds of postoperative complications including mortality, cerebrospinal fluid leak, nervous system complications, bleeding, infection, in-hospital complications, adverse discharge disposition, and delay in diagnosis. Further, AAs were found to have increased odds of readmission and longer length of stay. Finally, AAs were found to have higher odds of nonoperative treatment for spinal cord injury, were more likely to undergo posterior approach in the treatment of cervical spondylotic myelopathy, and were less likely to receive cervical disk arthroplasty compared with Ws for similar indications.

CONCLUSIONS

This systematic review of spine literature found that when compared with W patients, AA patients had worse health outcomes. Further investigation of root causes of these racial disparities in spine surgery is warranted.

Mortality differences by race over 20 years in individuals with peripheral artery disease

INTRODUCTION

Racial disparities exist in patients with peripheral artery disease (PAD), with Black individuals having worse PAD-specific outcomes. However, mortality risk in this population has been mixed. As such, we sought to evaluate all-cause mortality by race among individuals with PAD.

METHODS

We analyzed data from the National Health and Nutrition Examination Survey (NHANES). Baseline data were obtained from 1999 to 2004. Patients with PAD were grouped according to self-reported race. Multivariable Cox proportional hazards regression was performed to calculate adjusted hazard ratios (HR) by race. A separate analysis was performed to study the effect of burden of social determinants of health (SDoH) on all-cause mortality.

RESULTS

Of 647 individuals identified, 130 were Black and 323 were White. Black individuals had more premature PAD (30% vs 20%, p < 0.001) and a higher burden of SDoH compared to White individuals. Crude mortality rates were higher in Black individuals in the 40-49-year and 50-69-year age groups compared to White individuals (6.7% vs 6.1% and 8.8% vs 7.8%, respectively). Multivariable analysis demonstrated that Black individuals with both PAD and coronary artery disease (CAD) had a 30% higher hazard of death over 20 years compared to White individuals (HR = 1.3, 95% CI: 1.0-2.1). The cumulative burden of SDoH marginally (10-20%) increased the risk of all-cause mortality.

CONCLUSIONS

In a nationally representative sample, Black individuals with PAD and CAD had higher rates of mortality compared to their White counterparts. These findings add further proof to the ongoing racial disparities among Black individuals with PAD and highlight the necessity to identify ways to mitigate these differences.

Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations

Recently, the United States experienced its first resurgence of major amputations in more than 20 years. Compounding this rise is a longstanding history of disparities. Patients identifying as non-Hispanic Black are twice as likely to lose a limb as those identifying as non-Hispanic White. Those identifying as Latino face a 30% increase. Rural patients are also more likely to undergo major amputations, and the rural-urban disparity is widening. We used the National Institute on Minority Health and Health Disparities framework to better understand these disparities and identify common factors contributing to them. Common factors were abundant and included increased prevalence of diabetes, possible lower rates of foot self-care, transportation barriers to medical appointments, living in disadvantaged neighborhoods, and lack of insurance. Solutions within and outside the health care realm are needed. Health care-specific interventions that embed preventative and ambulatory care services within communities may be particularly high yield.

Disparities in limb preservation and associated socioeconomic burden among patients with diabetes and/or peripheral artery disease in the United States

Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (PAD). Higher rates of major LEA in disadvantaged groups are associated with increased health care utilization and higher costs of care. Functional decline that often follows major LEA confers substantial risk of disability and premature mortality, and the burden of these outcomes is more prevalent in racial and ethnic minority groups, people with low socioeconomic status, and people in geographic regions where limited resources or distance from specialty care are barriers to access. We present a narrative review of the existing literature on estimated costs of diabetic foot disease and PAD, inequalities in care that contribute to excess costs, and disparities in outcomes that lead to a disproportionate burden of diabetes- and PAD-related LEA on systematically disadvantaged populations.

The Relationship Between Peripheral Arterial Disease Severity and Socioeconomic Status

BACKGROUND

Although socioeconomic disparities in outcomes of peripheral artery disease (PAD) have been well studied, little is known about relationship between severity of PAD and socioeconomic status. The objective of this study was to examine this relationship.

METHODS

Patients who had operations for severe PAD (rest pain or tissue loss) were identified in the National Inpatient Sample, 2005-2014. They were stratified by the median household income (MHI) quartiles of their residential ZIP codes. Other characteristics such as race/ethnicity and insurance type were extracted. Factors associated with more severe disease (tissue loss) were evaluated using multivariable regression analyses.

RESULTS

There were 765,175 patients identified; 34% in the first MHI quartile and 18% in the fourth MHI quartile. Compared to patients in the first quartile, those in the fourth quartile were more likely White (69% vs. 42%, P < 0.001), more likely ≥65 years old (75% vs. 62%, P < 0.001), and were less likely to undergo amputations (25% vs. 34%, P < 0.001). After adjusting for patient characteristics, the fourth quartile was associated with more severe disease [Odds ratio: 1.19, 95% confidence interval (CI): 1.11-1.27] compared to the first quartile.

CONCLUSIONS

While higher MHI was associated with higher PAD severity, patients with high MHI were less likely to undergo amputations indicating a disparity in the choice of treatment for PAD. Increased efforts are necessary to reduce socioeconomic disparities in the treatment of severe PAD.

Racial disparities in treatment of ruptured abdominal aortic aneurysms

OBJECTIVE

The Society for Vascular Surgery has recommended immediate transfer of patients with ruptured abdominal aortic aneurysms (rAAAs) to a regional center when feasible. However, Black patients might be less likely to be transferred and more likely to be turned down for repair. We, therefore, examined the transfer rates, turndown rates, and outcomes for Black vs White patients presenting with rAAAs in two large databases.

