- Email: [email protected]
The Impact of Race on Advanced Chronic Venous Insufficiency
Accepted Manuscript The Impact of Race on Advanced Chronic Venous Insufficiency Anahita Dua, MD, MS, MBA, Sapan S. Desai, MD, PhD, MBA, Jennifer A. Heller, MD PII:
S0890-5096(16)30242-4
DOI:
10.1016/j.avsg.2016.01.020
Reference:
AVSG 2782
To appear in:
Annals of Vascular Surgery
Received Date: 23 May 2015 Revised Date:
25 August 2015
Accepted Date: 5 January 2016
Please cite this article as: Dua A, Desai SS, Heller JA, The Impact of Race on Advanced Chronic Venous Insufficiency, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.01.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Impact of Race on Advanced Chronic Venous Insufficiency Anahita Dua MD, MS, MBA1, Sapan S. Desai MD, PhD, MBA2, Jennifer A. Heller MD3
RI PT
1. Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 2. Department of Vascular Surgery, Southern Illinois University, Springfield, IL 3. Department of Surgery, Johns Hopkins Vein Center, Johns Hopkins Medical Center, Baltimore, MD
EP
TE D
M AN U
No conflicts of interest or financial disclosures
SC
Oral Presentation at the 27th Annual American Venous Forum (AVF) Meeting, Palm Springs, CA, February 25th – 27th, 2015
AC C
Corresponding author:
Anahita Dua MD, MS, MBA 8701 West Watertown Plank Road Milwaukee, WI 53226 [email protected]
ACCEPTED MANUSCRIPT
Abstract: Introduction: The study aimed to determine the association between race and patient variables,
RI PT
hospital covariates and outcomes in patients presenting with advanced chronic venous insufficiency.
Methods: The National Inpatient Sample (NIS) was queried to identify all Caucasian and
SC
African American patients with a primary ICD-9 diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were
M AN U
correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Students’ T-test, and the Fisher exact test. Trend analysis was completed using the Mann-Kendall test.
Results: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were
TE D
African American. Debridement procedures had the highest costs at $6,096 followed by skin grafting at $4,089. There was an overall decrease in the number of ulcer debridements, vein stripping, and sclerotherapy procedures between 1998 and 2011 (P<0.05) for both groups.
EP
However, African American patients had significantly more ulcer debridements than their
AC C
Caucasian counterparts.
Conclusion: African American patients with a primary diagnosis of venous stasis present with more advanced venous disease at a younger age compared to their Caucasian counterparts. This is associated with increased ulcer debridement, DVT rates and hospital charges in the African American cohort. There are no differences in sclerotherapy or skin grafting procedures, LOS or inpatient mortality between races.
ACCEPTED MANUSCRIPT
Introduction: Chronic venous insufficiency affects more than 2.5 million adults in the United States.
RI PT
Although early stages of chronic venous insufficiency may be limited to painless varicosities, patients with advanced stages of disease report debilitating symptoms. Pathognomonic features on physical examination include hemosiderin deposition, lipodermatosclerosis, dermatitis, and
SC
venous stasis ulcers.1,2
Established risk factors for chronic venous insufficiency include advanced age, female gender,
M AN U
parity, family history, obesity, and occupations associated with orthostasis.1 However, the association of race with the diagnosis, management, and treatment of chronic venous insufficiency has not been explored. Healthcare disparities associated with race have been substantiated in the vascular literature; however the focus has been placed on arterial disease.3-7
TE D
The objective of this study was to evaluate the association between race and disease presentation, management, and outcomes in patients with advanced (CEAP ≥4) chronic venous insufficiency
Methods:
EP
in the United States.
AC C
All adult patients associated with primary ICD-9 diagnosis codes for venous stasis with ulceration (454.0) or complications (454.2) were identified from the National Inpatient Sample (NIS) from 1998 to 2011. The NIS is a part of the Health Care Utilization Project (HCUP) that is maintained by the Agency for Healthcare Research and Quality (AHRQ).8 It is the largest allpayer inpatient database and includes a stratified 20% random sample of all nonfederal inpatient hospital admissions throughout the United States. Clinical records were obtained with the use of International Classification of Diseases, Ninth Revision (ICD-9) codes to include only patients
ACCEPTED MANUSCRIPT
with a primary diagnosis of ICD-9 code 454.0 and 454.2 (CEAP 5,6). Other codes with ulcers diagnosis were excluded as the codes chosen were encompassing and other codes may add
RI PT
patients with ulceration due to diabetes or arterial disease. CEAP scores were correlated with these ICD-9 diagnosis codes (Table I). Demographics, CEAP classification, admission type (elective, emergency) management (debridement, skin graft, vein
SC
stripping/ligation [unable to differentiate between great and small saphenous] and,
sclerotherapy), cost of care, length of stay (LOS), and inpatient mortality were compared
M AN U
between African American and Caucasian patients. Other ethnic groups with this disease process did not reach enough power within the NIS dataset from which to draw meaningful conclusion hence this study focused on African American and Caucasian patients. Costs were corrected using the Consumer Price Index and are presented as 2014 USD.
