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Impact Of Community-level Socioeconomic Disadvantage On Outcomes Following Lower Extremity Amputation
Mikayla Kricfalusi, BA
1, Elisa Caron, MD
1, Sai Divya Yadavalli, MD
1, Daniel Colome, BS
1, Emily St. John, BS
1, Mahmoud B. Malas, MD, MHS, RPVI, FACS
2, Peter Soden, MD
3, Marc L. Schermerhorn, MD
1, Christina L. Marcaccio, MD, MPH
1.
1Beth Israel Deaconess Medical Center, Boston, MA, USA,
2UC San Diego, San Diego, CA, USA,
3Brown University, Providence, RI, USA.
ObjectivesSocioeconomic disadvantage is linked to higher rates of peripheral arterial disease (PAD) and primary amputation compared with lower extremity revascularization. This study investigates the effect of community-level socioeconomic disadvantage on outcomes after lower extremity amputations (LEA) for critical limb-threatening ischemia (CLTI).
MethodsThe Vascular Quality Initiative (VQI) was used to analyze LEA for CLTI from 2003-2024. Area deprivation index (ADI) measured community-level socioeconomic disadvantage. Median ADI score was calculated for each patient and categorized into quintiles (Q1-Q5), with Q5 representing the highest socioeconomic disadvantage. Trends in patient characteristics across ADI quintiles were evaluated using the Cuzick test. Perioperative outcomes and 5-year mortality were assessed using multivariable logistic regression and Cox regression, respectively, and stratified by major (above ankle) versus minor amputation.
ResultsOverall, 22,242 patients underwent LEA for CLTI: 18% in Q1, 17% in Q2, 15% in Q3, 34% in Q4, and 16% in Q5. Most had major amputations (75%). From Q1 to Q5, there were lower rates of prior amputation/revascularization procedures (Q1: 69%, Q5: 65%, P-trend<0.004), but higher rates of major amputation (Q1: 73%, Q5: 79%, P-trend<0.001) and above-knee amputation (Q1: 24%, Q5: 38%, P-trend<0.001). Higher quintiles were more likely to present with ischemic tissue loss (Q1: 44%, Q5: 54%, P-trend<0.001), but less likely to have acute infection (Q1: 54%, Q5: 42%, P-trend<0.001). Perioperative mortality rates were similar across quintiles (Q1: 7%, Q5: 7%, P-trend=0.7), but 5-year mortality rose (Q1: 23%, Q5: 29%, P=0.02). After adjustment, there remained no difference in perioperative mortality between quintiles, however 5-year mortality was higher in Q2-Q5 (Table). Stratified analyses showed similar associations between ADI and mortality for major amputations, but not for minor amputations (Table). Prior procedures were independently associated with both lower perioperative (OR 0.76, 0.67-0.86) and 5-year mortality (OR 0.91, 0.86-0.96).
ConclusionsAmong CLTI patients undergoing LEA, those with higher community-level socioeconomic disadvantage have lower preoperative healthcare system engagement, present with more severe disease necessitating higher amputation level, and have similar perioperative mortality but higher 5-year mortality. This highlights substantial outcome disparities and suggests that the effect of socioeconomic disadvantage on procedural risk may be mitigated by improving timely access to vascular care.
Multivariable outcomes following lower extremity amputation, stratified by ADI (Reference Q1) | Q2 | Q3 | Q4 | Q5 |
| Perioperative Morality | aOR [95% CI], P-Value | aOR [95% CI], P-Value | aOR [95% CI], P-Value | aOR [95% CI], P-Value |
| All Amputations | 1.0 [0.81, 1.18], 0.8 | 0.9 [0.74, 1.10], 0.3 | 1.0 [0.85, 1.19], >0.9 | 1.1 [ 0.89, 1.34], 0.4 |
| Major Amputation | 1.0 [0.83, 1.28], 0.8 | 0.9 [0.71, 1.12], 0.3 | 1.0 [0.85, 1.24], 0.8 | 1.2 [0.92, 1.45], 0.2 |
| Minor Amputation | 0.7 [0.48, 1.10], 0.1 | 0.7 [0.47, 1.12], 0.2 | 0.8 [ 0.56, 1.14], 0.2 | 0.8 [0.52, 1.29], 0.2 |
| 5-Year Mortality | aHR [95% CI], P-Value | aHR [95% CI], P-Value | aHR [95% CI], P-Value | aHR [95% CI], P-Value |
| All Amputations | 1.15 [1.05, 1.26], 0.002 | 1.1 [1.00, 1.21], 0.04 | 1.15 [1.06, 1.25], <0.001 | 1.24 [1.13, 1.37], <0.001 |
| Major Amputation | 1.22 [1.09, 1.35], <0.001 | 1.1 [0.99, 1.23], 0.09 | 1.18 [1.08, 1.30], <0.001 | 1.27 [1.14, 1.42], <0.001 |
| Minor Amputation | 1.0 [0.83, 1.20], >0.9 | 1.1 [0.94, 1.38], 0.2 | 1.1 [0.91, 1.27], 0.4 | 1.2 [0.98, 1.46], 0.08 |
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