Tunis SR, Bass EB, Klag MJ, Steinberg EP.
Variation in utilization of procedures for treatment of peripheral arterial disease. A look at patient characteristics.
Arch Intern Med 1993;153(8):991-8.

The purpose of this case study of 7,080 procedures for treatment of peripheral arterial disease was “1.) to determine whether the type of revascularization procedure (angioplasty or bypass) used for treatment of lower-extremity peripheral arterial disease varied by age, sex, race, clinical diagnosis, or type of health insurance; and 2.) to determine whether the likelihood of undergoing amputation for lower extremity peripheral arterial disease differed” by these same factors.

Utilization of angioplasty was lower for blacks than whites at every age, with the greatest
disparity evident among patients over 75 years of age. In contrast, for all age strata, the
rate of performance of peripheral bypass surgery was higher in blacks than in whites.
The amputation rate was substantially higher in blacks. After adjustment for age, blacks were 22% less likely than whites to have undergone angioplasty, 39% more likely to have undergone bypass surgery, and over three times more likely to have undergone lower extremity amputation. Considering the distribution of angioplasty vs. bypass surgery for those who did undergo revascularization, blacks were 42% less likely to have an angioplasty than whites. The racial disparity in risk of amputation increased with age of patient. In the age cohort of 85 years or older, black patients were nearly 7 times more likely to undergo an amputation.

In sum, while blacks underwent procedures for peripheral arterial disease at a higher rate than whites, blacks were less likely to receive revascularization performed by angioplasty
than by bypass surgery. Furthermore, among patients who have undergone a procedure
for peripheral arterial disease, blacks were more likely than whites to have undergone
amputation. These racial differences persist after adjusting for age, gender, diabetes mellitus, hypertension, and insurance status.

The authors suggest that these racial disparities may be explained by (1) biologic differences between blacks and whites in the onset and progression of peripheral arterial disease, (2) the higher prevalence of hypertension, hyperlipidemia and smoking in blacks that may lead to more severe peripheral arterial disease in blacks, which in turn may increase the need for amputation, or (3) obstacles to access of care. “For example, blacks may be treated later in the course of their disease than whites, resulting in higher rates of bypass surgery and amputation. The fact that an increased likelihood of amputation among blacks compared with whites persisted after controlling for type of health insurance suggests that if blacks have reduced access to care, it is not likely to be related to ability to pay.” Ultimately, “whatever the explanation for it, the increased likelihood of amputation in poorly insured and black patients is of concern, given the impact of limb loss on personal well-being and the burden that limb loss places on individual and societal resources.”