Johns Hopkins University School of Medicine, Baltimore, Md; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
J Vasc Surg. 2021 Oct;74(4):1317-1326.e1. doi: 10.1016/j.jvs.2021.03.033. Epub 2021 Apr 15.
Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation.
Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses.
A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all).
Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.
社会经济劣势是糖尿病患者不良结局和截肢的已知预测因素。然而，其与主要截肢后结局的关系尚未描述。在这里，我们旨在确定马里兰州患者的社会经济劣势与糖尿病患者主要截肢后 30 天再入院和 1 年再截肢率之间的关系。
从马里兰州卫生服务成本审查委员会数据库中筛选出 2015 年至 2017 年间患有糖尿病并同时接受大下肢截肢手术的患者，根据区域剥夺指数（ADI）（ADI1[最不贫困]至 ADI4[最贫困]）进行社会经济劣势分层。主要结局为 30 天再入院和 1 年再截肢率，采用多变量逻辑回归模型和 Kaplan-Meier 生存分析进行评估。
共评估了 910 例患者（66.0%为男性，49.2%为黑人），其中 30.9%为 ADI1（最不贫困），28.6%为 ADI2，19.1%为 ADI3，21.2%为 ADI4（最贫困）。在调整了基线人口统计学和临床因素的差异后，30 天再入院的几率在 ADI 组之间相似（所有 P 值均>0.05）。30 天再入院的独立预测因素包括女性（比值比[OR]，1.45）、医疗保险（与私人保险相比；OR，1.76）和外周动脉疾病（OR，1.49）（所有 P 值均<0.05）。与 ADI1 相比，ADI4（OR，1.74）、因残端并发症或感染/败血症（OR，2.65）以及伴有充血性心力衰竭（OR，1.53）或外周动脉疾病（OR，1.59）的患者 1 年内再截肢的几率显著增加（所有 P 值均<0.05）。
在马里兰州接受糖尿病大截肢的患者中，地理社会经济劣势与 1 年再截肢独立相关，但与 30 天再入院无关。在社会经济弱势群体中，针对改善慢性疾病进展的术后管理的定向方法可能有助于降低这一高危人群的长期发病率。
