Disparities in the treatment and outcomes of vascular disease in Hispanic patients

Article Outline

• Abstract
• Methods
  • Data sources
  • Patient population
  • Standardization
  • Statistical analysis
• Results
  • Rates of utilization
  • Characteristics of patient populations
  • Status of disease progression at time of treatment
  • Outcomes after intervention
• Discussion
• Conclusion
• Author contributions
• References
• Copyright

Background

The Hispanic population represents the fastest growing minority in the United States. As the population grows and ages, the vascular surgery community will be providing increasing amounts of care to this diverse group. To appropriately administer preventive and therapeutic care, it is important to understand the incidence, risk factors, and natural history of vascular disease in Hispanic patients.

Methods

We analyzed hospital discharge databases from New York and Florida to determine the rate of lower extremity revascularization (LER), carotid revascularization (CR), and abdominal aortic aneurysm (AAA) repair in Hispanics relative to the general population. The rates of common comorbidities, the indications for the procedures, and outcomes during the same hospitalization as the index procedure were determined. Multivariate logistic regression analysis was used to determine the differences between Hispanics and white non-Hispanics with respect to rate of procedure, symptoms at presentation, and outcome after procedure. Demographic variables and length of stay were also analyzed.

Results

The rate of LER, CR, and AAA repair was significantly lower in Hispanic patients than in white non-Hispanics. Despite this lower rate of intervention, Hispanics were significantly more likely than whites to present with limb-threatening lower extremity ischemia (odds ratio [OR], 2.09; 95% confidence interval [CI], 1.91 to 2.29), symptomatic carotid artery disease (OR, 1.57; 95% CI, 1.4 to 1.75), and ruptured AAA (OR, 1.26; 95% CI, 1.04-1.52) than white non-Hispanics These differences were maintained after controlling for the presence of diabetes mellitus and other comorbidities. Hispanic patients had higher rates of amputation during the same hospitalization after LER (6.2% vs 3.4%, P < .0001) and higher mortality after elective AAA repair (5% vs 3.4%, P = .0032). Length of stay after LER, CR, and AAA repair was longer for Hispanic patients than white non-Hispanics.

Conclusion

Significant disparities in the rate of utilization of three common vascular surgical procedures exist between Hispanic patients and the general population. In addition, Hispanics appear to present with more advanced disease and have worse outcomes in some cases. Reasons for these disparities must be determined to improve these results in the fastest growing segment of our society.

Hispanics are the fastest growing minority in the United States (US), and are estimated to comprise one-quarter of the total US population by 2050.¹, ² Numerous public health studies have demonstrated the existence of substantial health disparities in this population, including higher rates of breast arterial calcification, diabetes mellitus, and renal failure, as well as an increased risk of death from prostate cancer and liver disease.³, ⁴, ⁵, ⁶, ⁷, ⁸ Previous research has shown that distinctive biologic, socioeconomic, and cultural factors may have an impact on the treatment and outcomes of vascular disease.², ⁹, ¹⁰, ¹¹ Therefore, understanding the health issues that uniquely impact Hispanics is essential to provide the appropriate combination of preventive, diagnostic, and therapeutic modalities to these patients.

Despite the well-documented rising prevalence in Hispanics of risk factors for vascular disease, such as diabetes and smoking, studies that focus on treatment and outcomes of vascular disease in this population are lacking. In this study, we aimed to determine, through large data set analysis, if differences exist between Hispanics and the general population with respect to the rate of treatment and clinical manifestations of common vascular diseases.

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Methods 

Data sources 

Publicly available hospital discharge data bases obtained from New York State Health Department, the Statewide Planning and Research Cooperative System (SPARCS),¹² and the Florida state Agency for Healthcare Administration,¹³ years 2000-2004, were used in the study. These are populous states with a substantial presence of Hispanics. State administrative databases contain clinical and demographic information, including ethnicity, associated with each hospital discharge.