TE D
Statistical analysis was completed using analysis of variance for continuous variables (age, race, gender) and χ2 test for categorical variables (hospital covariates, inpatient mortality, LOS). The Mann-Whitney U test was used for LOS and total cost. Trend analysis was completed using the
EP
Mann-Kendall test. Data analysis and management were completed using the IBM SPSS software package (SPSS version 22.0; SPSS Inc, Chicago, IL). P<0.05 was considered to be
AC C
statistically significant. Results:
A total of 20,648 patients were identified between 1998 and 2011, of which 83% (11) were Caucasian and 17% (2,554) African American. Table II depicts the comparative demographics and comorbidities between Caucasians and African Americans presenting for chronic venous insufficiency management. Caucasians were more likely to be older (68.2±15.8 vs 61.5±16.7
ACCEPTED MANUSCRIPT
years, P<0.001) and female (54.5% vs 50.3%, p<0.001) with a higher incidence of chronic obstructive pulmonary disease (COPD) [19.6% vs 16.5%, p<0.05) while African American patients were more likely to have congestive heart failure (CHF) (17.1% vs 15.1%, p<0.05) and
RI PT
hypertension (60.7% vs 50.9%, p<0.05) as comorbidities. There was no difference in the
incidence of diabetes between groups (unable to distinguish between non-insulin dependent diabetics and insulin-dependent diabetics). Table III depicts the comparative chronic venous
SC
insufficiency disease presentation between Caucasians and African American. African American patients. African American presented with higher incidence of deep vein thrombosis (DVT) than
M AN U
Caucasians (7.2% vs 6.5%, p<0.001). There was no difference in the rate of thrombophlebitis between Caucasians and African American patients.
African American patients underwent more debridement than their Caucasian counterparts (17.8% vs 6.5%, p<0.001); there was no difference in sclerotherapy or skin grafting between
TE D
groups but Caucasians were more likely to undergo ligation or vein stripping (11.4% vs 6.3%, p<0.001). African American patients were associated with increased costs ($7,116 vs $6,281,
Discussion:
EP
p<0.001). There was no difference in LOS or mortality between groups (Table IV).
AC C
Chronic venous insufficiency impacts a significant proportion of the USA adult population and results in a substantial socioeconomic burden. The financial implications of chronic venous insufficiency are significant; wound care for C6 disease has been estimated at $3 billion in the United States, accounting for almost 2% of the total healthcare budget in Western countries.2 Furthermore, associated disability from chronic venous insufficiency impacts up to 12% of people with the disease and results in an annual loss of nearly 2 million workdays.2,9
ACCEPTED MANUSCRIPT
Identification of patients who are at higher risk of this disease process is imperative to providing timely intervention and potentially positively impact clinical outcomes. While parity, advancing age, female sex, and genetics are known risk factors, there have been limited studies evaluating
RI PT
the impact of race on chronic venous insufficiency. However, health care disparity has been extensively studied in many other disease cohorts and significant racial disparities have been noted in healthcare within the USA.10 Data demonstrates that minority residents in the USA
SC
persistent have a lower socioeconomic status which results in a greater barrier to health-care access and a larger burden of disease when compared to Caucasian counterparts in the same
M AN U
communities.10 Notably, there were significant variations reported in risk factor prevalence, utilization of preventative services, and chronic condition burdens in minority communities, factors that linked with a number of arterial and venous vascular pathologies.10 In the vascular literature, the majority of the focus regarding racial disparities in healthcare has
TE D
revolved around arterial disease.3-5,11,12 African American patients are less likely to undergo endovascular treatment compared to open management for vascular diseases even though there has been an overall increase in the percentage of endovascular procedures performed over the
EP
last two decades in the USA.12,13 These racial disparities have been studied in the AAA
AC C
population.14,15 Studies demonstrate that African American patients were still less likely to undergo endovascular AAA repair even when controlling for differences in patient characteristics and the hospitals.11,14,15 African American males undergo elective AAA repair at a lower rate when compared to their Caucasian counterparts even after accounting for their decreased disease burden.11 Interestingly, urgent repair rates are higher among African American men.11 African American patients also have a higher mortality rate than non- African American patients after AAA repair.14,15 These differences have been attributed to African American
ACCEPTED MANUSCRIPT
patients receiving care in lower-quality hospitals due to a disparity in healthcare access however other studies have contradicted this philosophy by demonstrating that these healthcare discrepancies are exaggerated in settings where resources were greatest.10, 14-16 In fact, African
RI PT
American patients with peripheral artery disease (PAD) undergo amputation 2-4 times more frequently than their Caucasian counterparts even when treated by providers with the highest likelihood of revascularization.4,5,17 African American patients are also more likely to fail after
SC
an infra-inguinal bypass for PAD when compared to other races.18,19 Caucasian race has been independently linked to a greater likelihood of intervention in PAD patients with critical limb
M AN U
ischemia and in the carotid artery disease cohorts.20 Even with similar insurance, African American patients hospitalized with acute myocardial infarction (MI) are significantly less likely to receive revascularization when compared to Caucasians with similar health insurance.21 Overall, it is unclear whether these disparities are attributable to race-related differences in
TE D
disease severity or if patient preferences or physician decision-making are responsible. There are fewer studies reporting on racial disparities in venous disease. Research has demonstrated that African American patients tend to present with more significant venous