METHODS

We examined all rAAA repairs in the Vascular Quality Initiative from 2003 to 2020 to evaluate the transfer rates and outcomes for Black vs White patients. We used the National Inpatient Sample from 2004 to 2015 to examine the turndown rates. Mixed effects logistic regression, Cox regression, and marginal effects modeling were used to study the interaction between race, insurance status, surgery type (open repair vs endovascular aortic aneurysm repair), and hospital volume.

RESULTS

We identified 4935 patients with rAAAs in the Vascular Quality Initiative (6.2% Black) and 48,489 in the National Inpatient Sample (6.0% Black). The rates of transfer were high; however, Black patients were significantly less likely to undergo transfer before repair compared with White patients (49% Black vs 62% White; P = .002). The result was consistent in both crude and adjusted analyses when considering only stable patients and was not modified by insurance status, surgery type, or hospital volume. No significant differences were found in perioperative mortality (22% vs 26%; P = .098) or complications (52% vs 52%; P = .64). However, Black patients were significantly more likely to be turned down for repair (37% vs 28%; odds ratio, 1.5; 95% confidence interval, 1.2-1.9; P < .001). A significant interaction was found between race and insurance status with respect to turndown. Patients with private insurance had undergone surgery at a similar rate, regardless of race. However, among patients with Medicare or Medicaid/self-pay, Black patients were less likely than were White patients to undergo repair (Medicare, 64% vs 72%; P = .001; Medicaid/self-pay, 43% vs 61%; P = .031). Patients with Medicaid/self-pay were also less likely to undergo repair than were patients of the same race with either Medicare or private insurance (P < .05).

CONCLUSIONS

We found that Black patients with rAAAs are poorly served by the current systems of interhospital transfer in the United States, because they less often undergo transfer before repair. Although the postoperative outcomes appeared similar, this finding could be falsely optimistic, because Black patients, especially the underinsured, were turned down for repair more often even after adjustment. Significant work is needed to better understand the reasons underlying these disparities and identify the targets to improve the care of Black patients with rAAAs.

Black men's awareness of peripheral artery disease and acceptability of screening in barbershops: a qualitative analysis

INTRODUCTION

Peripheral artery disease (PAD) disproportionately burdens Black Americans, particularly Black men. Despite the significant prevalence and high rate of associated morbidity and mortality, awareness of and treatment initiation for PAD remains low in this demographic group. Given the well-established social cohesion among barbershops frequently attended by Black men, barbershops may be ideal settings for health screening and education to improve awareness, early detection, and treatment initiation of PAD among Black men.

METHODS

A qualitative study involving 1:1 participant interviews in Cleveland, Ohio assessed perspectives of Black men about barbershop-based screening and education about PAD. Inductive thematic analysis was performed to derive themes directly from the data to reflect perceived PAD awareness and acceptability of screening in a barbershop setting.

RESULTS

Twenty-eight African American/Black, non-Hispanic men completed a qualitative interview for this analysis. Mean age was 59.3 ± 11.2 years and 93% of participants resided in socioeconomically disadvantaged zip codes. Several themes emerged indicating increased awareness of PAD and acceptability of barbershop-based screenings for PAD, advocacy for systemic changes to improve the health of the community, and a desire among participants to increase knowledge about cardiovascular disease.

CONCLUSIONS

Participants were overwhelmingly accepting of PAD screenings and reported increased awareness of PAD and propensity to seek healthcare due to engagement in the study. Participants provided insight into barriers and facilitators of health and healthcare-seeking behavior, as well as into the community and the barbershop as an institution. Additional research is needed to explore the perspectives of additional stakeholders and to translate community-based screenings into treatment initiation.

Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States

BACKGROUND

After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers.

METHODS

In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up.

RESULTS

Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings.

CONCLUSIONS

In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.

Healthcare Disparities in Interventional Radiology

Racial, ethnic, and sex-based healthcare disparities have been documented for the past several decades. Nonetheless, disparities remain firmly entrenched in our care delivery systems, with multiple contributing factors, including patient interactions with care providers, systemic barriers to access, and socioeconomic determinants of health. Interventional radiology is also subject to these drivers of health inequity. In this review, documented disparities for the most common conditions being addressed by interventional radiologists are summarized; their magnitude is quantified where relevant, and underlying drivers are identified. Specific examples are provided to illustrate how medical, cultural, and socioeconomic factors interact to produce unequal outcomes. By outlining known disparities and common contributors, this review aims to motivate future efforts to mitigate them.

Predictors of amputation-free survival after endovascular intervention for chronic limb-threatening ischemia in the modern era

OBJECTIVE

Chronic limb-threatening (CLTI) is associated with 25% limb loss and 25% mortality at 1-year. Its lethality increases to 45% in patients subjected to a major amputation. Percutaneous peripheral intervention (PPI) constitutes an attractive and less morbid treatment option for patients with CLTI. The purpose of this study was to assess amputation-free survival in a contemporary cohort treated with endovascular recanalization and assess its predictors.

METHODS

Patients with CLTI undergoing endovascular revascularization at a single regional hospital between 2015-2019 were reviewed. Baseline demographic characteristics, Wound, Ischemia, and foot Infection (WIfI) stage, technical details, and clinical outcomes were tabulated. The primary endpoint was amputation-free survival; a p-value < 0.05 was used for univariate screening and inclusion in a multivariable model.

