Department of Student Affairs, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030.
Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX; Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX.
Semin Vasc Surg. 2023 Mar;36(1):49-57. doi: 10.1053/j.semvascsurg.2022.12.003. Epub 2022 Dec 23.
Medicaid coverage among patients with peripheral artery disease (PAD) has been associated with higher rates of primary amputations. We sought to determine the relative contributions of clinical, demographic, and hospital factors to leg amputations among Texas Medicaid patients. Patient-level data were used to identify patients who underwent treatment for PAD-related foot complications in Texas. Patients were categorized into groups by insurance provider (Medicaid, Medicare, dual-enrollee, commercial, and provider network). Individual- and area-level multivariate analyses were used to find associations with primary amputation. Of 21,592 patients identified, 8.8% were covered by Medicaid, 35.3% by Medicare, 27.8% by Medicare and Medicaid, 7.3% by commercial insurance, and 20.7% by a provider network. Compared with commercially insured patients, Medicaid patients more often underwent amputation (33% v 49%), were categorized as Black or Hispanic (45% v 64%), presented with gangrene (61% v 71%), were admitted through an emergency department (61% v 73%), and were admitted to a safety net hospital (3% v 16%). They had lower relative rates of outpatient evaluation (1.33 v 0.55) and their hospitalizations were less centralized (Gini coefficient 0.43 v 0.39) (P < .001 for all). Amputations among Medicaid patients were associated with infection and gangrene, care at safety net hospitals, rate of outpatient visits, and Black and Hispanic race, even after risk-adjustment (P < .001). Leg amputations among Medicaid patients were associated with race, disease severity, hospital characteristics, and outpatient evaluation rates, but not with provider density and location. Focusing efforts on preventative care and early outpatient referrals could help address this disparity.
医疗补助覆盖的外周动脉疾病（PAD）患者的主要截肢率较高。我们旨在确定临床、人口统计学和医院因素对德克萨斯州医疗补助患者下肢截肢的相对贡献。使用患者水平的数据来确定在德克萨斯州因 PAD 相关足部并发症接受治疗的患者。根据保险提供者（医疗补助、医疗保险、双重参保者、商业和提供者网络）将患者分为不同组别。使用个体和区域水平的多元分析来发现与主要截肢相关的因素。在确定的 21592 名患者中，8.8%由医疗补助覆盖，35.3%由医疗保险覆盖，27.8%由医疗保险和医疗补助共同覆盖，7.3%由商业保险覆盖，20.7%由提供者网络覆盖。与商业保险患者相比，医疗补助患者更常进行截肢（33%比 49%），更可能为黑人和西班牙裔（45%比 64%），出现坏疽（61%比 71%），通过急诊入院（61%比 73%），并收入安全网医院（3%比 16%）。他们的门诊评估率较低（1.33 比 0.55），住院治疗分布较分散（基尼系数 0.43 比 0.39）（所有 P 值均<.001）。即使在风险调整后，医疗补助患者的截肢仍与感染和坏疽、安全网医院的护理、门诊就诊率以及黑人和西班牙裔种族有关（P<.001）。医疗补助患者的下肢截肢与种族、疾病严重程度、医院特征和门诊评估率有关，但与提供者密度和位置无关。集中精力进行预防性护理和早期门诊转介可能有助于解决这一差异。