EP
disease as compared to their Caucasian counterparts.22 Our study supported this report given that
AC C
African American patients were significantly more likely to present with advanced chronic venous insufficiency with CEAP scores of 5 or 6 at a younger age than their Caucasian counterparts. Caucasians were much more likely to be admitted with a CEAP of 4. Interestingly, Caucasian patients were more likely to undergo vein stripping/ligation compared to African American patients indicating that perhaps African American patients may not be undergoing aggressive management of their venous disease early which may in turn result in these patients presenting with more advanced disease. African American patients in our study did undergo
ACCEPTED MANUSCRIPT
more ulcer debridement than Caucasian patients which likely contributed to the increased hospital charges even with a similar LOS to the comparative Caucasian cohort. This variability in care may have been confounded by the fact that physical stigmata associated with chronic
RI PT
venous insufficiency is underdiagnosed and underappreciated.23 Heterogeneous referral patterns and substantial variation in treatment regimens of thrombosis exist in the USA and these regional differences may be partial attributable for the discrepancies in chronic venous insufficiency
SC
care.23 Overall, our results indicate that racial disparities exist for patients with chronic venous
are the cause of this discrepancy. Limitations:
M AN U
insufficiency. It is unclear whether patient, hospital, physician or a combination of these factors
This study was limited by its retrospective design and the utilization of the NIS database which
TE D
does not allow for long term patient follow-up. Furthermore, limitations of ICD-9 codes resulted in an inability to document rates of sclerotherapy, microphlebectomy, and endothermal ablation. Another limitation of this study is that the majority of vein procedures are performed in an out-
EP
patient setting hence the NIS which only reviews inpatients may not be the ideal source to review vein disease management. We attempted to mitigate this limitation by limiting our study
AC C
population to those patients with the most severe venous disease (CEAP ≥ 5). Mixed venous disease could not be identified due to a lack of ICD-9 codes which was another limitation of this study; we used ICD-9 codes that would encompass the majority of primary venous disease and excluded a number of codes because they would have potentially included patients with additional ulcers due to diabetes or arterial disease. Hence, the results of this study are dependent upon the accuracy of the association between the CEAP classification and ICD-9 codes. Further
ACCEPTED MANUSCRIPT
studies will also include other racial groups including Asian-Americans and Hispanic populations.
RI PT
Conclusion: African American patients present with more advanced venous disease at a younger age
compared to their Caucasian counterparts. African American race is associated with increased
SC
ulcer debridement, DVT rates and hospital costs. Despite differences in presentation and
AC C
EP
TE D
M AN U
management, there is no difference in LOS or inpatient mortality between races.
ACCEPTED MANUSCRIPT
References: 1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic
RI PT
venous insufficiency and varicose veins. Ann Epidemiol. 2005 Mar;15(3):175-84. 2. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014 Jul
22;130(4):333-46. doi: 10.1161/CIRCULATIONAHA.113.006898. Review. No abstract
SC
available.
3. Kirksey L. Health care disparity in the care of the vascular patient. Vasc Endovascular
M AN U
Surg. 2011 Jul;45(5):418-21. doi: 10.1177/1538574411407082. Epub 2011 Apr 28. 4. Regenbogen SE, Gawande AA, Lipsitz SR, Greenberg CC, Jha AK. Do differences in
hospital and surgeon quality explain racial disparities in lower-extremity vascular amputations? Ann Surg. 2009 Sep;250(3):424-31. doi: 10.1097/SLA.0b013e3181b41d53.
TE D
5. Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of
revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011 Aug;54(2):420-6, 426.e1. doi: 10.1016/j.jvs.2011.02.035. Epub 2011 May 14
EP
6. Itakura H. Racial disparities in risk factors for thrombosis. Curr Opin Hematol. 2005
Sep;12(5):364-9. Review.
AC C
7. Philipp CS, Faiz AS, Beckman MG, Grant A, Bockenstedt PL, Heit JA, James AH,
Kulkarni R, Manco-Johnson MJ, Moll S, Ortel TL. Differences in thrombotic risk factors in black and white women with adverse pregnancy outcome. Thromb Res. 2014 Jan;133(1):108-11. doi: 10.1016/j.thromres.2013.10.035. Epub 2013 Nov 1.
8. Healthcare Cost and Utilization. http://www.ahrq.gov/research/data/hcup/index.html.
Accessed February 4th, 2015
ACCEPTED MANUSCRIPT
9. Silva Mde C. Chronic venous insufficiency of the lower limbs and its socio-economic
significance. Int Angiol. 1991 Jul-Sep;10(3):152-7. 10. Liao Y, Bang D, Cosgrove S, Dulin R, Harris Z, Taylor A, White S, Yatabe G, Liburd L,
RI PT
Giles W; Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease Control and Prevention (CDC). Surveillance of health status in minority communities - Racial and Ethnic Approaches to
SC
Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. MMWR Surveill Summ. 2011 May 20;60(6):1-44.
M AN U
11. Wilson CT, Fisher E, Welch HG. Racial disparities in abdominal aortic aneurysm repair
among male Medicare beneficiaries. Arch Surg. 2008 May;143(5):506-10. doi: 10.1001/archsurg.143.5.506.
12. Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of
TE D
treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010 Apr;51(4 Suppl):21S-26S. doi: 10.1016/j.jvs.2009.09.066. Epub 2010 Jan 15. 13. Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, McKinsey J,
EP
Morrissey N, Kent KC. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006 Feb;43(2):205-16.
AC C
14. Osborne NH, Upchurch GR Jr, Mathur AK, Dimick JB. Explaining racial disparities in
mortality after abdominal aortic aneurysm repair. J Vasc Surg. 2009 Oct;50(4):709-13. doi: 10.1016/j.jvs.2009.05.020. Epub 2009 Aug 22.
15. Osborne NH, Mathur AK, Upchurch GR Jr, Dimick JB. Understanding the racial
disparity in the receipt of endovascular abdominal aortic aneurysm repair. Arch Surg. 2010 Nov;145(11):1105-8. doi: 10.1001/archsurg.2010.213.
