Chapters Transcript Addressing Health Disparities in PAD Back to Symposium Thank you. Um I'm a bit under the weather. So bear with me. But I'll be talking about health disparities and p. 80. Um So um we're going to sort of shift from the surgical and procedural too. Some sort of medical management and how we can identify risk factors prior to progression and development of P. A. D. And how race and other disparities such as region and socioeconomic differences lead to this. So we kind of, everyone here knows about P. A. D. And we're going to focus on the obstructive disease in the lower extremities. So racial disparities in PDD prevalence is critical. So overall the prevalence of P. A. D. And individuals Greater than the age of 40 is up to 10% and increasing. Um African americans have the highest rates of P. A. D. In the United States. And um if you look at the top figure on the right there you can that's for males. And you can see that african american men and the solid line, It's about 2-3 times greater than all other ethnic groups For any given age above the age of 40. Um And that's pretty striking for women which is the figure below that. You can see that the rates for hispanic women which is the dash line um as well as african american women are much higher than other um ethnic groups. So the risk factors for P. A. D. Are similar to those of coronary artery disease. So tobacco use, diabetes, chronic kidney disease. All of these have shown to have a significantly increase Risk for Developing p. 80. So we'll focus on these sort of critical risk factors for P. A. D. And um how race can play a role. So cigarette smoking we know that the prevalence is similar among racial groups but african americans are less likely to quit. Um And this certainly could be um leading to the increased disparity that we see for the development of P. A. D. Because smoking is one of the highest risk factors for the development for diabetes species, higher prevalence in african americans, Hispanics and asians disproportionately hypertension is certainly much more likely to be present in african americans but also more likely to be undertreated compared to other ethnic groups that present with this. Um Similarly for african americans with hyper lipid E me a there less likely to be treated to a guideline recommended goal, chronic kidney disease is higher in african americans and they're much more likely to have end stage renal disease and be on dialysis. And then lastly, um for socioeconomic status and lower education levels. Um it's a complex factors that that that tie into that. But african americans are more likely to be disadvantaged in that regard. So looking at cigarette smoking while the prevalence of cigarette smoking has decreased among all ethnicities over the years. Um Those are the percentage of those who quit smoking is significantly higher among whites than blacks and that's what this figure is showing here. Um This is looking out of all smokers the percent that have quit and you can see that there's been a steady rise over the years but that non hispanic whites and the dash line are significant greater percent have quit compared to non hispanic blacks. And that this disparity has been stable over decades. Um diabetes is also strongly associated with P. A. D. And unlike cigarette smoking, the prevalence of diabetes is increasing both worldwide and in the United States. So people with PhD and diabetes are at much higher risk for amputation and critical limb ischemia compared to those without diabetes. So the top three countries per prevalence of diabetes is china U. S. And India. And within the U. S. You can see by ethnicity percent. African american 14 hispanic 20% asian 1%. And then the figure on the right is the percent of um the total U. S. Population with diabetes. And you can see that for both non hispanic blacks, Hispanics and non hispanic asians, they're disproportionately represent the diabetic population compared to their total Hypertension. African Americans experienced the highest reported rates of hypertension worldwide at 44%. And as I mentioned they're much less likely to be treated appropriately. Um And they also have a higher prevalence of um non hispanic whites have a higher prevalence of hypercholesterolemia. But african americans are just as likely to have inherited familial hypercholesterolemia and again they're much less likely to be treated. So socioeconomic disparities in income and education level. So the figure on the left is showing P. A. D. Prevalence as grouped by poverty income ratio in one study. And so you can see that people that are at or below the poverty line um are significantly more likely to have P. A. D. Um Whereas the higher you You go from being out of poverty, they're less likely. The lower the prevalence of P 80. Similarly for education, those with less than high school education or found to have higher prevalence of PhD compared to those with high school or some college or college graduates. Uh There's also disparities and the treatment of CLL, which much has been mentioned about critical limb ischemia. The first figure is just showing that there's more um amputations of men than than women. The second is showing that in populations where ZIP codes where African Americans make up greater than 50% of that neighborhood, the rates for amputation is substantial. That's the highest line that you see here. Whereas ZIP codes where African Americans that make up about 11-50% is the middle line. And then the zip codes where African Americans are less than 10% of the lowest rates of amputation. So it's a direct correlation there. Ah This is a Study, people. And they basically, we're able to look at independent variables on surgical decisions for amputation versus revascularization. So these odds ratios, our for those patients that went underwent amputations of gangrene, understandably is a major influence of variable as is redo of a previous revascularization. But after that being black is the highest variable um After that shown to lead to amputation as well as being on Medicaid and being in the poorest zip codes. And this figure on the right here. It's very interesting because it's showing um looking at the different hospitals that one could present to. So for hospitals that are amputation only as we would expect the rates for revascularization um would would be low. But for hospitals that are 1st, 2nd 3rd in accordance very centers, they have higher rates of revascularization as there have higher capacity to do so. So when you look at this, the it's equal numbers of whites and black presenting to these different hospitals. So there's no differences and where these patients end up. So that doesn't account for the differences that we see in the amputation. However, what you do see is that once they're at these hospitals, um blacks are significantly more likely to receive amputation even when the option is available for revascularization. So you can see that again by hospital quartile with the 4th quartile being a co ordinary center that can handle revascularization and the dark blue represents black americans which have significantly more amputation, right? Uh And then on the second figure here it's showing the amputation, odds ratios versus the wealth of the zip code. So they divided this up by um overall wealth of that area. So even african americans living in a very wealthy zip code, we're more likely to have amputations. And this is consistent with other research that has shown that even in wealthier um populations of african americans are still much more likely to have amputation versus revascularization. And in fact, if you look at this figure, the disparity is greater in the areas of the most wealthiest neighborhoods. Um So geographic disparities and we know that much of the geographic disparities and cli treatment is driven by racial disparities in regions with larger populations of african americans. The amputation Rates are as much as 3-4 times higher than the national average. And nationally the amputation rate among african american Medicare patients is nearly three times higher than the rate among other beneficiaries Nationwide, between two and three for 1000 patients with diabetes and PhD are at risk for amputations. And this is up to eight times higher in black communities. And when comparing black and non black patients, even low risk black patients are at greater risk for amputation than nearly all non black groups. So you can see here, the amputations, you have the highest rates and sort of the breast belt South bible belt south area. Um And so I wanted to kind of just wrap this up that, you know, health disparities is a huge problem, especially when it comes to p A. D. It's um one of the worst for all the cardiovascular diseases. Um And so in order to address that, we really need to develop programs for health equity to give everyone a fair shot. Um And it's not it's not easy, it's complicated because factors such as poverty discrimination and lack of opportunities sort of over many many years have led to where we're at. So it really will need to be a several pronged approach um to develop economic opportunities and empowerment um walkable neighborhoods. Um As we know that exercise plays a critical role in P. A. D. Um reaching people where they're at. Um I have a community based project that I've done in the barber shops here in Cleveland. And although I don't have time to get into that study today, it's certainly been effective at educating people about P. A. D. And reaching them where they're at, but certainly, and lastly, health policy. Um and recruiting a more diverse physician workforce because the data shows that clearly there's unconscious and conscious bias that plays a role. Um So all of these things are needed to sort of help reduce disparities related to ph d thank you for your time Created by Related Presenters Khendi White Solaru, MD Vascular Medicine, UH Harrington Heart & Vascular Institute Assistant Professor, Case Western Reserve University School of Medicine Expertise Depression Internal Medicine Preventive Medicine View full profile
