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Rolle NP, Kawaji Q, Morton C, Rosenberg KM, Kalsi R, Blitzer DN, Nagarsheth K. Risk Factors for Lower Extremity Minor Amputation Conversion to Major Amputation. Ann Vasc Surg 2024; 104:166-173. [PMID: 38387800 DOI: 10.1016/j.avsg.2023.12.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND Minor lower extremity amputations (LEAs) have become an important part of the limb salvage approach but are not as benign as previously thought. This study investigates the difference in outcome between toe/ray versus midfoot amputations and the risk factors for major amputation conversion associated with each procedure. METHODS We performed retrospective chart review of foot amputation patients at a single tertiary care medical center with a primary end point of conversion to major amputation and secondary end points of 1-year wound healing and mortality rate. We collected data on relevant medical comorbidities, noninvasive vascular imaging, revascularization, repeat amputations, wound healing rate, and 1-year mortality. Patients were separated into toe/ray amputations versus midfoot amputation groups and compared using descriptive statistics, Chi-squared tests, Cox proportional hazards, and a multivariate logistic regression model. RESULTS A total of 375 amputations were included in the analysis. 65.3% (245 patients) included toe/ray amputations and 34.7% (130 patients) included midfoot amputations. We compared these 2 cohorts with regard to their rate of conversion to repeat minor and/or major amputation in addition to overall mortality. The toe/ray group underwent more repeat minor amputations within 1 year after index amputation (34.7% vs. 21.5%, P = 0.008) and wound healing (epithelization) at 90 days was also higher in this group. The midfoot group had a higher conversion to major LEA within 1 year on univariate analysis (20.8 vs. 6.9%, P < 0.001). Overall 1-year mortality was 6.17% and there was no significant difference between groups. CONCLUSIONS While there is a consistency with previous studies that found no significant overall difference in mortality between types of minor LEA, we have extended this previous work by demonstrating the independent risk factors for conversion to major amputation between types of minor LEA. Comparing these 2 groups will assist surgeons in choosing the appropriate level of amputations and will enhance patient's understanding of their chance of wound healing and risk of repeat amputation.
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Affiliation(s)
- Nicholas P Rolle
- Department of Surgery, Inova Fairfax Medical Campus, Falls Church, VA.
| | - Qingwen Kawaji
- Department of Surgery, Medstar Health Baltimore, Baltimore, MD
| | - Claire Morton
- Department of Surgery, Yale School of Medicine, New Haven, CT
| | | | - Richa Kalsi
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - David N Blitzer
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
| | - Khanjan Nagarsheth
- Division of Vascular Surgery, Department of Surgery, University of Maryland Medical Center, Baltimore, MD
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Satapathy P, Khatib MN, Gaidhane S, Zahiruddin QS, Gaidhane AM, Rustagi S, Serhan HA, Padhi BK. Association of neighborhood deprivation and hypertension: A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102438. [PMID: 38301916 DOI: 10.1016/j.cpcardiol.2024.102438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 01/29/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Hypertension impacts nearly one billion individuals and is a primary health challenge. While traditional perspectives have focused on individual behavior and genetics as principal risk factors, recent research underscores the profound influence of socioeconomic factors within neighborhoods on the risk of hypertension. This systematic review and meta-analysis is aimed to elucidate the association between neighborhood deprivation and the risk of hypertension. METHODS A comprehensive literature search was conducted across PubMed, Embase, and Web of Science from inception until December 25, 2023. Observational studies defining neighborhood deprivation and reporting hypertension incidence were included. Nested Knowledge software was used for screening and data extraction, with study quality assessed using the Newcastle-Ottawa Scale. Statistical analysis was performed with R software (V 4.3), using a random-effects model to calculate the pooled relative risk (RR). RESULTS Twenty-six studies were included in the qualitative analysis and 22 in the meta-analysis, covering over 62 million participants. The pooled RR was 1.139 (95% CI: 1.006 - 1.290), p=0.04, indicating a higher hypertension risk in deprived neighborhoods. Subgroup analyses showed variability by country and deprivation assessment methods. RR varied from 1.00 in Japan (95% CI: 0.93-1.08) to 1.60 (95% CI: 1.07-2.39) in France and 1.57 (95% CI: 0.67-3.70) in Germany, with significant heterogeneity observed in measures of neighborhood deprivation. CONCLUSION Our analysis confirms a significant association between neighborhood deprivation and hypertension, underscoring the importance of socioeconomic factors in public health. It highlights the need for targeted local assessments and interventions. Future research should explore the causal mechanisms and effectiveness of interventions addressing neighborhood deprivation.