ACCEPTED MANUSCRIPT
16. Durazzo TS, Frencher S, Gusberg R. Influence of race on the management of lower
extremity ischemia: revascularization vs amputation. JAMA Surg. 2013 Jul;148(7):61723. doi: 10.1001/jamasurg.2013.1436.
RI PT
17. Hughes K, Seetahal S, Oyetunji T, Rose D, Greene W, Chang D, Cornwell E 3rd,
Obisesan T. Racial/ethnic disparities in amputation and revascularization: a nationwide
10.1177/1538574413510618. Epub 2013 Nov 7.
SC
inpatient sample study. Vasc Endovascular Surg. 2014 Jan;48(1):34-7. doi:
18. Selvarajah S, Black JH 3rd, Haider AH, Abularrage CJ. Racial disparity in early graft
M AN U
failure after infrainguinal bypass. J Surg Res. 2014 Jul;190(1):335-43. doi: 10.1016/j.jss.2014.04.029. Epub 2014 Apr 21.
19. Chew DK, Nguyen LL, Owens CD, Conte MS, Whittemore AD, Gravereaux EC, Menard
MT, Belkin M. Comparative analysis of autogenous infrainguinal bypass grafts in
TE D
African Americans and Caucasians: the association of race with graft function and limb salvage. J Vasc Surg. 2005 Oct;42(4):695-701. 20. Amaranto DJ, Abbas F, Krantz S, Pearce WH, Wang E, Kibbe MR. An evaluation of
EP
gender and racial disparity in the decision to treat surgically arterial disease. J Vasc Surg. 2009 Dec;50(6):1340-7. doi: 10.1016/j.jvs.2009.07.089. Epub 2009 Oct 17.
AC C
21. Cram P, Bayman L, Popescu I, Vaughan-Sarrazin MS. Racial disparities in
revascularization rates among patients with similar insurance coverage. J Natl Med Assoc. 2009 Nov;101(11):1132-9.
22. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, Golomb
BA.Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol. 2003 Sep 1;158(5):448-56.
ACCEPTED MANUSCRIPT
23. Dua A, Desai SS, Heller JA. Heterogeneity in venous disease practice patterns amongst
primary healthcare practitioners. Vascular. 2014 Sep 22. pii: 1708538114552011. [Epub
AC C
EP
TE D
M AN U
SC
RI PT
ahead of print]
ACCEPTED MANUSCRIPT
Tables: Table I: CEAP scores associated with ICD-9 codes within the NIS Description Leg varicosity with ulceration Varicosity of the leg with ulcer and inflammation
5, 6 5, 6
AC C
EP
TE D
M AN U
SC
454.0 454.2
CEAP Score
RI PT
ICD-9 Code
ACCEPTED MANUSCRIPT
Table II: Comparative Demographics and Co-morbidities between Caucasians and AfricanAmerican patients presenting for chronic venous insufficiency management
TE D EP AC C
P Value P<0.001 P<0.001 P<0.05 P<0.05 N.S. P<0.05 N.S. P<0.05
RI PT
African-Americans (n=2,554) 61.5 ± 16.7 50.3% 17.1% 16.5% 21.4% 60.7% 8.0% 4.5 ± 2.8
M AN U
Age Female CHF COPD Diabetes Hypertension PAD Number of chronic conditions
Caucasians (n=12,500) 68.2 ± 15.8 54.5% 15.1% 19.6% 20.8% 50.9% 8.8% 4.9 ± 3.0
SC
Variable
ACCEPTED MANUSCRIPT
Table III: Comparative chronic venous insufficiency disease presentation between Caucasians and African-American patients
6,548 (52%)
1,225 (348%)
123 (0.9%) 819 (6.5%)
22 (0.8%) 202 (7.9%)
TE D EP AC C
P Value P<0.001
RI PT
African-Americans (n=2,554) 1,329 (52%)
M AN U
Leg varicosity with ulcer (454.0; CEAP 5, 6) Varicosity of the leg with ulcer and inflammation (454.2; CEAP 5, 6) Thrombophlebitis DVT (acute or chronic)
Caucasians (n=12,500) 5,952 (48%)
P<0.05
NS P<0.001
SC
Variable
ACCEPTED MANUSCRIPT
Table IV: Comparative management choices, LOS, inpatient mortality, and total costs between Caucasians and African-American patients
P<0.001 NS P<0.001 NS NS
193 (1.5%) $6,281
25 (0.9%) $7,116
NS P<0.001
TE D EP AC C
P Value
RI PT
African-Americans (n=2,554) 455 (17.8%) 6 (0.2%) 161 (6.3%) 3 (0.1%) 5
M AN U
Debridement Skin graft Stripping or ligation Sclerotherapy Length of stay (median) Inpatient mortality Total costs (2014 USD)
Caucasians (n=12,500) 817 (6.5%) 33 (0.2%) 1,424 (11.4%) 33 (0.2%) 5
SC
Variable
S0890-5096(16)30242-4
DOI:
10.1016/j.avsg.2016.01.020
Reference:
AVSG 2782
To appear in:
Annals of Vascular Surgery
Received Date: 23 May 2015 Revised Date:
25 August 2015
Accepted Date: 5 January 2016
Please cite this article as: Dua A, Desai SS, Heller JA, The Impact of Race on Advanced Chronic Venous Insufficiency, Annals of Vascular Surgery (2016), doi: 10.1016/j.avsg.2016.01.020. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
The Impact of Race on Advanced Chronic Venous Insufficiency Anahita Dua MD, MS, MBA1, Sapan S. Desai MD, PhD, MBA2, Jennifer A. Heller MD3
RI PT
1. Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 2. Department of Vascular Surgery, Southern Illinois University, Springfield, IL 3. Department of Surgery, Johns Hopkins Vein Center, Johns Hopkins Medical Center, Baltimore, MD
EP
TE D
M AN U
No conflicts of interest or financial disclosures
SC
Oral Presentation at the 27th Annual American Venous Forum (AVF) Meeting, Palm Springs, CA, February 25th – 27th, 2015
AC C
Corresponding author:
Anahita Dua MD, MS, MBA 8701 West Watertown Plank Road Milwaukee, WI 53226 [email protected]
ACCEPTED MANUSCRIPT
Abstract: Introduction: The study aimed to determine the association between race and patient variables,
RI PT
hospital covariates and outcomes in patients presenting with advanced chronic venous insufficiency.
