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Black Patients More Likely Than White Patients to Receive Amputations

Key findings

  • At rates of 42.6% vs. 28.6%, respectively, black patients had higher amputation rates than white patients when being admitted for limb-threatening ischemia
  • Amputation rate differences were more pronounced among high total vascular volume surgeons, high amputation volume hospitals and surgeons who treat fewer black patients
  • 32% was the overall amputation rate among 215,480 inpatient admissions, with variances that went from 10% to 23.3% depending on region

A diverse surgical practice offsets a startling phenomenon for ischemia: that more black than white patients receive amputations than salvage surgery. Analysis revealed black patients had a 46% greater chance of receiving an amputation, signaling a need to better understand this bias.

Researchers led by Sahael Stapleton, MD, surgical resident and Torchiana fellow, Michael Watkins, MD surgeon and David Chang, PhD, MPH, MBA, director of healthcare research and policy development at the Massachusetts General Hospital Codman Center for Clinical Effectiveness in Surgery, hypothesized that patients with significant peripheral vascular disease were being routed to procedures differently based on surgeon and hospital factors.

The team analyzed 215,480 inpatient admissions from 1999 to 2014 within the New York Statewide Planning and Research Cooperative System (SPARCS) database. These admissions involved ICD9 codes for peripheral vascular disease and either amputation or salvage procedure. Primary categories evaluated included race, treatment choice, comorbidities, disease severity, surgeon, hospital annual volume and year of procedure.

When being admitted for limb-threatening ischemia, black patients were much more likely than white patients, at rates of 42.6% vs. 28.6%, respectively, to receive an amputation (p < 0.001). The overall amputation rate was 32%, with variances that went from 10% to 23.3% depending on SPARCS region.

Rate differences were more pronounced among high total vascular volume surgeons (>8 cases per year), high amputation volume hospitals and surgeons who treat fewer black patients.

While analysis adjusted for disease severity, it also revealed that sex, age, comorbidities, insurance and provider volume were significantly associated with amputation risk. Notably, black patients were more likely than white patients to present with advanced disease including rates of sepsis at 6.7% versus 3.6%, respectively.

Despite such differences, the team still concluded that care disparities were driven in large part by non-medical factors, such as type of medical practice. They point to a need for better understanding of disparities. One action step: implement a racial equity dashboard. It can sit alongside other measures tracked in health care performance improvement and quality initiatives.

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