title: Factors predicting resource utilization and survival after major amputation.
abstract: OBJECTIVE
  Major amputation is associated with increased short-term healthcare resource utilization (RU), early mortality, and socioeconomic status (SES) disparities. Our objective is to study patient-specific and SES-related predictors of long-term RU and survival after amputation.
  
  
  METHODS
  This retrospective analysis identified 364 adult patients who underwent index major amputation for critical limb ischemia from January 1995 through December 2000 at two tertiary centers with outcomes through December 2010. Age, gender, SES (race, income, insurance, and marital status), comorbidities (congestive heart failure [CHF], diabetes, diabetes with complications, and renal failure [RF]), subsequent procedures, cumulative length of stay (cLOS), and mortality were analyzed. Bivariate and multivariate Poisson regression for subsequent procedures and cLOS and Cox proportional hazard modeling for all-cause mortality were undertaken.
  
  
  RESULTS
  During a mean follow-up of 3.25 years, amputation patients had mean cLOS of 71.2 days per person-year (median, 17.6), 19.5 readmissions per person-year (median, 2.1), 0.57 amputation-related procedures (median, 0), and 0.31 cardiovascular procedures (median, 0). Below-knee amputation as the index procedure was performed in 70% of patients, and 25% had additional amputation procedures. Of readmissions at ≤ 30 days, 52% were amputation-related. Overall mortality during follow-up was 86.9%; 37 patients (10.2%) died within 30 days. Among patients surviving >30 days, multivariate Poisson regression demonstrated that younger age (incidence rate ratio [IRR], 0.98), public insurance (IRR, 1.63), CHF (IRR, 1.60), and RF (IRR, 2.12) were associated with increased cLOS. Diabetes with complications (IRR, 1.90) and RF (IRR, 2.47) affected subsequent amputation procedures. CHF (IRR, 1.83) and RF (IRR, 3.67) were associated with a greater number of cardiovascular procedures. Cox proportional hazard modeling indicated older age (hazard ratio [HR], 1.04), CHF (HR, 2.26), and RF (HR, 2.60) were risk factors for decreased survival. Factors associated with SES were not significantly related to the outcomes.
  
  
  CONCLUSIONS
  This study found that RU is high for amputees, and increased RU persists beyond the perioperative period. Results were similar across SES indices, suggesting higher SES may not be protective against poor outcomes when limb salvage is no longer attainable. These findings support the hypothesis that SES disparities may be more modifiable during earlier stages of care for critical limb ischemia.
authors: Division of Vascular and Endovascular Surgery, Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
authors: Antonia J
authors: AJ
authors: Henry
authors: Nathanael D
authors: ND
authors: Hevelone
authors: Alexander T
authors: AT
authors: Hawkins
authors: Michael T
authors: MT
authors: Watkins
authors: Michael
authors: M
authors: Belkin
authors: Louis L
authors: LL
authors: Nguyen
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000009:adverse effects / Q000401:mortality*; D001900:Boston; D015897:Comorbidity; D016638:Critical Illness; D003920:Diabetes Mellitus / Q000401:mortality; D005260:Female; D006295:Health Resources / Q000706:statistics & numerical data*; D006333:Heart Failure / Q000401:mortality; D006801:Humans; D007511:Ischemia / Q000401:mortality / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010359:Patient Readmission; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D016016:Proportional Hazards Models; D012042:Registries; D051437:Renal Insufficiency / Q000401:mortality; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D017741:Survivors / Q000706:statistics & numerical data; D062606:Tertiary Care Centers; D013997:Time Factors; D016896:Treatment Outcome