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A National Review Of What Factors Influence The Extent Of Major Lower Extremity Amputations
Mohamed A. Zayed, MD PhD, Fritz Bech, MD, Tina Hernandez-Boussard, PhD MPH.
Stanford University Medical Center, Stanford, CA, USA.
OBJECTIVES: Despite advancements in diagnosis and treatment of peripheral vascular disease, major lower extremity amputations are still performed at high rates with non-negligible economic burdens. Recent Medicare data suggests that in addition to patient co-morbidities, geographic region, and intensity of vascular care may influence rates of lower extremity amputations. We thought to further evaluate this using the Nationwide Inpatient Sample (NIS).
METHODS: From 2005 to 2008, all adult above (AKA) and below (BKA) knee amputation procedures were identified in the NIS. Patients with trauma and oncologic diagnoses were excluded from the analysis. Rates of AKA and BKA were evaluated according to patient demographics, co-morbidities, extent of pre-amputation vascular intervention, hospital setting/type, and geographic region. Multivariate logistic regression and 2-way ANOVA analyses was used to determine statistical significance.
RESULTS: A total of 228,623 patients met inclusion criteria (126,076 BKA, 102,548 AKA). Patients who received an AKA were more likely to be female (P < 0.001), older (P < 0.001), have non-private insurance (P < 0.001), and have a higher Charlson Index of co-morbidities (P = 0.05). Patients who received a BKA were more likely to have hypertension, diabetes, and a spinal cord injury (P < 0.001). Less revascularization interventions were attempted in patients who subsequently received AKA (P < 0.001), however more BKAs were performed in urban and teaching hospitals (P < 0.001). The majority of all amputations (46.4%) were preformed in southern states.
CONCLUSIONS: There are clear disparities that continue to influence higher than expected rates of major lower extremity amputations. Patient demographics and co-morbidites are important, but other factors such as insurance type, hospital setting, geographic region, and intensity of pre-amputation vascular care also appear to play a critical role. Surveillance and intensive treatment of at risk populations will be necessary in attempts to decrease rates of major lower extremity amputations.
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