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Affiliation(s)
- Prakasini Satapathy
- Center for Global Health Research, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; School of Pharmacy, Graphic Era Hill University, Dehradun, India; Medical Laboratories Techniques Department, AL-Mustaqbal University, Hillah, Babil 51001, Iraq
| | - Mahalaqua Nazli Khatib
- Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Shilpa Gaidhane
- One Health Centre (COHERD), Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education, Wardha, India
| | - Quazi Syed Zahiruddin
- South Asia Infant Feeding Research Network (SAIFRN), Division of Evidence Synthesis, Global Consortium of Public Health and Research, Datta Meghe Institute of Higher Education, Wardha, India
| | - Abhay M Gaidhane
- Jawaharlal Nehru Medical College, and Global Health Academy, School of Epidemiology and Public Health, Datta Meghe Institute of Higher Education, Wardha, India
| | - Sarvesh Rustagi
- School of Applied and Life Sciences, Uttaranchal University, Dehradun, Uttarakhand, India
| | - Hashem Abu Serhan
- Department of Ophthalmology, Hamad Medical Corporation, Doha, Qatar.
| | - Bijaya K Padhi
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
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Wees T, Pandey M, Nicolay S, Windigo J, Bitternose A, Kopriva D. Identifying barriers to preventive care among First Nations people at risk of lower extremity amputation: a qualitative study. CMAJ Open 2023; 11:E906-E914. [PMID: 37816546 PMCID: PMC10569813 DOI: 10.9778/cmajo.20220150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/12/2023] Open
Abstract
BACKGROUND First Nations people in Canada are overrepresented among those who have undergone nontraumatic lower extremity amputation, and are more likely to be younger, have diabetic foot infections and have no previous revascularization procedures than non-First Nations populations who have undergone lower extremity amputations. We sought to identify access barriers for high-risk First Nations patients, explore patients' experiences with health care systems and identify solutions. METHODS Employing a community participatory research design, we engaged representatives from 2 communities. They assisted with research design and data analysis, and approved the final manuscript. Using a hermeneutic phenomenological approach and purposeful sampling, we conducted 5 semistructured focus groups between August and December 2021 with community health care teams and patients at risk for, or who had previously undergone, a nontraumatic lower extremity amputation. RESULTS Patients' (n = 10) and community health care providers' (n = 18) perspectives indicated that barriers to health care access led to delayed care and increased complications and risk for lower extremity amputations, leading to aggressive procedures upon receiving care. Barriers to care led to negative experiences at urban centres and aggressive procedures created further distrust, leading to care disengagement and poor outcomes. Patients and providers both suggested building stronger partnerships between urban and rural health care providers, improving education for patients and health care providers and identifying innovative strategies to improve patients' overall health. INTERPRETATION Systemic changes, health promotional program and reliable on-reserve primary care are needed to create equitable access for First Nation patients at risk for lower extremity amputations. The study results imply that health care delivery for First Nations patients at risk for lower extremity amputations can be improved through stronger partnership and communication between urban and community providers, and continued education and cultural competency training for urban health care providers.
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Affiliation(s)
- Tyrell Wees
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask
| | - Mamata Pandey
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask
| | - Susanne Nicolay
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask
| | - Juandell Windigo
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask
| | - Agnes Bitternose
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask
| | - David Kopriva
- College of Medicine (Wees, Kopriva), University of Saskatchewan; Research (Pandey), Saskatchewan Health Authority; Wellness Wheel Medical Clinic (Nicolay), Regina, Sask.; Muskowekwan First Nation (Windigo), Lestock, Sask.; George Gordon First Nation (Bitternose), Regina, Sask.
