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Bias may explain disparity in leg amputations

By Andrew M. Seaman

NEW YORK (Reuters Health) - Although differences in cultural preferences, wealth or access to top hospitals are blamed for many healthcare disparities, a new study concludes those are not the main reasons that blacks with poor leg circulation are almost twice as likely to be amputated as whites with the same condition.

"The main take home point of the article is that a large disparity exists between the treatment that white and non-white patients receive, and this disparity appears to go beyond simple differences in insurance status and other variables that are often cited as the cause," wrote the study's lead author Dr. Tyler Durazzo, from Yale University in New Haven, Connecticut, in an email to Reuters Health.

Durazzo and his colleagues, who published their findings in JAMA Surgery on Wednesday, write that previous studies found black patients with leg ischemia - poor blood flow - are more likely to have their legs amputated, compared to white patients, who are more likely to have so-called revascularization surgery to restore blood flow to save the limb.

The reasons behind this difference have been unclear. It could be that black patients lacked access to the same treatments as whites, or that black patients' circulation problems are more severe by the time they seek help from a doctor, Durazzo's team writes.

For the new study, the researchers explored possible explanations by examining data from 774,399 U.S. patients who were treated for leg ischemia from 2002 to 2008.

Overall, about 56 percent of black patients and 35 percent of white patients had an amputation.

There were some differences between the two groups. For example, black patients were more likely to also have diabetes and chronic kidney failure, and white patients were more likely to also have high blood pressure, chronic heart failure and lung disease.

Black patients were also more likely to live in poorer neighborhoods and to be on government-run insurance for the poor, compared to white patients.

After adjusting for all those differences, as well as the capacity of the hospital where a patient was treated to perform complex revascularization surgery, the researchers still found that being black increased the odds of having an amputation by 78 percent, compared to whites.

"It does appear that race alone is a significant factor that influences the treatment received by patients presenting with lower limb ischemia," the researchers write.

"They didn't come right out and say it, but they pretty strongly implied the only thing left was provider bias - i.e. provider racism," said Dr. Karl Illig, who wrote a critique accompanying the new study.

But Illig, the chief of vascular surgery at University of South Florida Health in Tampa, said the study's authors should not rule out the possibility that genetic differences between black and white patients may also influence the likelihood of an amputation.

His commentary points to known differences between races in aspects of basic biology, ranging from malaria resistance to the behavior of breast tumors and responses to certain medications.

"There is the possibility that even with proper treatment, people of one race will have worse outcomes than people of another race," he told Reuters Health.

Durazzo said there are many possible explanations for the disparity, "and subconscious racial biases cannot be ruled out as one of them."

Dr. Schuyler Jones, a cardiologist at Duke University Medical Center in Durham, North Carolina, added that it's also hard to tease out specific differences between cases in such a large population.

"I think there are a number of these studies that race, sex and age play a role in the decision to amputate. A lot of that can be explained by comorbid illnesses like the adjustments this group has made, but there are things that are unmeasured," he said.

"Further studies are needed to delve deeper into all possible causes," Durazzo added.

SOURCE: http://bit.ly/16K4huI JAMA Surgery, online March 20, 2013.

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