Racial differences in primary and repeat lower extremity amputation: Results from a multihospital study

Objective: African Americans have a much higher risk of major (above- or below-knee) lower extremity amputation and a lower rate of limb-preserving vascular surgery or angioplasty than white patients. This article analyzes two potential pathways for racial disparities: primary amputation, defined as a major amputation performed without any prior attempt at revascularization, and repeat amputation, defined as a major amputation subsequent to a previous through-foot or major amputation. Methods: Randomly selected medical records were reviewed for 248 African American, 30 Hispanic, and 235 white or other-race patients undergoing above- or below-knee amputation between 1995 and 2003 at three Chicago teaching hospitals. Chronic disease prevalence and severity, preadmission functional status, clinical presentation, and vascular history were used to test the risk-adjusted effect of race and ethnicity on rates of primary and repeat amputation. Results: Controlling for demographic, functional, chronic disease, and clinical characteristics, African American patients were 1.7 times more likely to have undergone both primary (P = .01) and repeat (P = .03) amputation than white or other-race amputees. Race remained a significant independent risk factor even after controlling for the higher severity of illness, greater disability, and more complex presentation of African American amputees. Conclusions: Higher rates of primary and repeat amputation for African American patients at study hospitals, which all have significant vascular surgery capacity and an aggressive policy of limb salvage, suggest that these rates may be even higher at less well equipped institutions. Improving access to primary and preventive care for lower-income patients could reduce amputation rates among African Americans.