Racial Disparities Exist in Amputation Outcomes Associated with Critical Limb Ischemia
Melissa D'Andrea, BS1, Tia Sutton, BS1, Valerie Takyi, MD2, Carlos Bechara, MD2, Paul Crisostomo, MD2, Pegge Halandras, MD2, Michael Soult, MD2, Bernadette Aulivola, MD2.
1Loyola University Stritch School of Medicine, Maywood, IL, USA, 2Loyola University Medical Center, Maywood, IL, USA.
OBJECTIVE- We sought to investigate whether racial background or socioeconomic factors had any association with need for major amputation including recommendations for primary amputation rather than efforts at revascularization amongst patients with critical limb ischemia (CLI).
METHODS- A single-center electronic medical record database was queried for all patients with CLI presenting from 2007- 2017. Primary amputation was defined as major lower extremity amputation without prior attempts at revascularization within one year. Indications for primary amputation included extensive tissue loss, need for control of sepsis, non-ambulatory status and absence of revascularization target. Univariable generalized linear mixed effects models were used to solve for odds of amputation, recommendations for primary amputation, and efforts at revascularization prior to amputation. A generalized linear mixed effects model was used to estimate the odds of amputation as a function of multivariable age, sex, race, ethnicity, insurance type and geographic income in addition to comorbidities such as diabetes mellitus (DM) and chronic kidney disease (CKD).
RESULTS- A total of 2,544 limbs with CLI were identified. Within this group, 343 limbs (13.5%) underwent major lower extremity amputation. Primary amputation was performed in 4.3% of Blacks and 7.2% of Whites. Overall amputation rate in Blacks was 19.84% and in Whites was 10.4%. Controlling for all other variables, blacks were 2 (95% confidence) times more likely than whites to undergo major amputation (p<.001). CKD patients were 1.64 times more likely to undergo amputation (p = .001). Males and Hispanics were nominally more likely to undergo major amputation than females and non-Hispanics, respectively. Amongst amputees, univariable analysis showed that odds of undergoing primary amputation vs. revascularization attempts prior to amputation was not associated with any of the variables analyzed.
CONCLUSIONS- Racial disparities exist in CLI outcomes. Major lower extremity amputation is more common among the black, male, CKD, and Hispanic patients with CLI. Socioeconomic status did not have an impact on amputation rates. More efforts should be invested in identifying the appropriate methods of addressing this disparity in the early treatment of peripheral arterial disease.
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