Methods: The National Inpatient Sample (NIS) was queried to identify all Caucasian and
SC
African American patients with a primary ICD-9 diagnosis code for venous stasis with ulceration (454.0), inflammation (454.1), or complications (454.2) from 1998 to 2011. CEAP scores were
M AN U
correlated with ICD-9 diagnosis. Demographics, CEAP classification, management, cost of care, length of stay (LOS), and inpatient mortality were compared between races. Statistical analysis was via descriptive statistics, Students’ T-test, and the Fisher exact test. Trend analysis was completed using the Mann-Kendall test.
Results: A total of 20,648 patients were identified of which 85% were Caucasian and 15% were
TE D
African American. Debridement procedures had the highest costs at $6,096 followed by skin grafting at $4,089. There was an overall decrease in the number of ulcer debridements, vein stripping, and sclerotherapy procedures between 1998 and 2011 (P<0.05) for both groups.
EP
However, African American patients had significantly more ulcer debridements than their
AC C
Caucasian counterparts.
Conclusion: African American patients with a primary diagnosis of venous stasis present with more advanced venous disease at a younger age compared to their Caucasian counterparts. This is associated with increased ulcer debridement, DVT rates and hospital charges in the African American cohort. There are no differences in sclerotherapy or skin grafting procedures, LOS or inpatient mortality between races.
ACCEPTED MANUSCRIPT
Introduction: Chronic venous insufficiency affects more than 2.5 million adults in the United States.
RI PT
Although early stages of chronic venous insufficiency may be limited to painless varicosities, patients with advanced stages of disease report debilitating symptoms. Pathognomonic features on physical examination include hemosiderin deposition, lipodermatosclerosis, dermatitis, and
SC
venous stasis ulcers.1,2
Established risk factors for chronic venous insufficiency include advanced age, female gender,
M AN U
parity, family history, obesity, and occupations associated with orthostasis.1 However, the association of race with the diagnosis, management, and treatment of chronic venous insufficiency has not been explored. Healthcare disparities associated with race have been substantiated in the vascular literature; however the focus has been placed on arterial disease.3-7
TE D
The objective of this study was to evaluate the association between race and disease presentation, management, and outcomes in patients with advanced (CEAP ≥4) chronic venous insufficiency
Methods:
EP
in the United States.
AC C
All adult patients associated with primary ICD-9 diagnosis codes for venous stasis with ulceration (454.0) or complications (454.2) were identified from the National Inpatient Sample (NIS) from 1998 to 2011. The NIS is a part of the Health Care Utilization Project (HCUP) that is maintained by the Agency for Healthcare Research and Quality (AHRQ).8 It is the largest allpayer inpatient database and includes a stratified 20% random sample of all nonfederal inpatient hospital admissions throughout the United States. Clinical records were obtained with the use of International Classification of Diseases, Ninth Revision (ICD-9) codes to include only patients
ACCEPTED MANUSCRIPT
with a primary diagnosis of ICD-9 code 454.0 and 454.2 (CEAP 5,6). Other codes with ulcers diagnosis were excluded as the codes chosen were encompassing and other codes may add
RI PT
patients with ulceration due to diabetes or arterial disease. CEAP scores were correlated with these ICD-9 diagnosis codes (Table I). Demographics, CEAP classification, admission type (elective, emergency) management (debridement, skin graft, vein
SC
stripping/ligation [unable to differentiate between great and small saphenous] and,
sclerotherapy), cost of care, length of stay (LOS), and inpatient mortality were compared
M AN U
between African American and Caucasian patients. Other ethnic groups with this disease process did not reach enough power within the NIS dataset from which to draw meaningful conclusion hence this study focused on African American and Caucasian patients. Costs were corrected using the Consumer Price Index and are presented as 2014 USD.