RESULTS

137 limbs in 111 patients were studied. Comorbidities were prevalent and included diabetes (65%), congestive heart failure (21%), and dialysis dependence (18%). The majority of revascularized limbs presented with advanced wounds (66% WIfI stages 3-4; 47% Rutherford category 6). Presenting WIfI stages were similar across races (p=0.26). Peripheral interventions most commonly targeted femoropopliteal disease (69%) although 26% were multilevel. Percutaneous atherectomy, stenting and paclitaxel-coated or eluting devices were utilized in 68%, 28%, and 15% of cases, respectively. After a median follow-up of 16 months (IQR=4-29 months), significant independent predictors of reduced AFS included non-white race (HR=2.96 [1.42-6.17]; p=0.004) and WIfI stage 4 wounds (HR=2.23 [1.10-4.52]; p=0.026). At one year following successful revascularization, only 59%±1% of patients were alive with their limb intact.

CONCLUSIONS

Despite considerable and consistent advances in urban health care delivery and the techniques of PPI, CLTI remains a morbid and deadly disease. Even in the endovascular era, nearly half of all patients presenting with CLTI will lose their limb and/or life within the first year. Unfortunately, late-stage presentation continues to be commonplace. Although endovascular intervention can reliably restore patency to affected arteries, this appears insufficient to restore most patients to health.

Cultural Competence, Safety, Humility, and Dexterity in Surgery

Purpose of Review

As the United States’ population diversifies, urgent action is required to identify, dismantle, and eradicate persistent health disparities. The surgical community must recognize how patients’ values, beliefs, and behaviors are influenced by race, ethnicity, nationality, language, gender, socioeconomic status, physical and mental ability, sexual orientation, and occupation.

Recent Findings

Lately, health disparities have been highlighted during the COVID-19 pandemic. Surgery is no exception, with notable disparities occurring in pediatric, vascular, trauma, and cardiac surgery. In response, numerous curricula and training programs are being designed to increase cultural competence and safety among surgeons.

Summary

Cultural competence, safety, humility, and dexterity are required to improve healthcare experiences and outcomes for minorities. Various opportunities exist to enhance cultural competency and can be implemented at the medical student, resident, attending, management, and leadership levels.

Loss of independence as a metric for racial disparities in lower extremity amputation for diabetes: A National Surgery Quality Improvement Program (NSQIP) analysis

INTRODUCTION

This study assessed the association between race/ethnicity and amputation with mortality and loss of independence (LOI) for diabetic gangrene.

METHODS

We analyzed the American College of Surgeons National Surgery Quality Improvement Program database from 2016 to 2019. Chi-squared tests were performed to evaluate differences in baseline characteristics and complications. Multivariable logistic regression was performed to model LOI and 30-day mortality.

RESULTS

5250 patients with diabetes underwent lower extremity amputation as treatment for gangrene. Hispanic patients were more likely to undergo below the knee amputation (BKA) (P = 0.006). Guillotine amputation (GA) was associated with age > 65 (P < 0.0001), independent functional status prior to admission (P < 0.0001), and mortality (OR 1.989, 95%CI 1.29-3.065), but was not associated with LOI. Mortality was less frequent in Black patients (OR 0.432, 95%CI 0.207-0.902), but loss of independence (LOI) was more frequent in Black patients (OR 1.373, 95%CI 1.017-1.853). Hispanic patients were less likely to experience LOI (OR 0.575, 95%CI 0.477-0.693).

CONCLUSIONS

LOI and mortality provide contrasting perspectives on outcomes following lower extremity amputation. Further assessment of risk factors may illuminate healthcare disparities.

Racial and Ethnic Disparities in Peripheral Artery Disease

Peripheral artery disease is an obstructive, atherosclerotic disease of the lower extremities causing significant morbidity and mortality. Black Americans are disproportionately affected by this disease while they are also less likely to be diagnosed and promptly treated. The consequences of this disparity can be grim as Black Americans bear the burden of lower extremity amputation resulting from severe peripheral artery disease. The risk factors of peripheral artery disease and how they differentially affect certain groups are discussed in addition to a review of pharmacological and nonpharmacological treatment modalities. The purpose of this review is to highlight health care inequities and provide a review and resource of available recommendations for clinical management of all patients with peripheral artery disease.

Understanding Racial Disparities in Gastrointestinal Cancer Outcomes: Lack of Surgery Contributes to Lower Survival in African American Patients

BACKGROUND

Race/ethnicity-related differences in rates of cancer surgery and cancer mortality have been observed for gastrointestinal (GI) cancers. This study aims to estimate the extent to which differences in receipt of surgery explain racial/ethnic disparities in cancer survival.

METHODS

The National Cancer Database was used to obtain data for patients diagnosed with stage I-III mid-esophageal, distal esophagus/gastric cardia (DEGC), noncardia gastric, pancreatic, and colorectal cancer in years 2004-2015. Mediation analysis was used to identify variables influencing the relationship between race/ethnicity and mortality, including surgery.

RESULTS

A total of 600,063 patients were included in the study: 3.5% mid-esophageal, 12.4% DEGC, 4.9% noncardia gastric, 17.0% pancreatic, 40.1% colon, and 22.0% rectal cancers. The operative rates for Black patients were low relative to White patients, with absolute differences of 21.0%, 19.9%, 2.3%, 8.3%, 1.6%, and 7.7%. Adjustment for age, stage, and comorbidities revealed even lower odds of receiving surgery for Black patients compared with White patients. The observed HRs for Black patients compared with White patients ranged from 1.01 to 1.42. Mediation analysis showed that receipt of surgery and socioeconomic factors had greatest influence on the survival disparity.

CONCLUSIONS

The results of this study indicate that Black patients appear to be undertreated compared with White patients for GI cancers. The disproportionately low operative rates contribute to the known survival disparity between Black and White patients.

IMPACT

Interventions to reduce barriers to surgery for Black patients should be promoted to reduce disparities in GI cancer outcomes.See related commentary by Hébert, p. 438.

