Philip P. Goodney1, Lori L. Travis3, Benjamin S. Brooke1, Kerianne Holman4, Peter K. Henke4, David A. Goodman2, Jack L. Cronenwett1, John D. Birkmeyer4, Elliott S. Fisher2
1Section of Vascular Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH; 2The Dartmouth Institute for Health Policy and Clinical Practice, Hanover, NH; 3Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, ME; 4University of Michigan, Ann Arbor, MI.
OBJECTIVES: While lower extremity revascularization is effective in preventing amputation, the relationship between intensity of vascular care and amputation rate remains unclear.
METHODS: We studied all open and endovascular revascularizations provided to 20,464 Medicare patients in the year prior to vascular amputation. We examined associations between patient characteristics, regional rates of revascularization, and amputation rate among the 307 hospital referral regions (HRRs) described in the Dartmouth Atlas of Healthcare.
RESULTS: Population-based amputation rates varied across HRRs, from fewer than 1 per 10,000 Medicare patients to more than 44 per 10,000. Patients in regions with the highest amp. rate underwent 54% fewer revascs. for each amp. (4.8 vs. 2.2 revascs. per amp., p<0.0001) (Figure). Even the number of diagnostic angiograms performed for each amp. was significantly lower in high amp. regions (5.0 vs. 2.4 angios. per amp., p<0.0001). Across strata of amp. rate, patients were similar in terms of age, sex, and diabetes prevalence, but those in high amp. regions were more commonly black (50% vs. 12%, highest vs. lowest amp. regions) and indigent ($17,980 vs. $19,545 per capita income, highest vs. lowest amp. regions).
CONCLUSIONS: Medicare patients living in regions with the highest amputation rate are commonly poor, African American, and receive less than half as much vascular care than patients living in regions with lower burdens of vascular disease. Indigent African-American Medicare patients residing in regions with the highest amputation rate receive comparatively little vascular care, and represent the best opportunity for systematic efforts to reduce amputation.
AUTHOR DISCLOSURES: J. D. Birkmeyer, Nothing to disclose; B. S. Brooke, Nothing to disclose; J. L. Cronenwett, Nothing to disclose; E. S. Fisher, Nothing to disclose; D. A. Goodman, Nothing to disclose; P. P. Goodney, NIH, SVS, Research Grants; P. K. Henke, Nothing to disclose; K. Holman, Nothing to disclose; L. L. Travis, Nothing to disclose.
Posted April 2012