TE D
Statistical analysis was completed using analysis of variance for continuous variables (age, race, gender) and χ2 test for categorical variables (hospital covariates, inpatient mortality, LOS). The Mann-Whitney U test was used for LOS and total cost. Trend analysis was completed using the
EP
Mann-Kendall test. Data analysis and management were completed using the IBM SPSS software package (SPSS version 22.0; SPSS Inc, Chicago, IL). P<0.05 was considered to be
AC C
statistically significant. Results:
A total of 20,648 patients were identified between 1998 and 2011, of which 83% (11) were Caucasian and 17% (2,554) African American. Table II depicts the comparative demographics and comorbidities between Caucasians and African Americans presenting for chronic venous insufficiency management. Caucasians were more likely to be older (68.2±15.8 vs 61.5±16.7
ACCEPTED MANUSCRIPT
years, P<0.001) and female (54.5% vs 50.3%, p<0.001) with a higher incidence of chronic obstructive pulmonary disease (COPD) [19.6% vs 16.5%, p<0.05) while African American patients were more likely to have congestive heart failure (CHF) (17.1% vs 15.1%, p<0.05) and
RI PT
hypertension (60.7% vs 50.9%, p<0.05) as comorbidities. There was no difference in the
incidence of diabetes between groups (unable to distinguish between non-insulin dependent diabetics and insulin-dependent diabetics). Table III depicts the comparative chronic venous
SC
insufficiency disease presentation between Caucasians and African American. African American patients. African American presented with higher incidence of deep vein thrombosis (DVT) than
M AN U
Caucasians (7.2% vs 6.5%, p<0.001). There was no difference in the rate of thrombophlebitis between Caucasians and African American patients.
African American patients underwent more debridement than their Caucasian counterparts (17.8% vs 6.5%, p<0.001); there was no difference in sclerotherapy or skin grafting between
TE D
groups but Caucasians were more likely to undergo ligation or vein stripping (11.4% vs 6.3%, p<0.001). African American patients were associated with increased costs ($7,116 vs $6,281,
Discussion:
EP
p<0.001). There was no difference in LOS or mortality between groups (Table IV).
AC C
Chronic venous insufficiency impacts a significant proportion of the USA adult population and results in a substantial socioeconomic burden. The financial implications of chronic venous insufficiency are significant; wound care for C6 disease has been estimated at $3 billion in the United States, accounting for almost 2% of the total healthcare budget in Western countries.2 Furthermore, associated disability from chronic venous insufficiency impacts up to 12% of people with the disease and results in an annual loss of nearly 2 million workdays.2,9
ACCEPTED MANUSCRIPT
Identification of patients who are at higher risk of this disease process is imperative to providing timely intervention and potentially positively impact clinical outcomes. While parity, advancing age, female sex, and genetics are known risk factors, there have been limited studies evaluating
RI PT
the impact of race on chronic venous insufficiency. However, health care disparity has been extensively studied in many other disease cohorts and significant racial disparities have been noted in healthcare within the USA.10 Data demonstrates that minority residents in the USA
SC
persistent have a lower socioeconomic status which results in a greater barrier to health-care access and a larger burden of disease when compared to Caucasian counterparts in the same
M AN U
communities.10 Notably, there were significant variations reported in risk factor prevalence, utilization of preventative services, and chronic condition burdens in minority communities, factors that linked with a number of arterial and venous vascular pathologies.10 In the vascular literature, the majority of the focus regarding racial disparities in healthcare has
TE D
revolved around arterial disease.3-5,11,12 African American patients are less likely to undergo endovascular treatment compared to open management for vascular diseases even though there has been an overall increase in the percentage of endovascular procedures performed over the
EP
last two decades in the USA.12,13 These racial disparities have been studied in the AAA
AC C
population.14,15 Studies demonstrate that African American patients were still less likely to undergo endovascular AAA repair even when controlling for differences in patient characteristics and the hospitals.11,14,15 African American males undergo elective AAA repair at a lower rate when compared to their Caucasian counterparts even after accounting for their decreased disease burden.11 Interestingly, urgent repair rates are higher among African American men.11 African American patients also have a higher mortality rate than non- African American patients after AAA repair.14,15 These differences have been attributed to African American
ACCEPTED MANUSCRIPT
patients receiving care in lower-quality hospitals due to a disparity in healthcare access however other studies have contradicted this philosophy by demonstrating that these healthcare discrepancies are exaggerated in settings where resources were greatest.10, 14-16 In fact, African
RI PT
American patients with peripheral artery disease (PAD) undergo amputation 2-4 times more frequently than their Caucasian counterparts even when treated by providers with the highest likelihood of revascularization.4,5,17 African American patients are also more likely to fail after
SC
an infra-inguinal bypass for PAD when compared to other races.18,19 Caucasian race has been independently linked to a greater likelihood of intervention in PAD patients with critical limb
M AN U
ischemia and in the carotid artery disease cohorts.20 Even with similar insurance, African American patients hospitalized with acute myocardial infarction (MI) are significantly less likely to receive revascularization when compared to Caucasians with similar health insurance.21 Overall, it is unclear whether these disparities are attributable to race-related differences in
TE D
disease severity or if patient preferences or physician decision-making are responsible. There are fewer studies reporting on racial disparities in venous disease. Research has demonstrated that African American patients tend to present with more significant venous
EP
disease as compared to their Caucasian counterparts.22 Our study supported this report given that
AC C
African American patients were significantly more likely to present with advanced chronic venous insufficiency with CEAP scores of 5 or 6 at a younger age than their Caucasian counterparts. Caucasians were much more likely to be admitted with a CEAP of 4. Interestingly, Caucasian patients were more likely to undergo vein stripping/ligation compared to African American patients indicating that perhaps African American patients may not be undergoing aggressive management of their venous disease early which may in turn result in these patients presenting with more advanced disease. African American patients in our study did undergo
ACCEPTED MANUSCRIPT
more ulcer debridement than Caucasian patients which likely contributed to the increased hospital charges even with a similar LOS to the comparative Caucasian cohort. This variability in care may have been confounded by the fact that physical stigmata associated with chronic
RI PT
venous insufficiency is underdiagnosed and underappreciated.23 Heterogeneous referral patterns and substantial variation in treatment regimens of thrombosis exist in the USA and these regional differences may be partial attributable for the discrepancies in chronic venous insufficiency
SC
care.23 Overall, our results indicate that racial disparities exist for patients with chronic venous
are the cause of this discrepancy. Limitations:
M AN U
insufficiency. It is unclear whether patient, hospital, physician or a combination of these factors
This study was limited by its retrospective design and the utilization of the NIS database which
TE D
does not allow for long term patient follow-up. Furthermore, limitations of ICD-9 codes resulted in an inability to document rates of sclerotherapy, microphlebectomy, and endothermal ablation. Another limitation of this study is that the majority of vein procedures are performed in an out-
EP
patient setting hence the NIS which only reviews inpatients may not be the ideal source to review vein disease management. We attempted to mitigate this limitation by limiting our study
AC C
population to those patients with the most severe venous disease (CEAP ≥ 5). Mixed venous disease could not be identified due to a lack of ICD-9 codes which was another limitation of this study; we used ICD-9 codes that would encompass the majority of primary venous disease and excluded a number of codes because they would have potentially included patients with additional ulcers due to diabetes or arterial disease. Hence, the results of this study are dependent upon the accuracy of the association between the CEAP classification and ICD-9 codes. Further
ACCEPTED MANUSCRIPT
studies will also include other racial groups including Asian-Americans and Hispanic populations.