Contemporary Trends in Hospital Admissions and Outcomes in Patients With Critical Limb Ischemia: An Analysis From the National Inpatient Sample Database

BACKGROUND

Critical limb ischemia (CLI) morbidity and mortality rates have historically been disproportionately higher than for other atherosclerotic diseases, however, recent trends have not been reported. In patients admitted with CLI, we aimed to examine trends in in-hospital mortality, major amputations, length of stay, and cost of hospitalizations overall and stratified by type of revascularization procedures.

METHODS

Using 2011 to 2017 National Inpatient Sample data, we identified CLI-related admissions based on International Classification of Diseases, Ninth and Tenth Edition, Clinical Modification codes. Primary outcomes of interest were in-hospital mortality and major amputations. Secondary outcomes were the length of stay and cost of hospitalization. We stratified outcomes based on endovascular or open surgical interventions. We also performed hierarchical multivariable regression analyses of outcomes based on age, sex, race, hospital size, type, and location.

RESULTS

We identified 2 643 087 CLI-related admissions between 2011 and 2017. CLI admissions increased from 0.9% to 1.4% P_trend<0.0001 as well as overall peripheral artery disease admissions (4.5%-8.9%, P_trend<0.0001). In-hospital mortality for the entire CLI cohort decreased from 3.3% to 2.7%, P_trend<0.0001, and major amputations decreased from 10.9% to 7%, P_trend<0.0001. A decline was also noted for the length of stay from 5.7 (3.1-10.1) to 5.4 (3.0-9.2) days (P_trend<0.0001), whereas admission costs increased from USD $11 791 ($6676-$21 712) to $12 597 ($7248-$22 748; P_trend<0.0001). Endovascular interventions increased (P_trend<0.0001) against a decline in surgical interventions (P_trend<0.0001). Black race, female sex, and age ≥60 years were associated with higher in-hospital mortality, whereas Black race, male sex, and age<60 years were associated with higher major amputations.

CONCLUSIONS

A relatively small decrease in absolute numbers for mortality and major amputations were observed against a backdrop of increasing CLI admissions over recent years. Patients with CLI received more endovascular interventions than surgical interventions over time. However, admissions for endovascular interventions were characterized by higher risk patient profiles and a higher risk of major amputations as compared with surgical interventions.

Update on workforce diversity in vascular surgery

OBJECTIVE

Creating a diverse workforce is paramount to the success of the surgical field. A diverse workforce allows us to meet the health needs of an increasingly diverse population and to bring new ideas to spur technical innovation. The purpose of this study was to assess trends in workforce diversity within vascular surgery (VS) and general surgery (GS) as compared with orthopedic surgery (OS)-a specialty that instituted a formal diversity initiative over a decade ago.

METHODS

Data on the trainee pool for VS (fellowships and integrated residencies), GS, and OS were obtained from the U.S. Graduate Medical Education reports for 1999 through 2017. Medical student demographic data were obtained from the Association of American Medical Colleges U.S. medical school enrollment reports. The representation of surgical trainee populations (female, Hispanic, and black) was normalized by their representation in medical school. We also performed the χ² test to compare proportions of residents over dichotomized time periods (1999-2005 and 2013-2017) as well as a more sensitive trend of proportions test.

RESULTS

The proportion of female trainees increased significantly between the time periods for the three surgical disciplines examined (P < .001). Hispanic trainees also represented an increasing proportion of all three disciplines (P ≤ .001). The proportion of black trainees did not significantly change in any discipline between the two periods. Relative to their proportion in medical school, Hispanic trainees were well represented in all surgical specialties studied (normalized ratio [NR], 0.95-1.52: 0.95 OS, 1.00 GS, 1.53 VS fellowship, and 1.23 VS residency). Compared with their representation in medical school, women were under-represented as surgical trainees (NR: 0.32 OS, 0.82 GS, 0.56 VS fellowship, and 0.78 VS residency) as were black trainees (NR: 0.63 OS, 0.90 GS, 0.99 VS fellowship, and 0.81 VS residency).

CONCLUSIONS

Although there were significant increases in the number of women and Hispanic trainees in these three surgical disciplines, only Hispanic trainees enter the surgical field at a rate higher than their proportion in medical school. The lack of an increase in black trainees across all specialties was particularly discouraging. Women and black trainees were under-represented in all specialties as compared with their representation in medical school. The data presented suggest potential problems with recruitment at multiple levels of the pipeline. Particular attention should be paid to increasing the pool of minority medical school graduates who are both interested in and competitive for surgical specialties.

Racial disparities in comorbid conditions among patients undergoing thyroidectomy for Graves' disease: An ACS-NSQIP analysis

BACKGROUND

Studies indicate that racial disparities exist in the presentation and outcomes of patients undergoing thyroidectomy for cancer and benign disease. We examined the relationship between race, pre-operative characteristics and outcomes in patients undergoing thyroidectomy for GD.

METHODS

Patients were identified from the 2013-2016 American College of Surgeons NSQIP database using ICD-9/10 codes consistent with diffuse toxic goiter.

RESULTS

AA patients were more likely to have an ASA classification of ≥3 (41% vs 30%, p < 0.001), a higher rate of CHF (2.1% vs 0.5%, p = 0.01), hypertension (46% vs 32%, p < 0.001) and dyspnea (10% vs 5%, p < 0.001) compared to Non-Hispanic Caucasians (NH-C) patients. Complications were higher in patients with ASA≥3 and CHF but not affected by race.

CONCLUSIONS

Analysis of a national database of thyroidectomy for GD revealed a higher burden of preoperative comorbidities in AA patients compared to other races, although race was not an independent predictor of outcomes.

