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OBJECTIVE: A commonly cited reason contributing to lower extremity amputation secondary to peripheral arterial disease (PAD) is access to healthcare. This correlation has been demonstrated in urban populations, however, we postulate that large-scale socioeconomic factors may mitigate this effect in the rural southeastern United States.
METHODS: A retrospective case-control study was conducted among the PAD patient population referred between January 1, 2005 and March 31, 2011. All patients from this population who underwent either primary above or below-knee amputation during this time period were enrolled as cases. Concurrent controls (non-amputation cases) were identified from a cohort of critical limb ischemia patients. Data on patient demographics, socioeconomics, comorbidities, and outcomes were collected via interview and data abstraction from the medical record. Data were analyzed using univariate and multivariate techniques.
RESULTS: A total of 333 patients were identified; 221 cases and 112 controls. Cases were more likely to be diabetic (53% vs. 30%, P<0.05) and have end-stage renal disease (7.5% vs. 0.3%, P<0.05). Amputation status was correlated with patient socioeconomics (race, income below federal poverty level, and employment status). Access to healthcare (insurance status, reliable transportation, established primary care physician, distance to vascular referral center) was not significant between the two groups (Table, * P<0.05). Logistic regression analysis showed that non-white race was a strong correlate of amputation status (OR=3.67, 95% CI=2.19-6.17, P<0.01).
CONCLUSIONS: This study reveals that access to healthcare does not predict the likelihood of lower extremity amputation in a rural southeastern population. These data refute the premise that expanded access to care will decrease the incidence of lower extremity amputation. Underlying racial and socioeconomic forces strongly influence the domain of limb salvage.

	Cases (n=221)	Control (n=112)
Diabetes	53.0%	30.0%*
Renal Failure	7.5%	0.3%*
Non-White	63.3%	33.0%*
High School Graduation	33.0%	42.0%
Income Below Poverty Line	46.1%	17.3%*
Employed	30.0%	21.0%
Self-pay	2.1%	1.4%
Reliable Transportation	85.1%	85.0%
Primary Care Physician	85.1%	94.0%
Distance to Referral Center (mi)	41.5±3.1	46.1±2.5