Socioeconomic Status is Associated with Amputation Risk for Individuals with Peripheral Artery Disease

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Clinical Question: 

For individuals with peripheral artery disease, does the risk of major lower limb amputation increase with low socioeconomic status compared to high socioeconomic status?

Background:

In the United States, approximately 150,000 individuals undergo nontraumatic lower limb amputations per year.¹ Peripheral artery disease (PAD) and diabetes mellitus (DM) are the most common causes of nontraumatic amputation. Incidence of PAD and DM are often amplified within Black and Brown neighborhoods, underserved communities, and minoritized populations.^2,4 The most severe stage of PAD, “chronic limb-threatening ischemia”, is accompanied by a significant risk of limb amputation which can lead to the severe physical and financial burden of life-altering physical impairment.³ The communities with restricted access to quality healthcare and disproportionate incidence of PAD are the same communities that are being disproportionately burdened with the financial and medical costs of amputation. While race often serves as a proxy for socioeconomic status (SES) and access to quality healthcare, recent studies have explored the idea that SES may independently affect amputation risk.⁴ Understanding the associations between SES and amputation risk can give healthcare practitioners evidence and guidance to implement proactive initiatives to improve quality of care in the communities that need it the most. Therefore, this CAT was conducted to determine if the risk of major lower limb amputation decreases with high SES compared to low SES.

Search Strategy:

Databases Searched: PubMed and CINAHL

Search Terms: “Peripheral artery disease” (MeSH Terms), AND amputation OR amputation risk OR lower limb amputation AND socioeconomic status (MeSH Terms)

Inclusion Criteria: Original research, peer-reviewed and published, English language, US based, recent (<10 yrs), using previously collected medical data, patient population with peripheral artery disease

Synthesis of Results:

Four studies investigated a potential association between SES and amputation risk in patients diagnosed with PAD^4,5,6,7 or other circulatory conditions⁷ between the years 2003-2017. All studies were observational retrospective cohort^4,5,6 or cross-sectional⁷ studies with most sample sizes over 150,000.^4,5,6 The ability to draw conclusions about this specific population were limited by threats to validity such as previously collected medical record data used to identify participants and heterogeneity in inclusion criteria.^5,6,7 Although the participants were gleaned from distinct databases, together these samples serve as a comprehensive representation of the larger population of those with PAD. Eligible participants were defined through diagnosis codes and data from 8-11 years was analyzed, except one study limited to data from one year.⁷ A variety of markers such as median household income,^4,5,6 area deprivation index,⁴ distressed communities index,⁶ and US census bureau data⁷ were used to indicate SES status and all data analysis used regression models while adjusting for confounding variables. Study results indicate an association between major limb amputation rates and SES,^4,5,6,7 and amputation rates, SES, and race.^4,5,7 Specifically, low SES was associated with 12% greater risk of amputation⁴ and greater odds of leg amputation⁵ versus high SES, ZIP codes with low median SES had higher amputation rates,⁶ and county amputation rates were statistically significantly negatively associated with poverty.⁷

Clinical Message:

This medium quality body of evidence indicates a statistically significant negative association between amputation risk and low SES for a wide range of individuals with PAD or similar circulatory system disorders. Clinicians should be cognizant of this connection and implement proactive treatment for patients who show markers of low SES by amplifying preventative care, giving resources early and continuously, increasing follow-ups, and making prompt referrals. Further research should examine the underlying systemic causes of this disproportionality to inform interventions to address, propose, and trial outreach efforts to decrease the disparity.