Perioperative Outcomes of Lower Extremity Revascularization for Rest Pain and Tissue Loss

BACKGROUND

Critical limb ischemia (CLI) is the clinical manifestation of severe peripheral artery disease presenting as rest pain (RP) and tissue loss (TL). Most studies compare CLI as a homogenous group with claudication with limited database studies specifically studying these differences. We hypothesize that CLI should be stratified into RP and TL because of significant differences in disease severity, comorbidities, and outcomes.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database from 2012 to 2016 was reviewed. All patients with a postoperative diagnosis of CLI undergoing femoral to popliteal bypass (FPB) with vein or graft were identified. Patients were stratified into cohorts based on International Classification of Disease (ICD)-9 or ICD-10 codes for RP or TL (gangrene or ulcer). Univariate and multivariate analyses were performed to examine 30-day mortality, morbidity, major amputation, and readmission adjusting for demographics, comorbidities, and procedural details.

RESULTS

There were 5,304 patients. Compared to RP, patients with TL were older (P < 0.0001) and more likely to be dependent (P < 0.0001). TL patients were also more likely to have diabetes (P < 0.0001), congestive heart failure (P < 0.0001), renal failure (P = 0.004), dialysis (P < 0.0001), history of wound infection (P < 0.0001), and sepsis (P < 0.0001). TL patients had higher American Society of Anesthesiologists class (P < 0.0001), were less likely to be transferred from home (P < 0.0001), and more likely to receive an FPB with vein (P = 0.03). Patients with TL had worse perioperative outcomes compared with RP in terms of pneumonia (P = 0.004), unplanned intubation (P = 0.009), cardiac arrest requiring cardiopulmonary resuscitation (P = 0.003), bleeding requiring transfusions (P < 0.0001), sepsis (P < 0.0001), septic shock (P = 0.02), and reoperation (P < 0.0001). TL was associated with significantly higher 30-day morbidity (P < 0.0001), 30-day mortality (P < 0.0001), major amputation (P = 0.0004), and readmission rates (P = 0.005). Patients with TL compared with those with RP also had longer hospital stays (P < 0.0001) and days between operation to discharge (P < 0.0001). TL was independently associated with increased 30-day morbidity (OR: 1.16 [1.00-1.35]) and major amputation (OR: 2.48 [1.29-4.76]) compared with RP.

CONCLUSIONS

Patients with RP and TL have drastic differences that impact perioperative mortality and readmissions. TL is an independent predictor of 30-day morbidity and major amputation. The stratification of CLI into RP and TL can provide insight into variations in outcomes and provide a means to quantify the risks associated with the 2 manifestations of the disease.

Perfusion Assessment in Critical Limb Ischemia: Principles for Understanding and the Development of Evidence and Evaluation of Devices: A Scientific Statement From the American Heart Association

There are >12 million patients with peripheral artery disease in the United States. The most severe form of peripheral artery disease is critical limb ischemia (CLI). The diagnosis and management of CLI is often challenging. Ethnic differences in comorbidities and presentation of CLI exist. Compared with white patients, black and Hispanic patients have higher prevalence rates of diabetes mellitus and chronic renal disease and are more likely to present with gangrene, whereas white patients are more likely to present with ulcers and rest pain. A thorough evaluation of limb perfusion is important in the diagnosis of CLI because it can not only enable timely diagnosis but also reduce unnecessary invasive procedures in patients with adequate blood flow or among those with other causes for ulcers, including venous, neuropathic, or pressure changes. This scientific statement discusses the current tests and technologies for noninvasive assessment of limb perfusion, including the ankle-brachial index, toe-brachial index, and other perfusion technologies. In addition, limitations of the current technologies along with opportunities for improvement, research, and reducing disparities in health care for patients with CLI are discussed.

Racial factors and inpatient outcomes among patients with diabetes hospitalized with foot ulcers and foot infections, 2003-2014

Background

In patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved.

Methods and findings

Patients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003–2004 [aOR 1.7; (1.16–2.57), p<0.01]. Disparities in major foot amputations disappeared in 2013–2014 [aOR: 0.92 (0.58–1.44), p = 0.70]. Black patients had declining but persistently longer LOS (adjusted mean difference (aMD): 1.1 days (0.52–1.6) p<0.01 in 2003–2004 and 0.46 days (0.18–0.73) p<0.01 in 2013–2014). The main limitation of the study was that the NIS uses ICD-9 and ICD-10 CM codes, and hence prone to incorrect or missing codes.

Conclusions

Major foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003–2004 was absent by 2013–2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability.

Racial Differences in the Effect of Granulocyte Macrophage Colony-Stimulating Factor on Improved Walking Distance in Peripheral Artery Disease: The PROPEL Randomized Clinical Trial

Background The effects of race on response to medical therapy in people with peripheral artery disease ( PAD ) are unknown. Methods and Results In the PROPEL (Progenitor Cell Release Plus Exercise to Improve Functional Performance in PAD) Trial, PAD participants were randomized to 1 of 4 groups for 6 months: supervised treadmill exercise+granulocyte-macrophage colony-stimulating factor ( GM - CSF ) (Group 1), exercise+placebo (Group 2), attention control+ GM - CSF (Group 3), or attention control+placebo (Group 4). Change in 6-minute walk distance was measured at 12- and 26-week follow-up. In these exploratory analyses, groups receiving GM - CSF (Groups 1 and 3), placebo (Groups 2 and 4), exercise (Groups 1 and 2), and attention control (Groups 2 and 4) were combined, maximizing statistical power for studying the effects of race on response to interventions. Of 210 PAD participants, 141 (67%) were black and 64 (30%) were white. Among whites, GM - CSF improved 6-minute walk distance by +22.0 m (95% CI : -4.5, +48.5, P=0.103) at 12 weeks and +44.4 m (95% CI : +6.9, +82.0, P=0.020) at 26 weeks, compared with placebo. Among black participants, there was no effect of GM - CSF on 6-minute walk distance at 12-week ( P=0.26) or 26-week (-5.0 m [-27.5, +17.5, P=0.66]) follow-up, compared with placebo. There was an interaction of race on the effect of GM - CSF on 6-minute walk change at 26-week follow-up ( P=0.018). Exercise improved 6-minute walk distance in black ( P=0.006) and white ( P=0.034) participants without interaction. Conclusions GM - CSF improved 6-minute walk distance in whites with PAD but had no effect in black participants. Further study is needed to confirm racial differences in GM - CSF efficacy in PAD . Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 01408901.

