The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia

Abstract

Objectives: A consequence of delay in the diagnosis of peripheral vascular disease limb loss. This study was undertaken to determine the correlation of low socioeconomic status and race on the severity of ischemic presentation and the subsequent amputation rate. Methods: Data from the Nationwide Inpatient Sample (NIS) from 1998 to 2002 on patients from urban hospitals with the diagnosis of lower extremity ischemia were evaluated. The population was divided into two groups: the amputation group (AMP) and lower extremity revascularization group (LER). Comorbidities, age, gender, race, ischemic gangrene at presentation, insurance status (no/noncommercial or commercial), and income status at admission were determined. These variables were compared using multivariate logistic regression analyses of the data for risk adjustment. Results: Of 691,833 patients presenting with lower extremity ischemia, 363,193 underwent revascularization (66.3%) or amputation (33.7%). Univariate analysis correlated a statistically significant (P < .0001) higher rate of amputation and multivariate analysis associated significantly higher odds of amputation with the following variables: nonwhites (1.91, 95% confidence interval [CI], 1.65, 2.20), low-income bracket (1.41, 95% CI, 1.18, 1.60), and Medicare & Medicaid (1.81, 95% CI, 1.66, 1.97). Adjusting for other variables of statistical significance, multivariate regression analysis showed a statistically significant risk for amputation based on the nonteaching status of the institution (odds ratio [OR], 1.17, 95% CI, 1.08, 1.30). Conclusions: Primary amputation was performed with a higher frequency on patients with lower extremity ischemia who were nonwhite, low income, and without commercial insurance. The observed advanced ischemia among these economically disadvantaged patients suggests a delayed diagnosis of peripheral vascular disease, probably due to lack of access to adequate primary care or vascular surgery providers, or both. Better education of the general population and primary care providers to the symptoms and consequences of PVD may reduce the amputation rate in this group.

Race and Socioeconomic Status Independently Affect Risk of Major Amputation in Peripheral Artery Disease

“…A recent analysis of lower extremity bypasses in the National Surgical Quality Improvement Project database found that black patients had a higher incidence of femoral–tibial or popliteal–tibial bypasses compared with white PAD patients 28. Involvement of distal tibial vessels in PAD may preclude successful attempts at revascularization and increase the need for primary amputation 7, 22, 23. Despite revascularization, black race has been shown to affect patency of open and endovascular procedures 4, 8, 9, 28.…”

Do Women Have Worse Amputation-Free Survival Than Men Following Endovascular Procedures for Peripheral Arterial Disease? An Evaluation of the California State-Wide Database

“…Among 691 833 patients with PAD identified in the National Inpatient Sample (NIS) during 1998 to 2002, women were more likely than men to undergo an amputation. 7 Furthermore, in an analysis of 2.4 million lower extremity inpatient PADrelated hospitalizations in New York, New Jersey, and Florida from 1998 through 2007, women were less likely than men to undergo a lower extremity revascularization procedure. 2 The most pronounced difference in mortality rate was following open surgical procedures, with a mortality rate of 6.02% in women and 4.51% in men.…”

Ethics in Rehabilitation: Access to Prosthetics and Quality Care Following Amputation

“…Similarly, Hispanic Americans are 1.5 times as likely to suffer an amputation as white Americans [29]. Non-whites, those with low income, and those without commercial insurance are more likely than members of other groups to undergo a lower limb amputation for PVD rather than revascularization (a limb-saving procedure associated with better outcomes), even controlling for the severity of disease [30]. In the rehabilitation period, those with an income at or near the poverty line are 2.5 to 3 times as likely as their peers who are not in poverty to perceive barriers in their access to work or community life, and some studies have found that a smaller percentage of women with limb loss remained employed following their amputation(s) than their male counterparts [31,32].…”