Available online 23 December 2022

Author links open overlay panelABSTRACTObjective/Background

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.

Methods

Patient-level data was 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, provider network). Individual and area-level multivariate analyses were used to find associations with primary amputation.

Results

Out 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 to commercially insured patients, Medicaid patients more often: underwent amputation (33% vs 49%), were categorized as Black or Hispanic (45% vs 64%), presented with gangrene (61% vs 71%), were admitted through an emergency department (61% vs 73%), and were admitted to a safety net hospital (3% vs 16%). They had lower relative rates of outpatient evaluation (1.33 vs 0.55), and their hospitalizations were less centralized (Gini coefficient 0.43 vs 0.39) (p<0.001 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<0.001).

Conclusions/Relevance

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.

Section snippetsINTRODUCTION

For patients with peripheral artery disease (PAD), foot complications such as ulcers, infections, or gangrene represent a threat to the limb1. Access to specialists who can perform arterial interventions (endovascular angioplasty with or without stent placement) or operations (leg bypasses) are vital to minimizing the risk of limb loss.

Texans with peripheral artery disease (PAD) and foot complications who have Medicaid healthcare coverage have a two-fold higher rate of leg amputations than

METHODS

The population of interest was Texas adults age 45 or older who presented to inpatient facilities with (1) PAD; and (2) a limb-threatening foot complication (including a foot ulcer, gangrene of some part of the foot, or foot infection); and (3) underwent an index operation: either revascularization (leg bypass or endovascular angioplasty done with or without stent placement) or leg amputation (also called “major” or above-ankle amputation). These patients were identified within an all-payers

Individual Level Characteristics

Compared with commercial insurance patients, Medicaid only patients were more often categorized as Black or Hispanic. Fewer lived in rural regions. More were admitted through an emergency department (rather than electively), and more presented with gangrene and/or foot infection (rather than an uninfected foot ulcer; p<0.001 for all, Table 1). The proportion of persons who underwent leg amputation was highest in the Medicaid alone and dual enrolled groups and lowest for those with commercial

DISCUSSION

Many patients with significant PAD still undergo primary leg amputation without an attempt at revascularization, often without even a diagnostic procedure to assess severity or extent of PAD9. Because leg amputation is associated with a higher risk-adjusted perioperative mortality rate than revascularization10 as well higher economic costs12, it is important to identify factors more strongly associated with leg amputation than with revascularization13. Beyond clinical characteristics,

LIMITATIONS

Our study was limited by the anonymization of the patients and providers in the dataset used. Each patient encounter included in the analyses was interpreted as an individual patient. However, there is a possibility that multiple encounters represented the same patient undergoing multiple admissions. This may alter our perception of primary amputations. The anonymization of providers in the dataset prevented us from including specialty of provider as a clinical variable in the analysis.

In

ACKNOWLEDGEMENTS

Author Contributions: Dr. Barshes and Deeksha Bidare had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors were involved in reviewing and finalizing the manuscript and have approved the final version of the paper.

Study Design: Barshes, Bidare

Data Acquisition, Analysis, Interpretation: Barshes, Bidare, Cerise, Sharath

Drafting of the manuscript: Barshes, Bidare, Cerise, Sharath

Critical revision of

R EFERENCES1

N.R. Barshes, M. Belkin, A framework for the evaluation of “value” and cost-effectiveness in the management of critical limb ischemia, Journal of the American College of Surgeons. 213 (2011) 552–566.

2

N.R. Barshes, S. Sharath, N. Zamani, K. Smith, H. Serag, S.O. Rogers, Racial and geographic variation in leg amputations among texans, Texas Public Health Journal. 70 (2018) 22.

3

N. Zamani, S.E. Sharath, N.R. Barshes, Physician Reimbursement by Medicaid Favors Major Amputation over Limb Preservation,

View full text

© 2022 Elsevier Inc. All rights reserved.