RI PT
Conclusion: African American patients present with more advanced venous disease at a younger age
compared to their Caucasian counterparts. African American race is associated with increased
SC
ulcer debridement, DVT rates and hospital costs. Despite differences in presentation and
AC C
EP
TE D
M AN U
management, there is no difference in LOS or inpatient mortality between races.
ACCEPTED MANUSCRIPT
References: 1. Beebe-Dimmer JL, Pfeifer JR, Engle JS, Schottenfeld D. The epidemiology of chronic
RI PT
venous insufficiency and varicose veins. Ann Epidemiol. 2005 Mar;15(3):175-84. 2. Eberhardt RT, Raffetto JD. Chronic venous insufficiency. Circulation. 2014 Jul
22;130(4):333-46. doi: 10.1161/CIRCULATIONAHA.113.006898. Review. No abstract
SC
available.
3. Kirksey L. Health care disparity in the care of the vascular patient. Vasc Endovascular
M AN U
Surg. 2011 Jul;45(5):418-21. doi: 10.1177/1538574411407082. Epub 2011 Apr 28. 4. Regenbogen SE, Gawande AA, Lipsitz SR, Greenberg CC, Jha AK. Do differences in
hospital and surgeon quality explain racial disparities in lower-extremity vascular amputations? Ann Surg. 2009 Sep;250(3):424-31. doi: 10.1097/SLA.0b013e3181b41d53.
TE D
5. Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of
revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011 Aug;54(2):420-6, 426.e1. doi: 10.1016/j.jvs.2011.02.035. Epub 2011 May 14
EP
6. Itakura H. Racial disparities in risk factors for thrombosis. Curr Opin Hematol. 2005
Sep;12(5):364-9. Review.
AC C
7. Philipp CS, Faiz AS, Beckman MG, Grant A, Bockenstedt PL, Heit JA, James AH,
Kulkarni R, Manco-Johnson MJ, Moll S, Ortel TL. Differences in thrombotic risk factors in black and white women with adverse pregnancy outcome. Thromb Res. 2014 Jan;133(1):108-11. doi: 10.1016/j.thromres.2013.10.035. Epub 2013 Nov 1.
8. Healthcare Cost and Utilization. http://www.ahrq.gov/research/data/hcup/index.html.
Accessed February 4th, 2015
ACCEPTED MANUSCRIPT
9. Silva Mde C. Chronic venous insufficiency of the lower limbs and its socio-economic
significance. Int Angiol. 1991 Jul-Sep;10(3):152-7. 10. Liao Y, Bang D, Cosgrove S, Dulin R, Harris Z, Taylor A, White S, Yatabe G, Liburd L,
RI PT
Giles W; Division of Adult and Community Health, National Center for Chronic Disease Prevention and Health Promotion; Centers for Disease Control and Prevention (CDC). Surveillance of health status in minority communities - Racial and Ethnic Approaches to
SC
Community Health Across the U.S. (REACH U.S.) Risk Factor Survey, United States, 2009. MMWR Surveill Summ. 2011 May 20;60(6):1-44.
M AN U
11. Wilson CT, Fisher E, Welch HG. Racial disparities in abdominal aortic aneurysm repair
among male Medicare beneficiaries. Arch Surg. 2008 May;143(5):506-10. doi: 10.1001/archsurg.143.5.506.
12. Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of
TE D
treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010 Apr;51(4 Suppl):21S-26S. doi: 10.1016/j.jvs.2009.09.066. Epub 2010 Jan 15. 13. Nowygrod R, Egorova N, Greco G, Anderson P, Gelijns A, Moskowitz A, McKinsey J,
EP
Morrissey N, Kent KC. Trends, complications, and mortality in peripheral vascular surgery. J Vasc Surg. 2006 Feb;43(2):205-16.
AC C
14. Osborne NH, Upchurch GR Jr, Mathur AK, Dimick JB. Explaining racial disparities in
mortality after abdominal aortic aneurysm repair. J Vasc Surg. 2009 Oct;50(4):709-13. doi: 10.1016/j.jvs.2009.05.020. Epub 2009 Aug 22.