Patient population 

Patients were selected using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) procedure and diagnoses codes, as described earlier.¹⁴, ¹⁵ Treatment groups were identified by matching all relevant procedure codes with the primary and secondary diagnosis codes. Four code groups were analyzed: carotid revascularizations (CR), elective and ruptured abdominal aortic aneurysm (AAA) repair, lower extremity revascularizations (LER), and lower limb amputation. Patients undergoing AAA repair were categorized as 441.4 (unruptured) or 441.3 (unruptured). Patients who underwent carotid procedures were divided into symptomatic and asymptomatic groups:

Patients who underwent LER with diagnoses of rest pain (440.22), ulceration (440.23 or 707.1), and gangrene (440.24 or 785.4) were included in the limb-threatening conditions group and were compared with patients who had diagnoses of claudication (440.21). If LER and major amputation were performed during the same hospitalization, these cases were considered as failed LER.

We assessed the following comorbidities (primary and all secondary diagnosis): diabetes, hypertension, emphysema, coronary disease, peripheral vascular disease, renal disease, cerebrovascular disease, and lipid metabolism disorder. Complications included (primary and all secondary diagnosis) cardiac, postoperative stroke, respiratory complications, bleeding, infection, shock, acute renal failure, and mesenteric infarction. Table I outlines the codes used to determine comorbidities and complications. A list of ICD9 diagnosis codes for comorbidities and complications is provided in our earlier publications.¹⁴, ¹⁵

Table I. List of International Classification of Diseases, 9th revision, Clinical Modification codes for comorbidities and postoperative complications

ICD-9CM, International Classification of Diseases, 9th revision, Clinical Modification.

Standardization 

The risk of developing vascular diseases and consequently undergoing a vascular procedure varies across the age groups. We used direct adjustment procedures to account for age and gender differences among Hispanics and white non-Hispanics (WnHs) in the usage of vascular procedures over time and to ensure a proper comparison.¹⁶ Age and gender distribution by race for New York and Florida populations were obtained from National Census Bureau (www.census.gov). The 2000 Florida WnH population was chosen as the standard population. We identified the number of vascular procedures and calculated rates for the following age groups of Hispanics and WnH of both sexes: <15, 14 to 44, 45 to 54, 55 to 64, 65 to 74, 75 to 84, and >85 years. The age and gender adjusted rates were calculated by applying the age-specific and gender-specific rates to the standard population and dividing by the total in the standard population. By this type of adjustment, we removed possible confounding caused by age and gender variation. Rates adjusted for age and gender were presented as the number of vascular procedures per 10,000 standard population.

Statistical analysis 

Statistical analysis was performed using SAS software (SAS Institute Inc, Cary, NC). Means were compared with the Student t test, and proportions were analyzed using the χ² test. Statistical significance was expressed as P values and 95% confidence intervals (CIs). CIs for proportions were calculated using normal approximation to the binomial distribution. Multivariate logistic regression analysis was used to analyze risk factors for severity of disease at presentation and outcomes after intervention. The variables analyzed are summarized in Table II. Results of the multivariate logistic regression are presented as odds ratios (ORs) with the appropriate 95% CIs.

Table II. Comorbid conditions^⁎

LER, Lower extremity revascularization; CR, carotid revascularization; AAA, elective abdominal aortic aneurysm; WnH, white non-Hispanic; H, Hispanic.

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Results 

Rates of utilization 

Utilization of vascular procedures differed substantially between Hispanics and WnH during the period from 2000 to 2004 (Fig 1). Hispanics underwent significantly fewer LER procedures, AAA repairs, and CR compared with WnHs throughout the 5 years analyzed. In contrast, major lower extremity amputations were more common among Hispanics than WnHs. The magnitude of difference in rates of intervention between Hispanics and WnHs was most dramatic for AAA repair and CR, where WnHs had approximately three times as many CR and AAA repairs than did Hispanics.

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• Fig 1. 

  Rate of utilization of vascular procedures for Hispanics (filled circles) and white non-Hispanics (WnH, clear circles), 2000-2004. A, Lower extremity revascularization (LER). B, Carotid revascularization (CR). C, Abdominal aortic aneurysm (AAA). D, Major lower extremity amputation.

