Invited commentary

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In 2001, the Institute of Medicine¹ recommended a reorganization of health care in the United States, specifically proposing the provision of equitable care regardless of gender, ethnicity, geographic location, and socioeconomic status. Six years after that report, these current data continue to document a persistent disparity in amputation rates based on race and socioeconomic inequality.

Optimistically, this study demonstrates that the overall rate of nontraumatic amputation is declining, even though there has been a rise in obesity and diabetes, coronary artery disease, and kidney disease. As such, the data seem to support the supposition that aggressive medical intervention in the diabetic population can reduce the incidence of amputation; conversely, it may also imply that such efforts have not been afforded to minority populations.

Ultimately, these data should prompt a critical appraisal of how we, as practitioners, deliver health care. The authors have previously shown² that well equipped, high volume centers and providers can produce better outcomes in patients with peripheral arterial disease. These centers have the full array of vascular, cardiac, and wound care specialists with the resources necessary to retain providers. In our present health care system, these centers of excellence must also draw patients from higher socioeconomic areas for financial viability.

This study, along with others, also strongly supports the need for a consolidated research effort to identify those factors that predispose minority patients to the increased risk of amputation. This effort will need to cut across multiple specialties. There will need to be continued research into the basic science of vascular disease; racial and ethnic differences, if present, may provide clues to new therapeutic approaches for all populations. Clinical researchers, social scientists, and epidemiologists will need to assess potential disparities in the availability and access to primary and specialty medical care, the quality of care, and patient compliance with care recommendations. Once seen by a provider, are there racial and ethnic biases in care processes, referral recommendations and treatment decisions? Do variations in primary or specialty care influence the mitigation or control of risk factors promoting vascular disease, such diabetes, hypertension, hyperlipidemia, and smoking?

Ultimately, minority populations need to receive aggressive preventative care, with timely referrals to wound care and vascular surgery centers and with heightened attention to foot and wound care regardless of comorbidities. Unfortunately, these disparities in treatment and outcomes will most likely remain until the elimination of the hypersegregated, socially-isolated, high-poverty neighborhoods. In the end, implementing improvements in the most basic care for these populations has the potential to result in a profound social and economic impact, with an improved life expectancy and quality of life and decreased long-term nursing care costs.

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References 

1. Committee on Quality of Health Care in America, Institute of Medicine. Crossing the Quality Chasm; A New Health System for the 21st Century. Washington DC: National Academies Press; 2001;
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2. Ebaugh JL, Feinglass J, Pearce WH. The effect of hospital vascular operation capability on outcomes of lower extremity arterial bypass procedures. Surgery. 2001;130:1561–1567
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