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Living in a medically underserved county is an independent risk factor for major limb amputation
Katharine L McGinigle, Corey A Kalbaugh, William A Marston
University of North Carolina, Chapel Hill, NC

BACKGROUND:
Despite an increase in the incidence of hospital admissions for comorbid conditions, such as diabetes, there has been a decrease in the incidence of major limb amputation in North Carolina. The decline in amputation rate has not been uniformly realized across the state.
We designed this study to determine risk factors associated with major vascular limb amputation in patients admitted for hospital care with a diagnosis related to peripheral arterial disease in North Carolina.
METHODS:
We analyzed hospital discharges aged 18-100 years old with a peripheral arterial disease related condition from the North Carolina Inpatient Discharge Database from 2006-2009. Risk factors analyzed for their association with amputation included gender, age, diabetes (DM), end stage renal disease (ESRD) and living in a medically underserved county. Medically underserved counties are defined by the United States Health Resources and Services Administration as having too few primary care providers, high infant mortality, high poverty, or high elderly population. The association between major amputation prevalence and medically underserved counties was calculated using a logistic regression model adjusted for gender, age, diabetes, end stage renal disease, peripheral arterial disease, and critical limb ischemia. The effect of each confounder on the relationship between being underserved and undergoing major amputation was assessed using backward elimination modeling.
RESULTS:
Among the 222,920 discharges with a peripheral arterial disease related condition from 2006-2009, there were 8,601 (3.9%) from medically underserved counties. There were 7,328 major amputations. As expected, gender, age, DM, and ESRD all were associated with the incidence of amputation. An unexpected finding was the relationship between living in an underserved county and major vascular limb amputation. The adjusted prevalence odds ratio of this association was significant at 1.29 (CI 1.16-1.44) and was independent of the effect of the other studied risk factors.
CONCLUSION:
Living in an underserved county in North Carolina is associated with a 29% increase in the odds of undergoing major limb amputation. Gender, age, and comorbidities including diabetes, end stage renal disease, and peripheral arterial disease, also risk factors for major amputation, do not significantly affect this relationship.


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