Racial and ethnic disparities in 3-year outcomes following infrainguinal bypass for chronic limb threatening ischemia. Journal Article

Authors: Anjorin, AC; Marcaccio, CL; Patel, PB; Wang, SX; Rowe, V; Aulivola, B; Wyers, MC; Schermerhorn, ML
Article Title: Racial and ethnic disparities in 3-year outcomes following infrainguinal bypass for chronic limb threatening ischemia.
Abstract: OBJECTIVE: Black and Hispanic patients have higher rates of chronic limb-threatening ischemia (CLTI) and suffer worse perioperative outcomes after lower extremity bypass compared with White patients. The underlying reasons for these disparities are unclear, and data on 3-year outcomes are limited. Therefore, we examined differences in 3-year outcomes after open infrainguinal bypass for CLTI by race/ethnicity and explored potential factors contributing to these differences. METHODS: We identified all CLTI patients undergoing primary open infrainguinal bypass in the Vascular Quality Initiative registry from 2003-2017 with linkage to Medicare claims through 2018 for 3-year outcomes. Our primary outcomes were 3-year major amputation, re-intervention, and mortality. We also report 30-day major adverse limb events (MALE) defined as major amputation or re-intervention. We used Kaplan-Meier estimation methods and multivariable Cox regression analyses to evaluate outcomes by race/ethnicity and to identify contributing factors. RESULTS: Among 7,108 bypass procedures performed in CLTI patients, 5,599 (79%) were in non-Hispanic White patients, 1,053 (15%) were in Blacks, 48 (1%) were in Asians, and 408 (6%) were in Hispanics. Compared with White patients, Black patients had higher rates of 3-year major amputation (Black: 32% vs White: 19%; hazard ratio (HR):1.9 [95% confidence interval:1.7-2.2]), re-intervention (61% vs 57%; HR:1.2[1.1-1.3]), and 30-day MALE (8.1% vs 4.9%; HR:1.3[1.2-1.4]), but lower mortality (38% vs 42%; HR:0.9[0.8-0.99]). Hispanic patients experienced higher rates of amputation (Hispanic: 27% vs White: 19%; HR:1.6[1.3-2.0]), re-intervention (70% vs 57%; HR:1.4[1.2-1.6]), and MALE (8.7% vs 4.9%; HR:1.5 [1.3-1.7]); however, mortality was similar between the groups (38% vs 42%; HR:0.88[0.76-1.0]). The low number of Asian patients prevented meaningful assessment of amputation (Asian: 20% vs White: 19%; HR:0.93[0.44-2.0]), re-intervention (55% vs 57%; HR:0.79[0.51-1.2]), MALE (8.5% vs 4.9%; HR:0.71[0.46-1.1]), or mortality (36% vs 42%; HR:0.83[0.52-1.3]) in this group. In adjusted analyses, the association of Black race and Hispanic ethnicity with amputation and re-intervention was explained by differences in demographic characteristics (age, sex) and baseline comorbidities (tobacco use, diabetes, renal disease). CONCLUSIONS: Compared with White patients, Black and Hispanic patients had higher 3-year major amputation and re-intervention rates; however, mortality was lower among Black patients and similar between Hispanic and White patients. Disparities in amputation and re-intervention are partly attributable to demographic characteristics and the higher prevalence of comorbidities in Black and Hispanic patients with CLTI. Future work is necessary to determine if interventions to improve access to care and reduce the burden of comorbidities in these populations confer limb salvage benefits.
Journal Title: Journal of vascular surgery
ISSN: 1097-6809; 0741-5214
Publisher: Mosby, Inc  
Date Published: 2022