Characteristics of patient populations 

Hispanic patients were significantly younger than WnHs, with the largest difference seen among LER patients (2.6 years on average; Table III). The relative proportion of women and men in both groups was similar in LER and CR patients, whereas there were more men among Hispanic AAA patients and amputees. To gain further insight into the cause of the different utilization of vascular procedures, we analyzed the comorbidities affecting these patients. Consistent with a body of evidence indicating a high prevalence of diabetes mellitus type 2 in the Hispanic population, our data show a higher proportion of Hispanic patients had diabetes compared with WnHs for all procedures analyzed (Table II). Diabetes was more prevalent among Hispanic patients undergoing LER (60.3%) and CR (41.7%) than among Hispanic patients undergoing AAA repairs. In fact, these patients had less diabetes (17.4%) than what has been reported for the general Hispanic population aged 40 to 74 years. Hypertension and renal disease also affected more patients among Hispanics than among WnHs across all procedures analyzed (Table II). WnHs undergoing LER showed an increased prevalence of emphysema, coronary, cerebral, and lipid metabolism complications than did Hispanics; however, with the exception of emphysema, these differences were not noted in patients receiving CR or AAA repairs.

Table III. Age and sex in Hispanic and white non-Hispanic vascular patients

WnH, White non-Hispanic; H, Hispanic; LER, lower extremity revascularization; CR, carotid revascularization; AAA, elective abdominal aortic aneurysm.

Status of disease progression at time of treatment 

We analyzed potential differences in symptoms at the time of treatment between WnHs and Hispanics. Hispanics were significantly more likely to present with limb-threatening ischemia, symptomatic carotid artery disease, and ruptured AAA than WnHs independent of age, gender, and other comorbidities (Table IV). Because of the high prevalence of diabetes in Hispanics, we specifically analyzed the relationship between diabetes and disease status of patients undergoing lower extremity revascularizations. As expected, diabetes was associated with a higher rate of a limb-threatening condition, including rest pain, ulceration, or gangrene, and less so with claudication (Fig 2). When Hispanics and WnHs in the diabetic and nondiabetic cohorts were compared, however, more Hispanics presented with limb-threatening symptoms than did WnHs in both groups. Thus, although Hispanics undergo significantly fewer interventions for common arterial pathologies, they are more likely than WnHs to present with advanced disease.

Table IV. Clinical manifestation of disease at the time of treatment

Indication for procedure	Patients receiving procedure (%)			OR (95% CI) for H vs WnH
	WnH	H	P
Limb threatening ischemia	62.2	80.9	<.0001	2.09(1.91-2.29)
Symptomatic carotid disease	7.9	11.8	<.0001	1.57(1.40-1.75)
RAAA	11.0	13.5	.0179	1.26(1.04-1.52)

OR, Odds ratio; CI, confidence interval; H, Hispanic; WnH, white non-Hispanic; RAAA, ruptured abdominal aortic aneurysm.

Number of observations: lower extremity revascularization—WnH, 43,904; Hispanics, 3727; carotid revascularization—WnH, 85,038; Hispanics, 3072; all aortic abdominal aneurysm repairs—WnH, 25,632; Hispanics, 1004.

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• Fig 2. 

  Disease status of Hispanic (filled bars) and white non-Hispanic (WnH, clear bars) patients undergoing lower extremity revascularization (LER) in diabetic and non-diabetic cohort.

Outcomes after intervention 

We asked if vascular procedures in Hispanic and WnH patients resulted in different outcomes. Our data source limited the analysis to outcomes occurring during the hospital admission for the index treatment. Consistent with the more severe symptom profile, our findings indicate that Hispanic patients had significantly higher rates of major amputation after LER and deaths after elective AAA repair (Table V). No significant differences were found in postoperative stroke for patients undergoing CR. We also found that for all procedures the hospital, length of stay was longer for Hispanics than for WnHs, although for AAA this difference was less dramatic (Table VI).

