Health Services Research & Development

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2011 HSR&D National Meeting Abstract

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2011 National Meeting

1079 — Trends in Initial Lower Extremity Amputation Rates among Veterans Health Administration Health Care System Users from 2000 to 2004

Tseng C (DVA-NJHS-Center for Healthcare Knowledge Management, East Orange, NJ; University of Medicine and Dentistry of New Jersey), Rajan M (DVA-NJHS-Center for Healthcare Knowledge Management, East Orange, NJ), Miller DR (DVA-Center for Health Quality, Outcomes and Economic Research; Boston University-School of Public Health), Lafrance J (DVA-Center for Health Quality, Outcomes and Economic Research; Boston University-School of Public Health), Pogach L (DVA-NJHS-Center for Healthcare Knowledge Management, East Orange, NJ; University of Medicine and Dentistry of New Jersey)

Objectives:
Reducing the rate of lower extremity amputations (LEAs) was a major objective of Healthy People 2010. Methodological limitations temper interpretation of the clinical and policy significance of findings of current studies of population trends in LEA rates. The patient-level electronic records in the Veterans Health Administration (VHA) healthcare system in the United States provide means in addressing these limitations. Our objective was to evaluate temporal trends in rates of initial lower extremity amputation (ILEAs) among patients with diabetes in the VHA using patient-level data.

Methods:
We conducted a retrospective administrative data analysis of VHA clinic users with diabetes in fiscal years (FY) 2000 to 2004 (10/1/1999-9/30/2004). We calculated annual age- and sex- standardized rates of initial major, minor, and total amputations overall and in various racial/ethnic groups (African Americans, Hispanics, and Whites). Trends in ILEA risk were evaluated with adjustment for potential risk factors, including age, sex, race/ethnicity, marital status, census regions, census rural/urban continuum, VHA enrollment priority status, and presence of micro- and macro-vascular diseases, and anti-glycemic treatment.

Results:
Study populations of VHA patients with diabetes and without prior amputations ranged from 405,580 in FY2000 to 739,377 in FY2004. Age- and sex-standardized ILEA rates decreased by 34% over the five-year period with similar trends for minor (-33%) and major (-36%) amputations. Minor amputation rates decreased from 4.59 in FY 2000 to 3.06 in FY 2004 per 1,000 patients. Of major amputations, below knee rates decreased from 1.08/1,000 to 0.87/1,000 (-19%), and above knee, from 1.41/1,000 to 0.72/1,000 (-49%). Similar trends were seen for all racial groups. Risk of ILEA decreased by 22% when comparing FY 2004 to FY 2000 (adjusted odds ratio = 0.78 [0.74 – 0.82]).

Implications:
Under national policies to identify high-risk veterans, downward five-year trends in ILEA rates were found for all amputation levels and among all racial groups, even after adjustment for possible risk differences over time.

Impacts:
A better understanding of variations in outcomes related to processes of care could inform foot care systems redesign efforts. Results will also be presented to VACO leadership for consideration of inclusion in PACT reports to external oversight committees.