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Non-White Race Is Associated With Higher Risk Of Amputation In Patients With Lower WIfi Scores
Gloria Sanin, Caroline Minnick, Ashlee Stutsrim Sanin, Timothy Williams, Gabriela Velazquez, Cody Blazek, Matthew Edwards, Matthew Goldman
Atrium Health Wake Forest Baptist Health, Winston Salem, NC

INTRODUCTION: Chronic lower extremity wounds represent a significant source of debilitation and morbidity with disparate outcomes based upon multiple racial, socioeconomic, and patient-specific factors. This study explored the outcomes of patients evaluated by an inpatient limb preservation service, particularly focusing on the relationship between race and amputation.

METHODS: A retrospective review of prospectively-collected data was performed evaluating patients seen by the Limb Preservation service at a large academic medical center between 2018 and 2023. Wound, Ischemia, foot infection (WIfI) scores, demographics, and outcomes were collected on the cohort. Patients were categorized into two racial/ethnic groups: “non-white” (including Hispanics and those with unknown race/ethnicity) and “white” (non-Hispanic). Associations between race/ethnicity and amputation outcomes (including potential two-way interactions with other factors) were examined using logistic regression models.

RESULTS: 731 patients were evaluated. 37% were female and 36% were non-white/non-Hispanic. There was no difference in WIfI scores based on race or ethnicity. 62% of non-white participants and 56% of white participants had moderate/high WIfI amputation risk scores. Minor amputations occurred in 20% of patients, and 17% underwent major limb amputations. Non-whites experienced higher rates of both minor (25% vs. 17%, p=0.012) and major amputations (26% vs. 13%, p<0.0001). Intervention/revascularization rates were similar between groups. Higher WIfI score was associated with an increased risk of any amputation compared to lower WIfI scores [47% vs. 8%, OR 10.9 (6.7-17.7)]. In multivariable models, non-white race was significantly associated with risk of any amputation at the very low, low, and moderate risk WIfI scores (OR 4.9, 95% CL 1.0-35 at WIfI=1; OR 8.5, 95% CL 2.4-41 at WIFI=2; OR 2.3, 95% CL 1.1-4.9 at WIfI=3). There was no difference in amputation risk between race/ethnicity groups at the high risk WIfI score (OR 1.0, 95% CL 0.6-1.7 at WIfI =4; race/ethnicity×WIfI interaction P=0.010). Non-white patients with lower WIfI (stage 1 or 2 vs. 3 or 4) were significantly more likely to receive a minor amputation (OR 5.5 (1.5-26) vs. 1.3 (0.8-2.2)) and major amputation (OR 8.2 (2.0-55) vs. 1.5 (0.9-2.6)) when compared to their white counterparts.

CONCLUSIONS: Non-white race was significantly associated with adverse limb events irrespective of WIfI amputation risk score, which is consistent with previous research. However, our findings suggest non-white patients appear to be at significantly higher risk for minor/major limb amputation at lower WIfI scores when controlling for common risk factors. The underlying reasons for this disparity remain unclear. Future research is needed to elucidate the underlying mechanisms contributing to these disparities and develop effective strategies to address and mitigate racial disparities in patients with lower extremity wounds.
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