Table V. Major outcomes within the same hospitalization after lower extremity revascularization, abdominal aortic aneurysm and carotid revascularization procedures in Hispanics and white non-Hispanics^⁎

Major outcome	Patients receiving the procedure, %			OR (95%CI) for H vs WnH
	WnH	H	P
Amputations after LER	3.4	6.2	<.00011	.67(1.48-1.88)
Deaths after elective AAA	3.4	5	.00321	.63(1.18-2.27)
Stroke after CR	1.2	1.3	.47351	.12(0.82-1.54)

WnH, White non-Hispanic; H, Hispanic; OR, odds ratio; CI, confidence interval; LER, lower extremity revascularization; AAA, abdominal aortic aneurysm; CR, carotid revascularization.

Table VI. Length of stay of vascular patients receiving lower extremity revascularization, carotid revascularization, and abdominal aortic aneurysm repair^⁎

Procedure	WnH	H	P
LER
Mean	8	12.3	<.0001
Median	5	8
CR
Mean	2.9	4.9	<.0001
Median	2	2
AAA (elective)
Mean	7.5	8.6	.003
Median	6	6

WnH, White non-Hispanic; H, Hispanic; LER, lower extremity revascularization; CR, carotid revascularization; AAA, elective abdominal aortic aneurysm.

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Discussion 

In this study we report major differences between Hispanics and WnHs in the treatment and outcomes of major vascular procedures. Evidence that ethnicity and race are predictors of screening disparities, treatment variations, and health outcomes has been reported in the medical and surgical literature.¹⁷, ¹⁸, ¹⁹, ²⁰, ²¹, ²² Racial differences in the utilization of surgical procedures have been seen in joint replacements, myocardial revascularization, renal transplant, and even dialysis access, with minorities more likely than whites to have prosthetic arteriovenous grafts vs primary fistulas.¹⁷, ¹⁸, ¹⁹ For lower extremity amputations,¹⁰, ¹¹, ²³, ²⁴, ²⁵ numerous publications have shown that race-related differences exist in presentation and rates of intervention. These differences are often attributed to genetic variations, lack of screening, inferior access to care and awareness, delayed intervention, and treatment discrepancies.

A recent study by Jha et al,²⁶ found that racial differences in the rate of utilization of major therapeutic procedures did lessen significantly during the 1990s. Our study detected significant differences in the rates of treatment of AAA, carotid artery disease, and lower extremity arterial disease between Hispanic and WnH patients. Having noted these disparities, attempts at explaining them and reducing them represent the critically important aspect of this project.

Previous studies have shown an increased prevalence of diabetes and renal insufficiency in Hispanics.⁷, ⁸ Consistent with these reports, we observed significantly higher rates of diabetes and renal insufficiency in Hispanics undergoing LER, AAA repair, and CR (Table II). A possible confounding factor may be that diabetes is less well controlled in Hispanics and therefore more severe sequelae may be expected. This would explain why diabetes alone did not fully explain disparities we have identified but could still be responsible for a significant portion of the results we demonstrated. Higher rates of diabetes may be related to biologic tendency or dietary and socioeconomic factors.

Our data also showed a higher rate of hypertension, a known risk factor for vascular disease, among Hispanics (Table II). The Northern Manhattan Stroke Study demonstrated an increased prevalence within the Hispanic population of untreated and unrecognized hypertension.²⁷, ²⁸ Therefore, efforts directed at detection and control of diabetes and hypertension would be an important component of a strategy aimed at addressing vascular disease in Hispanics.

Socioeconomic factors may affect patients’ access to proper preventive and diagnostic care. One survey describes Hispanics to have the highest reported uninsured rate among all ethnic groups and to lack basic access to medical care largely due to poor communication and understanding between patient and physician.²⁹ We believe insurance status may result in inferior access to preventive and diagnostic care in Hispanic patients, thus resulting in more advanced disease at the time of treatment. Cigarette smoking, a well-known risk factor for vascular disease, is lower among Hispanics than WnHs.³⁰, ³¹ Although we have not specifically analyzed this risk factor in our study, the lower rate among Hispanics makes this factor less likely to be a confounding variable in our analysis. Indeed, lower rates of tobacco abuse among Hispanics make our results appear more dramatic with respect to ethnicity as a risk factor for vascular disease.