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Alahakoon C, Thanigaimani S, Seng L, Fernando M, Lazzarini P, Golledge J. Editor's Choice - A Systematic Review and Meta-Analysis of the Incidence and Risk Factors for Re-admission to Hospital in People with Diabetes Related Foot Disease. Eur J Vasc Endovasc Surg 2023; 66:195-202. [PMID: 37182607 DOI: 10.1016/j.ejvs.2023.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 04/18/2023] [Accepted: 05/05/2023] [Indexed: 05/16/2023]
Abstract
OBJECTIVE The aim of this study was to systematically review the incidence and risk factors for 30 day re-admission to hospital following an index admission to treat diabetes related foot disease (DFD). DATA SOURCES A literature search was conducted using Medline/PubMed, Scopus, Cochrane Library, and CINAHL databases. METHODS The study was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Studies that reported the rate of total or DFD related 30 day re-admissions were included. Meta-analysis was performed using a random effects model to calculate the pooled mean (95% confidence interval [CI]) of the proportion of patients re-admitted to hospital within 30 days. Meta-regression was performed to determine the association between risk factors and 30 day re-admission. RESULTS Sixteen retrospective studies with a total of 124 683 participants were included. The mean total 30 day re-admission rate was 22.0% (95% CI 17.0 - 27.0%) while the mean DFD related 30 day re-admission rate was 10.0% (95% CI 7.0 - 15.0%). Meta-regression found that greater prevalence of peripheral neuropathy (p = .045) was associated with a higher rate of any 30 day re-admission, and male sex (p = .023) and private health insurance (p = .048) were associated with lower rates of any 30 day re-admission. Coronary artery disease (p= .025) was associated with a higher rate of DFD related re-admission. All studies had low or moderate risk of bias. CONCLUSION This systematic review suggested that about one fifth of patients with DFD are re-admitted to hospital within 30 days, of which about half are to treat DFD. Risk factors for re-admission included female gender, peripheral neuropathy, lack of private health insurance, and coronary artery disease.
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Affiliation(s)
- Chanika Alahakoon
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; Faculty of Medicine, University of Peradeniya, Peradeniya, Sri Lanka; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Shivshankar Thanigaimani
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Leonard Seng
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Malindu Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia; Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, New South Wales, Australia
| | - Peter Lazzarini
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia; Allied Health Research Collaborative, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia; The Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia; Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia.
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Bidare D, Barshes NR. Hospital Payer Mix and Amputation Rates Among Patients with Peripheral Artery Disease Complications. Ann Vasc Surg 2022; 86:251-259.e1. [PMID: 35483615 DOI: 10.1016/j.avsg.2022.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND /Objective: Studies have shown that Medicaid coverage is associated with higher rates of primary amputation among patients with peripheral artery disease (PAD). We sought to identify whether hospital payer makeup also influences outcomes among these patients. METHODS Patients who underwent treatment for foot complications in Texas were identified and aggregated by hospital. Hospitals were grouped by payer mix: low-income payer predominant vs high-income payer predominant. Variance analyses were used to find differences between the groups. Individual and hospital-level regression analyses were used to find associations with amputation rates. RESULTS Out of 21,592 patients, 9,098 (42%) underwent amputation. They presented to 337 hospitals out of which 49 (15%) had a low-income predominant payer mix and 109 (32%) had a high-income predominant payer mix. Patients at low-income payer predominant hospitals were more likely to present with gangrene (0.74 vs 0.65, p<0.01), undergo emergency admissions (0.67 vs 0.50, p<0.01), undergo amputation (0.53 vs 0.42, p<0.05), and incur higher per-day charges ($8145 vs $6790, p<0.05). At the individual level, despite risk-adjusting for disease-specific factors, amputation rate was associated with hospital payer mixes with greater proportions of Medicaid and lower proportions of commercially insured patients. At the hospital level, amputation rate was associated with higher proportion of Medicaid patients in hospital payer mix, lower hospital volumes, lower per-day charges, and higher gangrene and osteomyelitis rates (R2=0.30, p<0.01). CONCLUSION Higher proportion of Medicaid patients in a hospital payer mix is associated with an increased risk of primary amputation for PAD patients regardless of insurance coverage.
