Patients who are people of color are at increased risk for severe presentation of critical limb ischemia (CLI), have higher rates of amputation, and a decreased utilization of salvage techniques. Recognizing that it is critical to close the disparity gap, the Society of International Radiology (SIR) funded a Research Consensus Panel (RCP) on September 23 to 24, 2021, which sought to prioritize a research agenda entitled “Closing the Gaps in Racial Disparities in CLI Outcomes and Amputation Rates.” Results of the analysis, which presented the proceedings and recommendations from the panel, were published in the Journal of Vascular and Interventional Radiology.1
The objective of the SIR RCP was to provide a summary of the existing knowledge, to identify gaps in knowledge and practice, and to prioritize research topics regarding racial disparities in CLI outcomes and amputation rates. The panel included a multidisciplinary group of experts, of whom 12 panelists provided 13 presentations, with the topics as follows:
- Scope of CLI and implications of limb amputation
- Patient-centered economical impactors of CLI outcome: socioeconomic status and insurance type
- Regional and resource-centered impactors of CLI outcome: geography, distance to hospital, hospital ability to perform angiography, and availability of vascular specialists
- Association of race with comorbidities strongly associated with CLI
- Challenges and considerations in studying the impact of race on disease: lessons learned
- Impact of race on CLI outcome
- Impact of unconscious bias on health care
- Public awareness and early diagnosis of PAD and CLI
- Reasons for the lack of meaningful data in CLI and ways to improve
- Improving racial inclusivity in clinical trials
- Standardizations and classifications to capture patients at risk of amputation in a CLI prospective trial
- Designing a regional or national registry-based trial
- Designing a practice changing multi-institutional prospective trials: lessons learned
Low socioeconomic status represents a critical driver of underlying health care disparities, often delaying diagnosis and limiting efforts to preserve limbs. Black veterans have been shown to be significantly more likely to live in low socioeconomic neighborhoods and to present with advanced PAD. Further, Black patients have a higher risk for amputation in each socioeconomic stratum compared with White patients. Per the use of regression models, Black race was associated with a higher risk for amputation compared with White race.
Results of a 2020 study that used the National Vascular Quality Initiative disclosed that patients who were people of color in rural areas had a 2-fold higher likelihood of undergoing primary amputation than did rural White patients (adjusted odds ratio [aOR], 2.06; 95% CI, 1.53-2.78), as well as a 52% increased likelihood of undergoing primary amputation than did patients who were people of color living in urban areas (aOR, 1.52; 95% CI, 1.19-1.94),2 thus demonstrating the heightened impact of race on primary amputation in rural areas.
The researchers highlighted that patients from minority populations, such as patients who are Black, Hispanic, and Native Americans, are disproportionately affected by CLI and amputation because of a variety of factors, including socioeconomic status, lack of access to health care, capacity and expertise of local hospitals, unconscious bias, type or lack of insurance, and prevalence of diabetes.
The following research objectives were ultimately prioritized: randomized controlled trial with PAD screening of at-risk patients with an oversampling of high-risk racial groups; a prospective trial with the introduction of an intervention to alter a social determinant of health; and a prospective trial with the implementation of an algorithm that requires criteria to be fulfilled prior to an amputation.
Disclosure: Some of the study authors have declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
1. Bryce Y, Katzen B, Patel P, et al. Closing the gaps in racial disparities in critical limb ischemia outcome and amputation rates: proceedings from a Society of Interventional Radiology Foundation Research Consensus Panel. J Vasc Interv Radiol. Published online May 1, 2022. doi:10.1016/j.jvir.2022.02.010
2. Minc SD, Goodney PP, Misra R, Thibault D, Smith GS, Marone L. The effect of rurality on the risk of primary amputation is amplified by race. J Vasc Surg. Published online January 18, 2020. doi:10.1016/j.jvs.2019.10.090