15. Osborne NH, Mathur AK, Upchurch GR Jr, Dimick JB. Understanding the racial
disparity in the receipt of endovascular abdominal aortic aneurysm repair. Arch Surg. 2010 Nov;145(11):1105-8. doi: 10.1001/archsurg.2010.213.
ACCEPTED MANUSCRIPT
16. Durazzo TS, Frencher S, Gusberg R. Influence of race on the management of lower
extremity ischemia: revascularization vs amputation. JAMA Surg. 2013 Jul;148(7):61723. doi: 10.1001/jamasurg.2013.1436.
RI PT
17. Hughes K, Seetahal S, Oyetunji T, Rose D, Greene W, Chang D, Cornwell E 3rd,
Obisesan T. Racial/ethnic disparities in amputation and revascularization: a nationwide
10.1177/1538574413510618. Epub 2013 Nov 7.
SC
inpatient sample study. Vasc Endovascular Surg. 2014 Jan;48(1):34-7. doi:
18. Selvarajah S, Black JH 3rd, Haider AH, Abularrage CJ. Racial disparity in early graft
M AN U
failure after infrainguinal bypass. J Surg Res. 2014 Jul;190(1):335-43. doi: 10.1016/j.jss.2014.04.029. Epub 2014 Apr 21.
19. Chew DK, Nguyen LL, Owens CD, Conte MS, Whittemore AD, Gravereaux EC, Menard
MT, Belkin M. Comparative analysis of autogenous infrainguinal bypass grafts in
TE D
African Americans and Caucasians: the association of race with graft function and limb salvage. J Vasc Surg. 2005 Oct;42(4):695-701. 20. Amaranto DJ, Abbas F, Krantz S, Pearce WH, Wang E, Kibbe MR. An evaluation of
EP
gender and racial disparity in the decision to treat surgically arterial disease. J Vasc Surg. 2009 Dec;50(6):1340-7. doi: 10.1016/j.jvs.2009.07.089. Epub 2009 Oct 17.
AC C
21. Cram P, Bayman L, Popescu I, Vaughan-Sarrazin MS. Racial disparities in
revascularization rates among patients with similar insurance coverage. J Natl Med Assoc. 2009 Nov;101(11):1132-9.
22. Criqui MH, Jamosmos M, Fronek A, Denenberg JO, Langer RD, Bergan J, Golomb
BA.Chronic venous disease in an ethnically diverse population: the San Diego Population Study. Am J Epidemiol. 2003 Sep 1;158(5):448-56.
ACCEPTED MANUSCRIPT
23. Dua A, Desai SS, Heller JA. Heterogeneity in venous disease practice patterns amongst
primary healthcare practitioners. Vascular. 2014 Sep 22. pii: 1708538114552011. [Epub
AC C
EP
TE D
M AN U
SC
RI PT
ahead of print]
ACCEPTED MANUSCRIPT
Tables: Table I: CEAP scores associated with ICD-9 codes within the NIS Description Leg varicosity with ulceration Varicosity of the leg with ulcer and inflammation
5, 6 5, 6
AC C
EP
TE D
M AN U
SC
454.0 454.2
CEAP Score
RI PT
ICD-9 Code
ACCEPTED MANUSCRIPT
Table II: Comparative Demographics and Co-morbidities between Caucasians and AfricanAmerican patients presenting for chronic venous insufficiency management
TE D EP AC C
P Value P<0.001 P<0.001 P<0.05 P<0.05 N.S. P<0.05 N.S. P<0.05
RI PT
African-Americans (n=2,554) 61.5 ± 16.7 50.3% 17.1% 16.5% 21.4% 60.7% 8.0% 4.5 ± 2.8
M AN U
Age Female CHF COPD Diabetes Hypertension PAD Number of chronic conditions
Caucasians (n=12,500) 68.2 ± 15.8 54.5% 15.1% 19.6% 20.8% 50.9% 8.8% 4.9 ± 3.0
SC
Variable
ACCEPTED MANUSCRIPT
Table III: Comparative chronic venous insufficiency disease presentation between Caucasians and African-American patients
6,548 (52%)
1,225 (348%)
123 (0.9%) 819 (6.5%)
22 (0.8%) 202 (7.9%)
TE D EP AC C
P Value P<0.001
RI PT
African-Americans (n=2,554) 1,329 (52%)
M AN U
Leg varicosity with ulcer (454.0; CEAP 5, 6) Varicosity of the leg with ulcer and inflammation (454.2; CEAP 5, 6) Thrombophlebitis DVT (acute or chronic)
Caucasians (n=12,500) 5,952 (48%)
P<0.05
NS P<0.001
SC
Variable
ACCEPTED MANUSCRIPT
Table IV: Comparative management choices, LOS, inpatient mortality, and total costs between Caucasians and African-American patients
P<0.001 NS P<0.001 NS NS
193 (1.5%) $6,281
25 (0.9%) $7,116
NS P<0.001
TE D EP AC C
P Value
RI PT
African-Americans (n=2,554) 455 (17.8%) 6 (0.2%) 161 (6.3%) 3 (0.1%) 5
M AN U
Debridement Skin graft Stripping or ligation Sclerotherapy Length of stay (median) Inpatient mortality Total costs (2014 USD)
Caucasians (n=12,500) 817 (6.5%) 33 (0.2%) 1,424 (11.4%) 33 (0.2%) 5
SC
Variable