Social and Hospital-Level Disparities Shape Amputation Risk in Advanced Peripheral Artery Disease: Study
USA: A new US analysis highlights widening disparities in major lower-extremity amputations among patients with chronic limb-threatening ischemia (CLTI). More than 40% of amputations occurred in patients from the lowest income quartile, while nearly 80% were performed at hospitals serving moderate-to-high proportions of Medicaid patients.
The findings suggest that both socioeconomic status and the hospital where patients receive care increasingly influence limb-loss risk, highlighting the need for improved access to timely vascular care and limb-preservation strategies. The study was published in the Journal of Vascular Surgery by Sherene E. Sharath, Department of Surgery, State University of New York, Downstate Health Sciences University, Brooklyn, New York, and colleagues.
Major lower-extremity amputation is a devastating complication of chronic limb-threatening ischemia, often leading to disability, reduced quality of life, and increased mortality. Although previous reports had shown declining amputation rates, more recent evidence suggests that this trend has reversed. To examine how patient socioeconomic factors and hospital characteristics have influenced this shift, researchers analyzed national trends spanning nearly three decades.
The investigators conducted a retrospective cohort study using data from the National Inpatient Sample between 1993 and 2021. They identified hospital admissions involving atherosclerosis, chronic limb-threatening ischemia, and chronic arterial occlusions. Major amputations, including below-knee amputations (BKA) and above-knee amputations (AKA), were identified using procedural codes. The researchers assessed amputation rates according to neighborhood income quartile, race, ethnicity, and hospital Medicaid burden, using multivariable analyses to evaluate changes over time.
The study included 2,769,388 hospital admissions, during which 197,018 below-knee amputations and 151,018 above-knee amputations were performed.
Key findings
- Nearly 42% of both below-knee and above-knee amputations occurred in patients from the lowest income quartile.
- Approximately 79% of major amputations were performed at hospitals caring for moderate-to-high proportions of Medicaid patients.
- Earlier in the study period, higher amputation risk was strongly associated with greater hospital Medicaid burden, lower income, and Black race.
- In more recent years, elevated amputation risk extended beyond the highest Medicaid-burden hospitals to include facilities with moderate Medicaid populations.
- The protective advantage associated with higher income widened over time, leaving patients in the lowest income groups at an increasingly greater risk of limb loss.
The findings suggest that major amputation risk is no longer limited to the most disadvantaged hospitals but has expanded across a broader range of healthcare settings, while continuing to disproportionately affect low-income patients.
The authors called for improved identification and management of patients with chronic limb-threatening ischemia, emphasizing the need for stronger preventive vascular care, better access to limb-salvage services, and resource-responsive policies to reduce avoidable amputations and socioeconomic disparities.
Reference:
Sharath, S. E., Natarajan, S., Sihaloho, D., Ferguson, C., Medvedovsky, S., Joseph, T., & Kougias, P. (2026). Shifting Burden of Major Lower Extremity Amputations Across Hospital Medicaid Burden and Socioeconomic Groups, 1993-2021. Journal of Vascular Surgery. https://doi.org/10.1016/j.jvs.2026.06.157
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