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 The racial disparities were greatest at hospitals with high volumes
of surgery and among the patients of surgeons who did high volumes
of vascular surgery or who had fewer black patients, researchers
report in the Journal of the American College of Surgeons.
The authors conclude that racial bias – in access to earlier care
that might avert the limb problem, and in assumptions about
patients’ ability to take care of themselves after a surgery – may
play a role in the disparity.
“While our health care system may have the potential to unite us as
Americans, it may be dividing us through subconscious bias,” said
lead study author Dr. Sahael Stapleton of Massachusetts General
Hospital and Harvard Medical School in Boston.
“We know that there is a difference in health outcomes between
groups of people based on unmodifiable factors such as race, gender,
ethnicity, or socioeconomic status,” Stapleton told Reuters Health
by email. “We are shifting the focus from patients and unmodifiable
patient factors to looking at systems.”
The researchers analyzed data for 1999 to 2014 from a statewide New
York database looking at more than 215,000 cases of treatment for
critical limb ischemia – when blood flow is severely or completely
blocked, usually to a leg. The condition is often caused by
hardening and narrowing of the arteries brought on by heart disease,
diabetes, smoking and other health conditions.
Overall, 65 percent of the cases were non-elective, meaning they
came in requiring urgent treatment. Among all the patients, 38
percent had amputations, including about 43 percent of black
patients and 27 percent of white patients. The rest had “salvage”
procedures, which can include unblocking blood vessels and placing a
stent to keep them open, as well as other measures to restore blood
flow.
Black patients were more likely to undergo unplanned procedures (78
percent versus 61 percent of white patients). After adjusting for
this as well as overall health, gender, age, insurance provider and
other factors, the researchers calculated that black patients were
46 percent more likely than white patients to be treated with
amputation.
The disparities were smallest when surgeons didn’t do a lot of
vascular surgery, and when surgeons had a high proportion of black
patients among the total number they treated.
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In future studies, Stapleton and colleagues plan to develop a
benchmarking tool that identifies disparities in other medical
specialties and then try to turn that into a quality improvement
system that reduces the variability in patient experiences.
“Basically, we are talking about creating a new performance metric,”
he said. “This has never been done for disparities in our health
care system, although we have extensive experience doing this for
clinical outcomes such as rates of postoperative wound infections,
pneumonias or control of blood pressure or diabetes.”
A limitation of the study is that it is based only on New York
numbers. Another is that prior studies have found racial bias
difficult to untangle from other factors that affect amputation
rates.
“There are so many inextricably tied variables, it’s hard to figure
out the ‘why,’ yet we’ve seen that this difference does exist,” said
Kristin Lefebvre of Widener University’s Institute for Physical
Therapy in Chester, Pennsylvania.
Blacks and females, for example, are more likely to receive an
above-the-knee amputation during knee surgery, which can be more
difficult for mobility and recovery after surgery, Lefebvre told
Reuters Health in a phone interview.
“This should increase our awareness to look at disparity and its
cross-sections,” she said.
“Although racial bias may play some role, probably much more
important is what hospitals and health systems are used by patients
of different races,” said Dr. Joe Feinglass of the Northwestern
University Feinberg School of Medicine in Chicago, who wasn’t
involved in the study
For example, hospitals in different neighborhoods may vary in
whether angiography is used to assess revascularization potential,
he explained, as well as how many amputations are performed by
orthopedic or general surgeons versus certified vascular surgeons.
“We know there are huge social class differences between black and
white patients that reflect underlying social determinants of
health,” Feinglass said by email.
SOURCE: http://bit.ly/2GiEQ9J Journal of the American College of
Surgeons, online January 19, 2018.
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