Regional Variation in Racial Disparities Among Patients with Peripheral Arterial Disease
Thomas FX O'Donnell, MD1, Chloe Powell, BS2, Sarah E. Deery, MD, MPH3, Jeremy D. Darling, MS1, Kakra Hughes, MD4, Kristina A. Giles, MD5, Grace J. Wang, MD6, Marc L. Schermerhorn, MD1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA, 2Harvard Medical School, Boston, MA, USA, 3Massachusetts General Hospital, Boston, MA, USA, 4Howard University Hospital, Washington, DC, USA, 5University of Florida Health, Gainesville, FL, USA, 6University of Pennsylvania, Philadelphia, PA, USA.
OBJECTIVES: Prior studies identified significant racial disparities as well as regional variation in outcomes of patients with peripheral arterial disease (PAD). We aimed to determine whether regional variation contributes to these racial disparities.
METHODS: We identified all White or Black patients who underwent infrainguinal revascularization or amputation in 15 de-identified regions of the VQI between 2003-2017. We excluded 3 regions with <100 procedures. We used multivariable linear regression allowing for clustering at the hospital level to calculate marginal effects of race and region on adjusted 30-day mortality, MALE, and amputation. We compared long-term outcomes using multivariable Cox regression.
RESULTS: We identified 90,418 patients; 15,527 (17%) of whom were Black. Patients underwent 31,263 bypasses, 52,462 endovascular interventions, and 6,693 primary amputations. Black patients were younger, less likely to smoke, have coronary artery disease, or chronic obstructive pulmonary disease, but more likely to have diabetes, limb-threatening ischemia, dialysis-dependence, hypertension, be self-insured or on Medicaid (all P<.05). Adjusted 30-day mortality ranged from 1.2-2.1% across regions for White patients and 0-3.0% for Black patients, adjusted 30-day MALE varied from 4.0-8.3% for White patients and 2.4-8.1% for Black patients, and adjusted 30-day amputation rates varied from 0.3-1.2% in White patients, and 0-2.1% for Black patients. Black patients experienced significantly different adjusted rates of 30-day mortality and amputation than White patients in several regions (P<.05), but not MALE. In addition, within each racial group, we found significant variation in the adjusted rates of all outcomes between regions (all P<.01). In adjusted analyses, compared to White patients, Black patients experienced consistently lower long-term mortality (HR 0.80 [0.73-0.88], P<.001), and higher rates of MALE (HR 1.15 [1.06-1.25], P<.001), and amputation (HR 1.33 [1.18-1.51], P<.001) with no variation across the regions. However, rates of all long-term outcomes varied within both racial groups across regions. CONCLUSIONS: Significant racial disparities exist in outcomes following lower extremity procedures in patients with PAD, with regional variation contributing to perioperative, but not long-term outcome disparities. Underperforming regions should utilize these data to generate quality improvement projects, as understanding the etiology of these disparities is critical to improving the care of all patients with PAD. 
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