Influence of Race on the Management of Lower Extremity Ischemia

Durazzo, Tyler S.; Frencher, Stanley K.; Gusberg, Richard J.

doi:10.1001/jamasurg.2013.1436

Cited by 104 publications

(73 citation statements)

References 42 publications

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“…Our findings are consistent with other studies showing that racial disparity and low SES may contribute to the increased amputation rate of PAD patients 7, 22, 23. The biological mechanisms postulated for this disparity include a proinflammatory state that tends to affect black patients10, 24 and people with low SES25 disproportionately, even after adjustment for difference in cardiovascular risk.…”

Section: Discussionsupporting

confidence: 92%

“…Most studies, including our analysis, find that black patients present late in the course of their disease and more frequently with gangrene compared with white patients 7, 22, 23, 29. Recent publications have attempted to evaluate whether the well‐described occurrence of primary amputation rather than attempt at revascularization for black patients is due to provider bias or lack of access to quality care compared with clinical presentation.…”

Section: Discussionmentioning

confidence: 90%

“…A recent analysis of lower extremity bypasses in the National Surgical Quality Improvement Project database found that black patients had a higher incidence of femoral–tibial or popliteal–tibial bypasses compared with white PAD patients 28. Involvement of distal tibial vessels in PAD may preclude successful attempts at revascularization and increase the need for primary amputation 7, 22, 23. Despite revascularization, black race has been shown to affect patency of open and endovascular procedures 4, 8, 9, 28.…”

Section: Discussionmentioning

confidence: 99%

“…A number of studies have shown black race to be a significant risk factor for amputation in PAD 3, 4, 5, 6. Advanced clinical stage, presence of comorbid diabetes mellitus (DM) and chronic kidney disease (CKD), and higher anatomic complexity of disease not amenable to revascularization have been put forth as reasons for poor limb salvage in black patients 7. Poorer patency of lower extremity bypasses and endovascular interventions in black patients suggest biological pathways affecting higher risk of amputation 4, 8, 9.…”

mentioning

confidence: 99%

“…Lack of access to care and regional clustering have been shown to affect black patients disproportionately 3, 7. Low SES has been clearly linked with higher prevalence of coronary artery disease (CAD), DM, hypertension, smoking, and physical inactivity as well as poor CAD outcomes such as myocardial infarction and cardiovascular death 14, 15.…”

mentioning

confidence: 99%

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Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

Arya

Binney

Khakharia

et al. 2018

JAHA

171

117

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BackgroundBlack race has been shown to be a risk factor for amputation in peripheral artery disease (PAD); however, race has been argued to be a marker for socioeconomic status (SES) rather than true disparity. The aim of this study is to study the impact of race and SES on amputation risk in PAD patients.Methods and ResultsPatients with incident PAD in the national Veterans Affairs Corporate Data Warehouse were identified from 2003 to 2014 (N=155 647). The exposures were race and SES (measured by median income in residential ZIP codes). The outcome was incident major amputation. Black veterans were significantly more likely to live in low‐SES neighborhoods and to present with advanced PAD. Black patients had a higher amputation risk in each SES stratum compared with white patients. In Cox models (adjusting for covariates), black race was associated with a 37% higher amputation risk compared with white race (hazard ratio: 1.37; 95% confidence interval, 1.30–1.45), whereas low SES was independently predictive of increased risk of amputation (hazard ratio: 1.12; 95% confidence interval, 1.06–1.17) and showed no evidence of interaction with race. In predicted amputation risk analysis, black race and low SES continued to be significant risk factors for amputation regardless of PAD presentation.ConclusionsBlack race significantly increases the risk of amputation within the same SES stratum compared with white race and has an independent effect on limb loss after controlling for comorbidities, severity of PAD at presentation, and use of medications.

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Section: Discussionsupporting

confidence: 92%

Section: Discussionmentioning

confidence: 90%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

See 3 more Smart Citations

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

Arya

Binney

Khakharia

et al. 2018

JAHA

171

117

View full text Add to dashboard Cite

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Diabetic Foot Ulcers

Armstrong

Tan

Boulton

et al. 2023

JAMA

314

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ImportanceApproximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.ObservationsNeurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.Conclusions and RelevanceDiabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

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