With respect to lower extremity arterial disease, our data indicate that Hispanic patients present with more advanced limb ischemia and have higher rates of failed LER and major amputation than WnHs (Fig 2, Table IV, Table V). Conversely, WnHs are more often treated for claudication as the indication for LER.

With strong evidence demonstrating that Hispanics have a higher prevalence of risk factors and comorbidities well known to promote peripheral vascular disease, it may seem appropriate to attribute the disparities discovered in this analysis to modifiable and treatable risk factors. However, Hispanic ethnicity remained associated with more advanced disease even after controlling for coexisting comorbidities, including diabetes. Certain socioeconomic factors such as lower level of education, lack of insurance, and low income are more prevalent in ethnic minorities and can potentially have a negative effect on health outcomes.³², ³³, ³⁴, ³⁵, ³⁶ Moreover, many Hispanics traditionally rely on generations of self-care methods and are reluctant to seek professional treatment and may even be less “willing” to consider prophylactic surgical interventions.³⁷, ³⁸, ³⁹ As a result, peripheral vascular disease may progress to later stages before treatment is sought. It is also possible that there are genetic differences in the nature and manifestation of vascular disease in Hispanics.

Our analysis shows that Hispanics have lower rates of carotid intervention and presented more often with symptomatic carotid disease, whereas WnHs are more likely asymptomatic at the time of diagnosis (Table IV). The reasons for an overall lower rate of carotid intervention in Hispanics are unclear but may include a tendency toward less plaque formation,⁴⁰ which may result in less extracranial disease. However, a higher incidence of ischemic strokes of all etiologies has been previously reported in Hispanics.⁴¹

Our consistent finding of advanced symptomatology at presentation among Hispanics may be partially due to lower rates of screening for asymptomatic carotid disease. This result suggests that proper access to screening and prophylactic intervention may significantly reduce strokes in this population by allowing treatment of asymptomatic patients. The paradox of lower intervention rates but more advanced disease at time of treatment suggests that a significant proportion of patients are not detected when prophylactic treatment is most effective.

We have demonstrated that Hispanics undergo elective AAA repair much less frequently than WnHs. The reasons for this finding are unclear, and published reports addressing AAA in Hispanics are scarce. Diabetes has been suggested as a negative predictor of AAA.⁴² An interesting observation was a low rate of diabetes when AAA repair was compared with LER and carotid intervention, a finding that supports a possible negative association between these two entities (Table II). The higher rate of diabetes among Hispanics may result in lower rates of AAA and in part explain our observation of fewer AAA repairs in this group. However, less access to screening may also lead to lower detection of AAA and hence fewer elective repairs.

Although Hispanics had significantly lower rates of AAA repair, they were more likely to present with rupture (Table IV). It is possible that Hispanics are less likely to be diagnosed and treated before the AAA requires urgent repair. Differences in disease presentation and rates of disease progression are also a possible explanation. The significant increase in the outcome of death after elective AAA repair for Hispanic may be partially attributed to the higher prevalence of renal failure in the Hispanic population studied compared with WnHs (Table II, Table V).⁴³, ⁴⁴, ⁴⁵, ⁴⁶

Administrative databases are quite powerful because of the amount of data they contain, but they have certain inherent limitations. This analysis relies on the assumption that ethnicity is reported accurately in the discharge data. Errors in coding of comorbidities, risk factors, and assignment of ethnicity are possible. The effects of such limitations are possibly diminished by the “randomization” of nonsystematic errors that results when massive numbers of observations are statistically analyzed.⁴⁷ In addition, the population defined as Hispanic by statewide databases is heterogeneous in many ways. Our results may not fully reflect the diverse experience of this population and may neglect important differences within this group. Nonetheless, important common cultural and socioeconomic factors support the use of this broad definition.

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Conclusion 

Hispanic patients underwent significantly fewer procedures for AAA and carotid artery disease than did white non-Hispanics but tended to present with more advanced disease at the time of treatment. Lower extremity revascularization procedures were more likely to be for limb-threatening ischemia in Hispanics than white non-Hispanics and were more likely to result in amputation. The reasons for such disparities are likely to be multifactorial and require further investigation.

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Author contributions 

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