Department of Surgery, Howard University and Hospital, Washington, D.C..
Howard University College of Medicine, Washington, D.C.
J Vasc Surg. 2019 Aug;70(2):580-587. doi: 10.1016/j.jvs.2018.11.028. Epub 2019 Mar 8.
Although it has been suggested that individuals of low socioeconomic status and those with Medicaid or no insurance may be more likely to have their peripheral artery disease treated by leg amputation rather than by limb-saving revascularization, it is not clear if this disparity occurs consistently on a national basis, and if it does so in a linear fashion, such that poorer individuals are at progressively greater risk for amputation.
We undertook this study to determine if lower median household income and Medicaid/no insurance status are associated with a higher risk for amputation, and if this occurs in a progressively linear fashion.
The National (Nationwide) Inpatient Sample Database was queried to identify patients who were admitted with a diagnosis of critical limb ischemia from 2005 to 2014 and underwent either a major amputation or a revascularization procedure during that admission. Patients were stratified according to their insurance status and their median household income into four income quartiles. Multivariate logistic regression was performed to determine the effect of income and insurance status on the odds of undergoing amputation vs leg revascularization.
Across the different insurance types, there was a significant decrease in the odds ratios for amputation as one progressed from one MHI quartile to a higher one: namely, Medicare (2.23, 1.87, 1.65, and 1.42 for the first, second, third, and fourth MHI quartiles); Medicaid (2.50, 2.28, 2.04, and 1.80 for the first, second, third, and fourth MHI quartiles); private insurance (1.52, 1.21, 1.16, and 1.00 for the first, second, third, and fourth MHI quartiles), and uninsured (1.91, 1.64, 1.10, and 1.22, for the first, second, third, and fourth MHI quartiles).
Lower MHI, Medicaid insurance, and uninsured status are associated with a greater likelihood of amputation and a lower likelihood of undergoing limb-saving revascularization. These disparities are exacerbated in stepwise fashion, such that lower income quartiles are at progressively greater risk for amputation.
尽管有人认为社会经济地位较低的个体和拥有医疗补助或没有保险的个体更有可能通过截肢而不是保肢血运重建来治疗外周动脉疾病，但尚不清楚这种差异是否在全国范围内一致存在，如果存在，是否呈线性方式，即较贫困的个体截肢风险逐渐增加。
我们进行这项研究旨在确定较低的家庭中位数收入和医疗补助/无保险状态是否与更高的截肢风险相关，以及这种情况是否呈渐进线性方式发生。
通过查询国家（全国）住院患者样本数据库，确定了 2005 年至 2014 年因严重肢体缺血入院并在该入院期间接受主要截肢或血运重建手术的患者。根据保险状况和家庭中位数收入将患者分为四个收入四分位组。采用多变量逻辑回归来确定收入和保险状况对接受截肢与下肢血运重建的几率的影响。
在不同的保险类型中，随着从中位数收入的一个四分位数进展到更高的四分位数，截肢的比值比显著降低：即，医疗保险（第一、第二、第三和第四中位数收入四分位数的比值比分别为 2.23、1.87、1.65 和 1.42）；医疗补助（第一、第二、第三和第四中位数收入四分位数的比值比分别为 2.50、2.28、2.04 和 1.80）；私人保险（第一、第二、第三和第四中位数收入四分位数的比值比分别为 1.52、1.21、1.16 和 1.00）和无保险（第一、第二、第三和第四中位数收入四分位数的比值比分别为 1.91、1.64、1.10 和 1.22）。
较低的中位数收入、医疗补助保险和无保险状态与更大的截肢可能性和更低的保肢血运重建可能性相关。这些差异呈逐步加剧的方式存在，即较低的收入四分位数截肢风险逐渐增加。
