Veterans Hospitals vs Non-Veterans Centers in the Prevention of Limb Loss.
Academic Article
Overview
abstract
IMPORTANCE: US veterans remain an at-risk population for limb loss, given the prevalent rates of coexisting diabetes and peripheral arterial disease (PAD). Moreover, despite the perception that a healed minor amputation might obviate the need for a future major amputation, previous work documented increased longitudinal rates of limb loss among non-veteran Medicare beneficiaries. OBJECTIVE: To document the corresponding incidence of major amputation among veterans after a prior minor amputation and accordingly benchmark Veterans Affairs (VA) health care delivery compared to non-VA civilian hospitals. DESIGN, SETTING, AND PARTICIPANTS: This cohort study used data from VA hospitals and identifiable linked VA-Medicare datasets using corporate data warehouse and community care data sources from January 2015 to December 2023. Of 1 451 297 veterans with information on diabetes, 64 808 had concomitant diabetes and PAD, and 62 295 of these were not receiving dialysis and were included in the study. Race and ethnicity data were derived from the electronic health record and were considered for this study to assess the association between race, ethnicity, and amputation (bearing in mind that race and ethnicity variables incompletely capture structural racism and systemic disparities in vascular disease). Race and ethnicity data are self-reported in the VA. Data were analyzed from May 2024 to January 2026. EXPOSURE: Prior minor (toe or forefoot) amputation. MAIN OUTCOME: Major (below-knee or above-knee) amputation. RESULTS: Among the 62 295 veterans included, the mean (SD) age was 72.3 (10.5) years; 60 132 (96.5%) were male; and 500 (0.8%) were Asian, 512 (0.8%) American Indian or Alaska Native, 9318 (15.4%) Black, 581 (1.0%) Native Hawaiian or Other Pacific Islander, 46 540 (77.0%) White, 2198 (3.6%) more than 1 race, and 760 (1.3%) unknown or other (unspecified). A total of 2791 (4.5%) had coronary artery disease, and 8633 (13.9%) chronic kidney insufficiency. Among included veterans, 1327 (2.1%) underwent a prior minor amputation and were more likely to be male (1306/1327 [98.4%] versus 58 826/60 968 [96.5%]; P < .001), to be Black (232/1290 [18.0%] versus 9086/59 119 [15.4%]; P < .001) or Native American (13/1290 [1.0%] versus 499/59 119 [0.8%]; P < .001), to have higher hemoglobin A1c (mean [SD], 7.2% [1.7] vs 6.7% [1.3]; P < .001), and to have undergone a prior open (106/1327 [8.0%] vs 1381/60 968 [2.3%]; P < .001) or endovascular revascularization (199/1327 [15.0%] vs 2298/60 968 [3.8%]; P < .001) compared to veterans without prior minor amputation. At 5 years, 20.4% (95% CI, 17.7-23.3) of veterans not receiving dialysis with diabetes and PAD and prior minor amputation underwent a major amputation. Among those who underwent minor amputation, 662 veterans (49.9%) had at least 1 podiatry visit and 699 (52.7%) veterans underwent hemoglobin A1c testing, compared to 146 273/202 304 (72.3%) and 106 054/202 304 (52.4%) Medicare beneficiaries, respectively. CONCLUSIONS AND RELEVANCE: In this cohort study, approximately 1 in 5 veterans with concomitant diabetes and PAD who underwent any prior minor amputation later underwent a major amputation. These results are comparable to previously published results among nonveteran Medicare beneficiaries of similar risk profile. These findings would suggest that the VA health care system can achieve comparable limb salvage outcomes when compared to non-VA hospitals in this high-risk patient population.
