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Survival and Functional Outcomes after Major Amputation: A Regional Analysis of U.S. PAD Patients
Subhan Ahmed
1, Emily Spangler
2, Danielle Sutzko
2, Adam W Beck
2, Zdenek Novak
2 1University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL;
2Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL
BACKGROUND: The highest non-traumatic amputation rates nationally are seen within the Deep South region (Louisiana, Mississippi, Alabama, Georgia, and South Carolina). While the role of racial disparities in peripheral arterial disease (PAD) outcomes are well described, 30-50% of the variation in amputation rates remains unexplained, implicating potential socioeconomic, educational, and geographic factors on an individual and systemic level. Among cases of amputations from PAD, we sought to examine variation in clinical and socioeconomic factors by US geographic regions and their associations with amputee survival and functional recovery.
METHODS:We conducted a retrospective analysis of patients with ischemic rest pain, tissue loss, or uncontrolled infection within the Society for Vascular Surgery Vascular Quality Initiative (VQI) Lower Extremity Amputation database (2013-2024). Regions were grouped as: Deep South; Southeast; Mountain West/Southwest/Pacific West; Northeast/Mid-Atlantic/Mountain East; and Great Lakes/Great Plains. Assessed factors reflecting socioeconomic impact to care included the Area Deprivation Index (ADI, >80 = disadvantaged), Distressed Communities Index (DCI), Rural-Urban Commuting Area (RUCA >9 = rural), and insurance type. Outcomes of interest were discharge disposition, 1-year mortality, prothesis use, and ambulation status.
RESULTS: Among 28,130 amputations for PAD indications, the Deep South cohort had the highest proportion of non-White patients (70.8%) and socioeconomic disadvantage (ADI disadvantaged in 31.2%, 61.0% with distressed DCI)(Table I). One-year mortality was highest in the Northeast (21.2%, p<0.001). Among 6,998 patients with follow-up, the Deep South had the highest rates of regular prosthesis use (29.6%), ambulation at 1 year (25.0%), and physical therapy participation (86.1%), while wheelchair dependence was most common in the Northeast and Southeast (p<0.001). Multivariable modeling showed higher amputation level predicted both lower likelihood of discharge home and higher 1-year mortality (p<0.001). Compared with the Deep South, the Northeast had higher 1-year mortality (HR 1.12, 95% CI 1.01-1.24). Commercial insurance/self-pay was associated with greater discharge home and lower 1-year mortality (p<0.001). Prior PVI/bypass history was associated with lower 1-year mortality (HR 0.91, 95% CI 0.864-0.968). Socioeconomic measures were not independently predictive for disposition and mortality in multivariable models as well as not associated with functional outcomes.
CONCLUSIONS: Significant geographic disparities in PAD-related amputation outcomes persist. Despite a disproportionate burden of socioeconomic disadvantage, Deep South patients demonstrated lower 1-year mortality adjusted for socioeconomic factors (ADI, DCI, rurality, and insurance status), patient demographics, and comorbidities as well as a greater likelihood of home discharge compared with other regions. This contrasts with historical trends of poorer outcomes in the Deep South, suggesting evolving patterns in demographics and functional recovery. Further investigation into the drivers of these outcomes may inform strategies to reduce regional disparities in amputation care.
Table I. Pre-Operative Demographic Comparison Between the Geographical Regions of the US| Variable | Deep South | Southeast | Mountain West/SW/Pacific Coast | Northeast/Mid-Atlantic/Mountain East | Great Lakes/Great Plains | p-value |
| N=28130 | n=2794 | n=3557 | n=888 | n=13090 | n=7801 | |
| Age [Mean±SD] | 63.34±12.49 | 64.01±12.59 | 66.54±13.92 | 65.68±12.44 | 64.10±12.48 | <0.001 |
| Male [n(%)] | 1748 (62.6) | 2389 (67.2) | 631 (71.1) | 8910 (68.1) | 5307 (68.0) | <0.001 |
| Non-White [n(%)] | 1977 (70.8) | 1904 (53.6) | 249 (28.0) | 5588 (42.7) | 2772 (35.6) | <0.001 |
| CAD [n(%)] | 811 (29.0) | 1163 (32.7) | 242 (27.3) | 4254 (32.5) | 2444 (31.4) | <0.001 |
| Mortality at 1-year [n(%)] | 476 (17.0) | 623 (17.5) | 98 (11.0) | 2769 (21.2) | 1363 (17.5) | <0.001 |
| ADI Disadvantaged [n(%)] | 851 (31.2) | 1124 (32.5) | 56 (6.5) | 1678 (12.9) | 2175 (28.3) | <0.001 |
| DCI Distressed [n(%)] | 1666 (61.0) | 1978 (56.8) | 314 (36.9) | 5481 (42.5) | 3680 (47.5) | <0.001 |
| RUCA Rural [n(%)] | 52 (1.9) | 146 (4.2) | 34 (4.0) | 476 (3.7) | 183 (2.4) | <0.001 |
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