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Affiliation(s)
| | - Neal R Barshes
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas 77030; Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas 77030.
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Abstract
Diabetic foot ulcer (DFU) is a severe complication of diabetes mellitus (DM). Patients with DFU have increased mortality and morbidity as well as decreased quality of life (QoL). The present scoping review aims to study the social issues of diabetic foot. Following PRISMA guidelines, the review was conducted in two databases (Scopus and Pubmed) with the use of the following keywords: “social aspects and diabetic foot”, “social characteristics and diabetic foot”, “social issues and diabetic foot”, “demographic profiles and diabetic foot”, “social determinants and diabetic foot”, “social capital and diabetic foot”, “social characteristics and gender and diabetic foot”, “social profiles and diabetic foot”, “social relationships and diabetic foot” and “social risk and diabetic foot”, from July to August 2021. Predetermined exclusion and inclusion criteria were selected. Forty-five studies (quantitative and qualitative) were eligible for inclusion in this review. Gender problems, socioeconomic status, social capital, and medical problems were the most important negative variables for diabetic foot. All the included variables reveal that the social impact of diabetic foot is the most important factor for management and prevention, in terms of aggravation and more, of the diabetic foot.
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7
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Zhang GQ, Canner JK, Kayssi A, Abularrage CJ, Hicks CW. Geographical socioeconomic disadvantage is associated with adverse outcomes following major amputation in diabetic patients. J Vasc Surg 2021; 74:1317-1326.e1. [PMID: 33865949 DOI: 10.1016/j.jvs.2021.03.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 03/14/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Socioeconomic disadvantage is a known predictor of adverse outcomes and amputation in patients with diabetes. However, its association with outcomes after major amputation has not been described. Here, we aimed to determine the association of geographic socioeconomic disadvantage with 30-day readmission and 1-year reamputation rates among patients with diabetes undergoing major amputation. METHODS Patients from the Maryland Health Services Cost Review Commission Database who underwent major lower extremity amputation with a concurrent diagnosis of diabetes mellitus between 2015 and 2017 were stratified by socioeconomic disadvantage as determined by the area deprivation index (ADI) (ADI1 [least deprived] to ADI4 [most deprived]). The primary outcomes were rates of 30-day readmission and 1-year reamputation, evaluated using multivariable logistic regression models and Kaplan-Meier survival analyses. RESULTS A total of 910 patients were evaluated (66.0% male, 49.2% Black), including 30.9% ADI1 (least deprived), 28.6% ADI2, 19.1% ADI3, and 21.2% ADI4 (most deprived). After adjusting for differences in baseline demographic and clinical factors, the odds of 30-day readmission was similar among ADI groups (P > .05 for all). Independent predictors of 30-day readmission included female sex (odds ratio [OR], 1.45), Medicare insurance (vs private insurance; OR, 1.76), and peripheral artery disease (OR, 1.49) (P < .05 for all). The odds of 1-year reamputation was significantly greater among ADI4 (vs ADI1; OR, 1.74), those with a readmission for stump complication or infection/sepsis (OR, 2.65), and those with CHF (OR, 1.53) or PAD (OR, 1.59) (P < .05 for all). CONCLUSIONS Geographic socioeconomic disadvantage is independently associated with 1-year reamputation, but not 30-day readmission, among Maryland patients undergoing a major amputation for diabetes. A directed approach at improving postoperative management of chronic disease progression in socioeconomically deprived patients may be beneficial to reducing long-term morbidity in this high-risk group.
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Affiliation(s)
- George Q Zhang
- Johns Hopkins University School of Medicine, Baltimore, Md; Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Joseph K Canner
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Ahmed Kayssi
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md
| | - Caitlin W Hicks
- Johns Hopkins Surgery Center for Outcomes Research, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md; Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins Hospital, Baltimore, Md.
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