Preventing Major Amputations in Patients with Critical Limb Ischemia

PURPOSE OF REVIEW

This review summarizes the risks of lower extremity amputation associated with critical limb ischemia (CLI) and discusses current therapies that can prevent amputation in CLI.

RECENT FINDINGS

CLI remains an under-recognized condition associated with high rates of major amputation and disparities in care. Optimal medical therapy can reduce the risk of major adverse cardiovascular and limb events, but revascularization combined with close wound care remains the cornerstone of amputation prevention. Endovascular revascularization has become more common over time and has been associated with a reduction in amputation rates. Ongoing clinical trials will help inform best practices for revascularization strategies and techniques. Vascular care is inconsistent across the USA, with significant variation in access to care revascularization rates and rates of major amputation. Major amputation can be prevented in patients with CLI when optimal medical therapy, lifestyle modification, and revascularization are provided in a multidisciplinary setting.

Influence of racial disparities on patient-reported satisfaction and short- and long-term perception of health status after elective lumbar spine surgery

OBJECTIVE

In spine surgery, racial disparities have been shown to impact various aspects of surgical care. Previous studies have associated racial disparities with inferior surgical outcomes, including increased complication and 30-day readmission rates after spine surgery. Recently, patient-reported outcomes (PROs) and satisfaction measures have been proxies for overall quality of care and hospital reimbursements. However, the influence that racial disparities have on short- and long-term PROs and patient satisfaction after spine surgery is relatively unknown. The aim of this study was to investigate the impact of racial disparities on 3- and 12-month PROs and patient satisfaction after elective lumbar spine surgery.

METHODS

This study was designed as a retrospective analysis of a prospectively maintained database. The medical records of adult (age ≥ 18 years) patients who had undergone elective lumbar spine surgery for spondylolisthesis (grade 1), disc herniation, or stenosis at a major academic institution were included in this study. Patient demographics, comorbidities, postoperative complications, and 30-day readmission rates were collected. Patients had prospectively collected outcome and satisfaction measures. Patient-reported outcome instruments—Oswestry Disability Index (ODI), visual analog scale for back pain (VAS-BP), and VAS for leg pain (VAS-LP)—were completed before surgery and at 3 and 12 months after surgery, as were patient satisfaction measures.

RESULTS

The authors identified 345 medical records for 53 (15.4%) African American (AA) patients and 292 (84.6%) white patients. Baseline patient demographics and comorbidities were similar between the two cohorts, with AA patients having a greater body mass index (33.1 ± 6.6 vs 30.2 ± 6.4 kg/m2, p = 0.005) and a higher prevalence of diabetes (35.9% vs 16.1%, p = 0.0008). Surgical indications, operative variables, and postoperative variables were similar between the cohorts. Baseline and follow-up PRO measures were worse in the AA cohort, with patients having a greater baseline ODI (p < 0.0001), VAS-BP score (p = 0.0002), and VAS-LP score (p = 0.0007). However, mean changes from baseline to 3- and 12-month PROs were similar between the cohorts for all measures except the 3-month VAS-BP score (p = 0.046). Patient-reported satisfaction measures at 3 and 12 months demonstrated a significantly lower proportion of AA patients stating that surgery met their expectations (3 months: 47.2% vs 65.5%, p = 0.01; 12 months: 35.7% vs 62.7%, p = 0.007).

CONCLUSIONS

The study data suggest that there is a significant difference in the perception of health, pain, and disability between AA and white patients at baseline and short- and long-term follow-ups, which may influence overall patient satisfaction. Further research is necessary to identify patient-specific factors associated with racial disparities that may be influencing outcomes to adequately measure and assess overall PROs and satisfaction after elective lumbar spine surgery.

Lower extremity bypass for critical limb ischemia decreases major adverse limb events with equivalent cardiac risk compared with endovascular intervention

OBJECTIVE

Lower extremity bypass (LEB) has traditionally been the "gold standard" in the treatment of critical limb ischemia (CLI). Infrainguinal endovascular intervention (IEI) has become more commonly performed than LEB, but comparative outcomes are limited. We sought to compare rates of major adverse limb events (MALEs) and major adverse cardiovascular events (MACEs) after LEB and IEI in a propensity score-matched, national cohort of patients with CLI.

METHODS

The National Surgical Quality Improvement Program (NSQIP) vascular targeted files (2011-2014) for LEB and IEI were merged. CLI patients were identified by ischemic rest pain or tissue loss. Patients were matched on a 1:1 basis for propensity to undergo LEB or IEI. Primary outcomes were 30-day MALEs and MACEs. Within the propensity-matched cohort, multivariate logistic regression was used to identify independent predictors of MALEs and MACEs.

