NATIONAL HARBOR, MD. – Lower-extremity revascularization can be effective in preventing amputation in peripheral arterial disease, but in some regions of the United States, the amount and intensity of vascular care is inversely related to the amputation rate, a large study of Medicare patients indicates.
To examine the relationship between intensity of vascular care and the risk of amputation, Dr. Philip P. Goodney and his colleagues at Dartmouth-Hitchcock Medical Center and the Dartmouth Institute for Health Policy in Lebanon, N.H., studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. They examined associations among patient characteristics, the regional rates of revascularization, and the regional amputation rate among the 307 hospital referral regions, as described in the Dartmouth Atlas of Health Care.
Dr. Philip P. Goodney
Population-based amputation rates varied across regions, from fewer than 1 to more than 44 amputations per 10,000 Medicare patients. Amputation rates were highest in rural regions of the southern and Appalachian United States, Dr. Goodney said at the Vascular Annual Meeting.
Patients in regions with high amputation rates were more commonly African American than were patients in regions with low amputation rates (50% vs. 12%). Furthermore, those in regions with high amputation rates had lower per-capita income, compared with those in regions with low amputation rates ($17,980 vs. $19,545).
Less vascular care was provided to patients who lived where amputation rates were highest. Those patients had 57% fewer therapeutic revascularization procedures (such as bypass surgery or stent placement) than did patients in regions with low amputation rates (2.2 vs. 4.8 revascularizations per amputation). Even the number of diagnostic angiograms was significantly lower in high amputation regions than in low amputation regions (2.4 vs. 5.0 angiograms per amputation).
"Medicare patients living in regions with the highest amputation rate are commonly poor and African American, and they receive less than half as much vascular care as those in regions with lower burdens of vascular disease," said Dr. Goodney. "In these regions, we believe patients commonly present late in their disease process, with ‘unsalvageable’ limbs. Because of wet gangrene or massive tissue loss, it is often too late for vascular care to matter, and surgeons are forced to simply perform an amputation rather than have the opportunity to revascularize and try to save a patient’s leg. However, we hope that our study will help to limit amputations in the future," Dr. Goodney said.
"Our work provides a ‘blueprint’ for improvement, by targeting the regions of the [United States] where early, integrated efforts to prevent amputation – medical, podiatric, and vascular – have the biggest potential to make a difference," he added.
Dr. Goodney reported no relevant disclosures.