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Cited by 162Peripheral Artery Disease ManagementDiabetic Foot Ulcer Assessment and ManagementHealthcare Policy and Management

Regional intensity of vascular care and lower extremity amputation rates

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Goodney, Philip P., Holman, Kerianne, Henke, Peter K., Travis, Lori L., Dimick, Justin B., Stukel, Therese A., Fisher, Elliott S., Birkmeyer, John D.·2013·Journal of Vascular Surgery
DOI 10.1016/j.jvs.2012.11.068PMC PMC3660510
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Abstract

Objective To examine the relationship between the intensity of vascular care and population-based rate of major lower extremity amputation (above-or below-knee) from vascular disease. Background Because patient-level differences do not fully explain the variation in amputation rate across the United States, we hypothesized that variation in intensity of vascular care may also affect regional rates of amputation. Methods Intensity of vascular care was defined as the proportion of Medicare patients who underwent any vascular procedure in the year prior to amputation, calculated at the regional level (2003–2006), using the 306 hospital referral regions in the Dartmouth Atlas of Healthcare. We examined relationship between intensity of vascular care and major amputation rate, at the regional level, between 2007–2009. Results Amputation rates varied widely by region, from 1 to 27 per 10,000 Medicare patients. Compared to regions in the lowest quintile of amputation rate, patients in the highest quintile were commonly African American (50% versus 13%) and diabetic (38% versus 31%). Intensity of vascular care also varied across regions: fewer than 35% of patients underwent revascularization in the lowest quintile of intensity, while nearly 60% of patients underwent revascularization in the highest quintile. Overall, there was an inverse correlation between intensity of vascular care and amputation rate ranging from R= −0.36 for outpatient diagnostic and therapeutic procedures, to R= −0.87 for inpatient surgical revascularizations. In analyses adjusting for patient characteristics and socioeconomic status, patients in high vascular care regions were significantly less likely to undergo amputation without an antecedent attempt at revascularization (OR 0.37, 95% CI 0.34–0.37, p<0.001). Conclusions The intensity of vascular care provided to patients at risk for amputation varies, and regions with the most intensive vascular care have the lowest amputation rate, although the observational nature of associations do not impart causality. High-risk patients, especially African-American diabetic patients residing in low-intensity vascular care regions, represent an important target for systematic efforts to reduce amputation risk.

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  • Patients living in the Southern United States undergo higher rates of amputation and inversely lower rates of open or endovascular revascularization for every amputation compared with other states with lower amputation rates.

    “Namely, patients living in Southern United States (the bible belt) undergo higher rates of amputation and inversely lower rates of open or endovascular revascularization for every amputation in comparison to other states with lower amputation rates.”

    From Racial and Ethnic Disparities in Peripheral Artery Disease (2021) · cites this paper as [117]

    The Results identify 12 high-amputation, low-vascular-care regions that were generally in the South. They also report fewer open or endovascular revascularizations per amputation in high-amputation regions than in moderate-amputation regions. The claim overgeneralizes these regional findings among Medicare patients to patients throughout the Southern United States and comparisons between states. (LLM, conf=0.85)

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  • Amputation rates were disproportionately higher among Black Americans in regions with higher amputation rates, but no significant racial differences were found in regions where amputations were lower.

    “Furthermore, Goodney et al 117 found that amputation rates were disproportionately higher among Black Americans in regions with higher amputation rates but found no significant racial differences in regions where amputations were lower.”

    From Racial and Ethnic Disparities in Peripheral Artery Disease (2021) · cites this paper as [117]

    The Results (Patient characteristics, by population-based amputation rate; page not provided) show that African-American patients made up a larger share of amputees in the highest-rate regions than in the lowest-rate regions (50% versus 13%). The Results (Regions with high amputation rates and low intensity of vascular care; page not provided) report no significant racial difference in amputation *without prior revascularization* in regions with high vascular-care intensity—not no racial difference in overall amputation rates in low-amputation regions. The claim conflates those measures and regional categories. (LLM, conf=0.88)

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  • Disparities in revascularization and amputation rates differ by region.

    “Disparities in revascularization and amputation rates differ by region.117”

    From Racial and Ethnic Disparities in Peripheral Artery Disease (2021) · cites this paper as [117]

  • Patients in the highest quintile for amputation rates were also more likely to be diabetic.

    “Notably, patients in the highest quintile for amputation rates were also more likely to be diabetic.”

    From Racial and Ethnic Disparities in Peripheral Artery Disease (2021) · cites this paper as [117]

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1 of the 32 references couldn’t be matched to a known paper.

Research works printed but not linked: 3

  1. [14]Quanstrum KH Henke P Dimick JB Birkmeyer JD Racial disparities in end-of-limb care among medicare amputees Journal of Vascular Surgery (in press) PMC3152619 21571495
  2. [17]Goodney PP Likosky DL Cronenwett JL Predicting amputation or graft occlusion after lower extremity bypass Annals of Vascular Surgery 2009 (Epub ahead of print) 19748222
  3. [31]Goldberg J Cronenwett J Goodney PP Effect of race and diabetes on amputation prevalence J Vasc Surg 2012 (in press) PMC3574810 22963815

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Authors
Goodney, P. P., Holman, K., Henke, P. K., Travis, L. L., Dimick, J. B., Stukel, T. A., Fisher, E. S., & Birkmeyer, J. D.
Affiliations
  • Dartmouth Institute for Health Policy and Clinical Practice (US)
  • University of Michigan (US)
  • Maine Medical Center (US)
Corresponding author
Goodney, Philip P.
ORCID
Venue
Journal of Vascular Surgery
Publisher
Elsevier BV
Published
2013-06
Volume
57
Issue
6
Pages
1471-1480.e3
ISSN
0741-5214 (ISSN-L)
DOI
10.1016/j.jvs.2012.11.068
PMC
PMC3660510
OpenAlex
W1973843107
Semantic Scholar
434abe9e01c9e8dc6bad6623ecd820d1b922e10a
Cited by
162
References
32
Citations by year
2026: 4 · 2025: 15 · 2024: 15 · 2023: 20 · 2022: 11 · 2021: 15 · 2020: 12 · 2019: 14 · 2018: 10 · 2017: 8 · 2016: 13 · 2015: 12 · 2014: 10 · 2013: 2
FWCI
12.06
Type
journal article
Language
en
Open access
Licence
Locations
  • Journal of Vascular Surgery (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • National Heart, Lung, and Blood Institute (1K08HL05676, K08HL105676)
  • National Institute on Minority Health and Health Disparities (L32 MD006323)
Topics
  • Health Sciences › Medicine › Surgery › Peripheral Artery Disease Management
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
  • Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
Keywords
lower limb amputation, regional variation in care, revascularization, Medicare beneficiaries, hospital referral regions, African American patients, diabetic patients, amputation risk
MeSH terms
Aged, Amputation, Surgical, Female, Medicare, Humans, Leg, Male, United States, Vascular Diseases, Vascular Surgical Procedures

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