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Greater severity of peripheral arterial disease among blacks may account for their higher rate of amputations

Black patients undergo amputation of a lower extremity (LE, at the above- or below-knee level) two to three times more often that white patients. Some have attributed this to a lack of access by blacks to lower extremity revascularization procedures such as angioplasty or LE arterial bypass graft surgery, when they are hospitalized for complications of peripheral arterial disease (PAD) or diabetes mellitus. However, a new study at an urban hospital with advanced vascular surgery facilities and a policy of aggressive limb salvage suggests that greater severity and progression of disease among blacks could account for these racial disparities independent of any access problems to hospitals for vascular surgery.

Mirroring regional findings, blacks were 1.7 times more likely than other patients to be admitted for a primary amputation, that is, a major amputation without any previous attempt at revascularization. However, after adjusting for age, sex, and diabetes mellitus prevalence, white and black patients were equally likely to undergo primary amputation.

Repeat amputees were 2.5 times more likely to be black than white. However, these patients had more advanced and aggressive PAD. It is not clear to what extent this outcome is related to less aggressive prior management of diabetes or to atherosclerosis risk factors or whether race is simply a marker for broader social determinants of health, notes Cheryl Rucker-Whitaker, M.D., M.P.H., of Rush-Presbyterian-St. Luke's Medical Center.

In the study, which was supported in part by the Agency for Healthcare Research and Quality (National Research Service Award training grant T32 HS00078), Dr. Rucker-Whitaker and colleagues used hospital discharge data for 1,127 patients undergoing LE arterial bypass graft, angioplasty, or major amputation from January 1, 1995, to February 1, 2000. They analyzed racial differences in the risk of admission for major amputation versus revascularization.

See "Explaining racial variation in lower extremity amputation," by Dr. Rucker-Whitaker, Joe Feinglass, Ph.D., and William H. Pearce, M.D., in the December 2003 Archives of Surgery 138, pp. 1347-1351.

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