RS24 - Achieving Equity in Limb Salvage Despite Socioeconomic Barriers: A Single-Center Experience

Objectives: We evaluated whether community-level distress influenced management and outcomes among patients undergoing minor lower extremity amputation within a standardized multidisciplinary limb-salvage pathway.

Methods: We conducted a retrospective cohort study of consecutive patients undergoing minor amputation (toe, ray, or transmetatarsal) from 2017–2023 at a single academic vascular center. Socioeconomic status was defined using ZIP code–linked Distressed Communities Index (DCI) values and categorized into quintiles. Primary outcomes included revascularization, progression to major amputation, reintervention, and one-year mortality. Comparisons focused on the least (Q1) and most distressed (Q5) communities. Analyses included generalized estimating equations adjusted for WIfI stage, demographics, and comorbidities; Kaplan–Meier survival analysis; and Cox regression. Penalized LASSO Cox identified independent predictors.

Results: A total of 848 patients were included. Mean age was 60±13 years; 67% were male, 55% White, and 73% resided in rural areas. Insurance coverage varied significantly across DCI quintiles (Medicare 52–71%, Medicaid 9–26%, private insurance 6–18%; p< 0.001). Limb-threat severity was substantial, with 58% presenting in WIfI stages 3–4. Overall, 25% underwent revascularization, 12% progressed to major amputation, 45% required reintervention, and one-year mortality was 10%. Despite demographic disadvantages among the most distressed communities (DCI Q5 vs Q1), patients were younger (58 vs 62 years), more often non-White (56% vs 41%), frequently rural (82% vs 61%), and had higher PAD prevalence (72% vs 58%), treatment patterns were similar between groups. Upstream disparities were evident: patients from distressed communities had substantially worse ischemia severity, with WIfI stage 4 increasing from 31.5% in Q1 to 43.8% in Q5 (p=0.002). Outcomes were equivalent across socioeconomic strata. Rates of revascularization (27% vs 27%, p=0.65), major amputation (12% vs 10%, p=0.75), and mortality (10% vs 11%, p=0.81) did not differ by DCI. Treatment decisions were driven by WIfI stage (OR 0.67, p< 0.001), not socioeconomic distress. LASSO showed WIfI stage (HR 1.54) and ESRD on hemodialysis (HR 2.14) as dominant predictors of major amputation(Figure1), while DCI, insurance status, age, and cardiovascular risk factors were eliminated.

Conclusions: Within a standardized multidisciplinary program, socioeconomic distress did not influence treatment intensity or postoperative outcomes after minor amputation, however it was associated with worse ischemia at presentation. Once patients enter coordinated limb-salvage pathways, outcomes are determined by disease severity rather than community-level socioeconomic status. Regional disparities in amputation rates likely reflect upstream access barriers rather than inequities in specialized vascular care delivery. Future efforts focused on earlier access to these defined programs may improve outcomes for deprived areas.