Geographic and Socioeconomic Disparities in Major Lower Extremity Amputation Rates in Metropolitan Areas

Abstract

Background Rates of major lower extremity amputation in patients with peripheral artery disease are higher in rural communities with markers of low socioeconomic status, but most Americans live in metropolitan areas. Whether amputation rates vary within US metropolitan areas is unclear, as are characteristics of high amputation rate urban communities. Methods and Results We estimated rates of major lower extremity amputation per 100 000 Medicare beneficiaries between 2010 and 2018 at the ZIP code level among ZIP codes with ≥100 beneficiaries. We described demographic characteristics of high and low amputation ZIP codes, and the association between major amputation rate and 3 ZIP code–level markers of socioeconomic status—the proportion of patients with dual eligibility for Medicaid, median household income, and Distressed Communities Index score—for metropolitan, micropolitan, and rural ZIP code cohorts. Between 2010 and 2018, 188 995 Medicare fee‐for‐service patients living in 31 391 ZIP codes with ≥100 beneficiaries had a major lower extremity amputation. The median (interquartile range) ZIP code–level number of amputations per 100 000 beneficiaries was 262 (75–469). Though nonmetropolitan ZIP codes had higher rates of major amputation than metropolitan areas, 78.2% of patients undergoing major amputation lived in metropolitan areas. Compared with ZIP codes with lower amputation rates, top quartile amputation rate ZIP codes had a greater proportion of Black residents (4.4% versus 17.5%, P <0.001). In metropolitan areas, after adjusting for clinical comorbidities and demographics, every $10 000 lower median household income was associated with a 4.4% (95% CI, 3.9–4.8) higher amputation rate, and a 10‐point higher Distressed Communities Index score was associated with a 3.8% (95% CI, 3.4%–4.2%) higher amputation rate; there was no association between the proportion of patients eligible for Medicaid and amputation rate. These findings were comparable to the associations identified across all ZIP codes. Conclusions In metropolitan areas, where most individuals undergoing lower extremity amputation live, markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation. Development of community‐based tools for peripheral artery disease diagnosis and management targeted to communities with high amputation rates in urban areas may help reduce inequities in peripheral artery disease outcomes.

The association between socioeconomic distress communities index and amputation among patients with peripheral artery disease

“…As a result, it is more difficult for these individuals to practice healthy behaviors, such as adequate physical activity and proper nutrition, that can help prevent PAD. Living in these distressed neighborhoods also decreases their access to primary care, specialty care, and pharmacy services, which are necessary to manage chronic conditions that are comorbidities of PAD ( 16 ). Structural racism is particularly relevant in our study, which is based on data from South Carolina.…”

“…However, amputation is generally considered a failure of treatment and should only be attempted after considering all other treatment options. The majority of amputations are preventable, especially among individuals with PAD who have claudication, with timely diagnosis and optimal medical treatment ( 15 , 16 ).…”

Preliminary Stiffness-Driven Redesign of a Laminated Prosthetic Component Using Additive Manufacturing

“…As a result, composite prosthetic feet are expensive devices. Considering that higher lower limb amputations are more frequent in lower-income areas, lowering the costs of these devices is of extreme importance [ 6 , 7 ].…”

Real-World Racial Variation in Treatment and Outcomes Among Patients with Peripheral Artery Disease

“…For example, a study by Chen and colleagues reported that, compared with non-Hispanic White Americans, Black patients with PAD had nearly 50% higher odds of PAD with chronic limb ischemia (CLI), and over 70% higher odds of major limb amputation [ 16 ]. Fanaroff et al similarly reported that markers of lower socioeconomic status and Black race were associated with higher rates of major lower extremity amputation [ 17 ]. Black patients with PAD may also be at an even greater risk of adverse CV events due to atherosclerotic occlusion [ 18 ].…”