Introduction: Disparities in amputation rates for limb ischemia between white and black patients have been extensively studied, and are often been attributed to differences in patient disease burden. The goal of this study is to determine whether bias in provider decision-making plays a role in contributing disparities. We hypothesize that the magnitude of the disparity is not consistent across surgeons of different operative volumes.
Methods: Analysis of the New York Statewide Planning and Research Cooperative System database was performed for 2000-2014. Patients >18yrs old with claudication or chronic limb ischemia undergoing amputation or salvage procedures were included. Primary outcome was amputation versus salvage. Multivariable analysis compared black vs white patients, adjusting for demographics, comorbidities, disease severity, surgical volumes, and year. Difference-in-difference analyses were performed across surgeon types and hospital types.
Results: 215,700 admissions, representing 136,318 patients, were analyzed. Overall amputation rate was 32.0%, and was significantly higher among black vs white patient encounters (42.6% vs 28.6%,p<0.01), a difference of 13.6%. Unadjusted racial difference in amputation rates ranged from 0.73%-23.3%. On multivariable analysis, black patients had significantly higher risk of amputation vs whites (OR-1.46, 95%-CI:1.32-1.62,p<0.001). On subset analysis, odds ratios for amputation ranged from 1.13 (95%-CI:0.98-1.30,p<0.00) to 2.06 (95%-CI:1.52-2.80,p<0.00).
Conclusion: Black patients are significantly more likely to receive an amputation than a salvage procedure when presenting with severe peripheral vascular disease. This disparity is more pronounced in high-volume surgeons than in low-volume surgeons and suggests that there is unrecognized provider bias which may be amenable to quality improvement efforts.
