The Impact of Sociodemographic Variables on Functional Recovery following Lower Extremity Amputation

Abstract

ObjectiveWe hypothesize that sociodemographic variables, particularly disadvantaged financial environments, impact both rate of prosthetic utilization and the achievement of ambulation post major amputation. MethodsAll cases in the Vascular Quality Initiative (VQI) amputation module were queried between April 2013 and January 2024. Inclusion was limited to patients who underwent below knee, through knee, and above knee amputation. Two primary outcomes were investigated : Non-ambulatory status after amputation (minimum of 120 days follow up); and, not having obtained a prosthetic limb (minimum of 90 days follow up). The ambulation status and prosthetic status analyses had 6984 and 6793 patients meet inclusion respectively. Multivariable binary logistic regression analysis was performed utilizing variables which achieved univariable significance (P<.05) for the outcomes. ResultsMean follow up for those meeting inclusion was 432 days. Amongst all patients meeting inclusion, 46.7% of patients did not acquire a prosthetic limb and 44.1% were non-ambulatory. Sociodemographic factors with significant multivariable association for the outcome of no prosthetic limb acquisition in follow up were : advancing age (aOR 1.011/year (1.006-1.016), P<.001); female sex (aOR 1.43 (1.28-1.61), P<.001); top 20% ADI representing highest deprivation (aOR 1.24 (1.09-1.41) P=.001); race (P=.002) Insurance status (P=.028) with protective status for commercial insurance (39% rate of no prosthetic) and non US insurance (33%) versus Medicare (51%), Medicaid (48%), VA insurance (49%), Self Pay (42%) and Medicare Advantage (51%). There were numerous co-morbidities which also had association with lack of prosthetic limb acquisition.Sociodemographic variables which achieved multivariable significance (P<.05) for the outcome of non-ambulatory status after major amputation were : female sex (aOR 1.37 (1.23-1.54), P<.001); Medicare insurance (P=.016); advancing age (aOR 1.009/year (1.004-1.014), P<.001); CHF (aOR 1.15 (1.02-1.31), P=.028); and, not living at home in follow up (aOR (3.53 (2.99-4.17) P<.001). Physical therapy at any point after surgery (aOR .742 (.662-.832), P<.001) and commercial insurance (aOR .839 (.737-.956), P=.008) were protective. There were numerous co-morbidities which also had association with non-ambulatory status in follow up. ConclusionsLiving within the most financially disadvantaged areas and race both have a significant independent association with lack of prosthetic limb acquisition following major amputation. Black, Native American and Pacific Islander demographic patients experience lack of acquisition at a higher rate than White and Asian patients independent of co-morbidities and socioeconomic co-variables. Female patients obtain a prosthetic limb and ambulate less frequently than males after major amputation, largely due to a higher rate of above knee amputation. Co-morbidities, and not socioeconomic variables are the leading drivers of non-ambulation.