RESULTS

A total of 13,294 LEBs and IEIs were identified, with 8066 cases performed for CLI. Propensity matching identified 3848 cases (1924 per group). There were no differences in preoperative variables between the propensity-matched LEB and IEI groups (all P > .05). At 30 days, rates of MALEs were significantly lower in the LEB group (9.2% LEB vs IEI 12.2%; P = .003). On multivariate logistic regression, bypass with single-segment saphenous vein vs IEI (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.54-0.92; P = .01), bypass with alternative conduit (prosthetic, spliced vein, or composite) vs IEI (OR, 0.7; 95% CI, 0.56-0.98; P = .04), antiplatelet therapy (OR, 0.8; 95% CI, 0.58-1.00; P = .049), and statin therapy (OR, 0.8; 95% CI, 0.62-0.99; P = .04) were protective against MALEs, whereas infrageniculate intervention (OR, 1.4; 95% CI, 1.09-1.72; P = .01) and a history of prior bypass of the same arterial segment (OR, 1.8; 95% CI, 1.41-2.41; P <. 0001) were predictive. Rates of 30-day MACEs were not significantly different (4.9% LEB vs 3.7% IEI; P = .07) between the groups. Independent predictors of MACEs included age (OR, 1.02; 95% CI, 1.01-1.04; P = .01), steroid use (OR, 1.8; 95% CI, 1.08-2.99; P = .03), congestive heart failure (OR, 1.7; 95% CI, 1.00-1.96; P = .02), beta blocker use (OR, 1.6; 95% CI, 1.09-1.43; P = .01), dialysis (OR, 2.3; 95% CI, 1.55-3.45; P < .0001), totally dependent functional status (OR, 3.1; 95% CI, 1.25-7.58; P = .02), and suboptimal conduit for LEB compared with IEI (OR, 1.6; 95% CI, 1.08-2.36; P = .02).

CONCLUSIONS

Within this large, propensity-matched, national cohort, LEB predicted lower risk-adjusted 30-day MALE rate compared with IEI. Furthermore, there was no difference in 30-day MACE rate between the groups despite higher inherent risk with open surgical procedures. Therefore, this study supports the effectiveness and primacy of LEB for revascularization in CLI.

Racial differences in functional decline in peripheral artery disease and associations with socioeconomic status and education

OBJECTIVE

The objective of this study was to determine whether blacks with lower extremity peripheral artery disease (PAD) have faster functional decline than whites with PAD.

METHODS

Participants with ankle-brachial index <0.90 were identified from Chicago medical centers and observed longitudinally. Mobility impairment and the 6-minute walk were assessed at baseline and every 6 to 12 months. Mobility loss was defined as becoming unable to walk up and down a flight of stairs or to walk ¼ mile without assistance.

RESULTS

Of 1162 PAD participants, 305 (26%) were black. Median follow-up was 46.0 months. Among 711 PAD participants who walked 6 minutes continuously at baseline, black participants were more likely to become unable to walk 6 minutes continuously during follow-up (64/171 [37.4%] vs 156/540 [28.9%]; log-rank, P = .006). Black race was associated with becoming unable to walk 6 minutes continuously, adjusting for age, sex, ankle-brachial index, comorbidities, and other confounders (hazard ratio, 1.45; 95% confidence interval, 1.05-1.99; P = .022). This association was attenuated after adjustment for income and education (P = .229). Among 844 participants without baseline mobility impairment, black participants had a higher rate of mobility loss (64/209 [30.6%] vs 164/635 [25.8%]; log-rank, P = .009). Black race was associated with increased mobility loss, adjusting for potential confounders (hazard ratio, 1.42; 95% confidence interval, 1.04-1.94; P = .028). This association was attenuated after additional adjustment for income and education (P = .392) and physical activity (P = .113). There were no racial differences in average annual declines in 6-minute walk, usual-paced 4-meter walking velocity, or fast-paced 4-meter walking velocity.

CONCLUSIONS

Black PAD patients have higher rates of mobility loss and becoming unable to walk for 6 minutes continuously. These differences appear related to racial differences in socioeconomic status and physical activity.

Explaining Racial Disparities in Amputation Rates for the Treatment of Peripheral Artery Disease (PAD) Using Decomposition Methods

INTRODUCTION

While studies have documented racial and ethnic disparities in amputation rates for patients with peripheral artery disease (PAD), the importance of specific factors has not been quantified. This research seeks to provide such evidence and to quantify how much of the difference reflects observable versus unexplained factors.

METHODS

This study used the nationally representative HCUP inpatient database from 2006 to 2013 for patients with a primary diagnosis of PAD who were either Caucasian, African-American, or Hispanic. Multivariable logistic regression models were estimated to identify the determinants of amputation rates.

RESULTS

Multivariable results revealed that African-Americans and Hispanics are approximately twice as likely to be amputated as are Caucasians. Observed factors in the models collectively account for 51 to 55 % of the disparities for African-Americans and 64 to 69 % for Hispanics. The results suggest that African-Americans and Hispanics have less access to care, because they are being admitted when sicker and more likely on an emergent basis.

CONCLUSIONS

Racial and ethnic disparities in amputation rates are substantial, with disease severity and hospital admission source being key factors.

Explaining Racial Disparities in Amputation Rates for the Treatment of Peripheral Artery Disease (PAD) Using Decomposition Methods

INTRODUCTION

While studies have documented racial and ethnic disparities in amputation rates for patients with peripheral artery disease (PAD), the importance of specific factors has not been quantified. This research seeks to provide such evidence and to quantify how much of the difference reflects observable versus unexplained factors.

METHODS

This study used the nationally representative HCUP inpatient database from 2006 to 2013 for patients with a primary diagnosis of PAD who were either Caucasian, African-American, or Hispanic. Multivariable logistic regression models were estimated to identify the determinants of amputation rates.

