Invited commentary

Abstract

The Vascular Quality Initiative (VQI) is a collaborative of regional quality groups collecting and analyzing data in an effort to improve patient care.—VQI website I believe this study to be of critical importance to a mission (like that of the VQI) dedicated to improving health care in this country; it should be read by every vascular surgeon, in fact by every physician. The authors found that black patients in this country have more severe vascular disease at the time of treatment in virtually every geographic region studied. Although they softened these primary observations with clinical data like operating times, extubations, and epidurals, until we confront the real problem, which is persistent racism in this country, whether it be in education, voting rights, police protection, or access to vascular health care, we will never succeed in “improving” the glaring disparities observed in this study. And, in the current health care deliberations, this appears only likely to get worse. Since I am old enough to have been steered away from “colored-only” bathrooms in my youth, I feel obliged to expand this point. Peripheral arterial disease (PAD) is four to five times more common in men, but almost half the PAD treatments in black patients in the VQI were in women! Bravely, the authors did not fall back on “biological differences between black and white patients” and at least “suspected” that “the majority of the disparities highlighted in this manuscript are not from biologic differences but instead from social, economic, and health care delivery factors.” What this most clearly suggests is that there are untold numbers of black men throughout the country with undiagnosed and untreated carotid disease, abdominal aortic aneurysm, and PAD (and hypertension, and diabetes, and chronic kidney disease) because they do not have equitable access to health care in the United States in the 21st century. The type of insurance was unknown for 30% of black patients in the VQI. For a database that tracks extubations and epidurals, this seems a striking deficit, but one can be certain that most of those undocumented black patients did not have Aetna. Perhaps the VQI could more thoroughly document the insurance status of patients in the future, particularly because with the American Health Care Act, many may soon lose the coverage they have. Finally, why deidentify geographic regions? A casual look at Fig 2 suggests that almost half the geographic regions had 30% to 50% more black patients with severe symptoms than white. Why not identify those regions specifically so those regional quality VQI groups could actually begin to work medically and politically to address these obvious disparities in access? When you identify the geographic groups with the widest disparities, you could also compare them to the states that failed to expand their Medicaid programs as part of the Affordable Care Act, leaving millions of low-income, black Americans without health care coverage. The Affordable Care Act is no rose, and Trumpcare will provide tax cuts for most vascular surgeons, but the American Health Care Act will not make America great for black patients who (as this study clearly demonstrates) desperately need earlier diagnosis and treatment of their vascular diseases. This study and its potential expansions give the VQI and the vascular surgery community a unique opportunity to significantly contribute to the health care debate. I hope we have both the scientific rigor and the political courage to pursue it aggressively. The opinions or views expressed in this commentary are those of the authors and do not necessarily reflect the opinions or recommendations of the Journal of Vascular Surgery or the Society for Vascular Surgery. Black patients present with more severe vascular disease and a greater burden of risk factors than white patients at time of major vascular interventionJournal of Vascular SurgeryVol. 67Issue 2PreviewAlthough many studies have demonstrated racial disparities after major vascular surgery, few have identified the reasons for these disparities, and those that did often lacked clinical granularity. Therefore, our aim was to evaluate differences in initial vascular intervention between black and white patients. Full-Text PDF Open Archive