Researchers from Brigham and Women’s Hospital at Harvard Medical School in Boston have published a study in the Journal of Vascular Surgery stating that disparities in limb salvage procedures may be driven by socioeconomic status (SES) and access to high-volume hospitals.
Senior-author Louis L. Nguyen, MD, MBA, MPH, from the hospital’s division of vascular and endovascular surgery as well as the Center for Surgery and Public Health explained that 958,120 cases containing lower extremity revascularization (LER) or major amputation were reviewed. Data for patients with critical limb ischemia (CLI) also were collected. All patients were 21 years old or older and the data was taken from the 2003-2007 Nationwide Inpatient Sample. Findings showed an increased risk of major amputation among minority patients, while adjusting for income, insurance status, hospital-level factors and LER volume.
Several indicators of low SES were clustered by demographic group. Compared with Caucasian patients, Native Americans were the most likely to have income in the lowest quartile. Similar lower median income was seen for Black and Hispanic patients. Non-whites were more likely to be on Medicaid and had lower income than patients with Medicare.
“Minority patients tend to have more comorbidities including diabetes, peripheral artery disease (PAD) and renal failure that influence treatment options as they are more likely to receive care at low-volume and potentially under-resourced hospitals,” Nguyen stated in a press release. “These factors, independently and in combination, are associated with a greater likelihood of major amputation. This outcome profoundly impacts the function of CLI patients and their quality-of-life. Our data are similar to other reports that patients with CLI who present to higher volume hospitals are more likely to undergo a limb salvage procedure.”
In comparison to patients at the highest volume centers, patients at the lowest volume centers were at 15.2 times higher odds of undergoing major amputation. Patients in the second quartile were also at significantly increased odds of undergoing major amputation and those at hospitals in the third quartile were at 77% higher odds of undergoing major amputation compared to those at the highest volume.
“Our findings suggest there are gaps in access to care despite controlling for hospital level factors and procedural volume,” Nguyen said. “Addressing SES, hospital factors and the inverse relationship between LER procedure volume and risk of major amputation for CLI, highlights potential solutions for disparities related to hospital-level factors. Also increasing state and local funding to facilities that provide care to patients at high risk for major amputation may improve professional resources.”