RESULTS

Multivariable results revealed that African-Americans and Hispanics are approximately twice as likely to be amputated as are Caucasians. Observed factors in the models collectively account for 51 to 55 % of the disparities for African-Americans and 64 to 69 % for Hispanics. The results suggest that African-Americans and Hispanics have less access to care, because they are being admitted when sicker and more likely on an emergent basis.

CONCLUSIONS

Racial and ethnic disparities in amputation rates are substantial, with disease severity and hospital admission source being key factors.

Explaining Racial Disparities in Amputation Rates for the Treatment of Peripheral Artery Disease (PAD) Using Decomposition Methods

INTRODUCTION

While studies have documented racial and ethnic disparities in amputation rates for patients with peripheral artery disease (PAD), the importance of specific factors has not been quantified. This research seeks to provide such evidence and to quantify how much of the difference reflects observable versus unexplained factors.

METHODS

This study used the nationally representative HCUP inpatient database from 2006 to 2013 for patients with a primary diagnosis of PAD who were either Caucasian, African-American, or Hispanic. Multivariable logistic regression models were estimated to identify the determinants of amputation rates.

RESULTS

Multivariable results revealed that African-Americans and Hispanics are approximately twice as likely to be amputated as are Caucasians. Observed factors in the models collectively account for 51 to 55 % of the disparities for African-Americans and 64 to 69 % for Hispanics. The results suggest that African-Americans and Hispanics have less access to care, because they are being admitted when sicker and more likely on an emergent basis.

CONCLUSIONS

Racial and ethnic disparities in amputation rates are substantial, with disease severity and hospital admission source being key factors.

Advanced Chronic Venous Insufficiency

Introduction:

Intervention for advanced chronic venous insufficiency is considered an appropriate standard of care. However, outcomes vary among patients who present in advanced clinical stages of disease. The main objectives of this study were to determine whether racial disparity exists at initial presentation and response to intervention.

Methods:

A retrospective database was created to include all radiofrequency ablation procedures performed by a single surgeon from January 14, 2009, through May 25, 2011. Demographics, clinical traits, race, procedure, and outcomes were analyzed. Stepwise model selection reduced candidate baseline factors to a final parsimonious model, which was analyzed using analysis of variance.

Results:

The database consisted of 300 patients with a predominant female (n = 215, 85%) base and 85 (15%) males, with a mean age distribution of 53 years. The mean body mass index was 30.2. Racial distribution revealed Asian (n = 9, 3.3%), Pacific Islander (n = 1, 0.4%), African American (n = 37, 13.6%), and Caucasian (CAU, n = 225, 82.7%). African Americans presented with more advanced clinical stages than the CAU group—C2: African American 21.6%, CAU 36.7%; C4: African American 35%, CAU 24.3%; and C6: African American 35.1%, CAU 7.5%. African Americans demonstrated a higher preoperative venous clinical severity score (VCSS) than their CAU counterparts. Postprocedural decrease in VCSS score was lower in African Americans than their CAU counterparts.

Conclusion:

African American patients present with more advanced venous insufficiency than CAUs. Postprocedural analysis reveals not only slower ulcer healing times but also higher ulcer recurrence rates.

Critical Limb Ischemia: An Expert Statement

Critical limb ischemia (CLI), the most advanced form of peripheral artery disease, is associated with significant morbidity, mortality, and health care resource utilization. It is also associated with physical, as well as psychosocial, consequences such as amputation and depression. Importantly, after a major amputation, patients are at heightened risk of amputation on the contralateral leg. However, despite the technological advances to manage CLI with minimally invasive technologies, this condition often remains untreated, with significant disparities in revascularization and amputation rates according to race, socioeconomic status, and geographic region. Care remains disparate across medical specialties in this rapidly evolving field. Many challenges persist, including appropriate reimbursement for treating complex patients with difficult anatomy. This paper provides a comprehensive summary that includes diagnostic assessment and analysis, endovascular versus open surgical treatment, regenerative and adjunctive therapies, and other important aspects of CLI.

Lower Extremity Arterial Reconstruction in Octogenarians and Older

BACKGROUND

Despite previous single-institution studies showing that lower extremity arterial reconstruction (LEAR) in octogenarians and older patients may be undertaken with acceptable postoperative morbidity and mortality, there continues to be significant reluctance, in the vascular surgical community, to undertaking these complex revascularization procedures in this very elderly population. We undertook this study in an effort to determine the outcomes of LEAR in octogenarians and older patients on a national level.

METHODS

The American College of Surgeons' National Surgical Quality Improvement Program database was queried to identify all patients who underwent LEAR between January 1, 2005 and December 31, 2009. Patient demographics and presenting comorbidities were recorded, and multivariate analyses were performed to compare outcomes in patients 80 and older to those in younger patients.

RESULTS

There were 19,028 patients who underwent open infrainguinal LEAR during this time period. Patients ≥80 comprised 18% (3,486 patients), and patients <80 years comprised 82% (15,542 patients). Multivariate analysis demonstrated that patients aged ≥80 years had an increased likelihood of mortality (odds ratio [OR] 1.79; 95% confidence interval [CI] 1.42-2.26), cardiovascular (OR, 1.46; 95% CI, 1.12-1.89), respiratory (OR, 1.37; 95% CI, 1.12-1.67), and renal (OR, 1.57; 95% CI, 1.27-1.95) complications. There was, however, no significant difference in the likelihood of graft failure (OR, 1.04; 95% CI, 0.86-1.27), wound infection (OR, 0.92; 95% CI, 0.79-1.06), or major amputation (OR, 0.59; 95% CI, 0.13-2.74) between these 2 groups.

CONCLUSIONS

LEAR in octogenarians is associated with an increased risk of postoperative morbidity and mortality but no increased risk of wound infection, amputation, or graft failure.