Role of Socioeconomic Status in Amputation Rates With Comorbid PVD and Diabetes

A study was conducted to determine the relationship between socioeconomic status and major amputation in patients with diabetes and peripheral vascular disease.

Individuals with concomitant peripheral vascular disease (PVD) and diabetes mellitus (DM) who reside in neighborhoods of low socioeconomic status have an increased likelihood of undergoing major lower limb amputation despite receiving medical care in the same health care system as individuals with a higher socioeconomic status. These findings were published in the Annals of Vascular Surgery.

Recognizing that both PVD and DM are leading causes of lower-extremity amputation, the researchers sought to explore the impact of socioeconomic status on major amputation among patients with diabetes and PVD from a single health care system. A cross-sectional, retrospective study was conducted among patients at the St. Louis Veterans Affairs Health Care System (St. Louis, Missouri). All individuals who presented to the system, either for inpatient or outpatient visits, between January 1, 2012, and December 31, 2017, with ICD 9 and 10 codes for both PVD and DM on the same day were included in the study.

The Area Deprivation Index (ADI) score was used to estimate an individual’s socioeconomic status based on their 9-digit ZIP code, with this value having been shown to be associated with poor health outcomes. Patients who underwent major amputation below the knee or above the knee were identified and compared with individuals who had not undergone an amputation.

A total of 2009 individuals were identified, of whom 85 underwent a major amputation. Following adjustment for comorbidities, participants in the amputation cohort had significantly higher ADI scores than those in the non-amputation arm (8 vs 6, respectively; P <.05). Per logistic regression modeling, an odds ratio of 1.10 (95% CI, 1.01-1.19) was reported, thus demonstrating that the likelihood of being in the amputation group was increased by 10% for every 1-point increase in ADI score.

Several limitations to the study are characteristic of those with a retrospective design, such as lack of randomization and unavailable chart data. It should be noted that patients enrolled in the study may have received part of their medical or surgical care for PVD or DM outside of the VA Health System.

“Patients residing in neighborhoods with low socioeconomic status have increased odds of undergoing major lower limb amputation as the outcome of concomitant [PVD] and [DM],” the study authors wrote. “Further study is warranted to determine factors contributing to this difference.”

Disclosure: None of the study authors has declared affiliations with biotech, pharmaceutical, and/or device companies.  


Fan RR, Gibson AK, Smeds MR, Zakhary E. Impact of socioeconomic status on major amputation in patients with peripheral vascular disease and diabetes mellitus.Ann Vasc Surg. Published online April 5, 2022. doi:10.1016/j.avsg.2022.03.035