Article 3: Comparing amputation patterns in veterans affairs medical centers from 1997 to 2000

Objectives: To examine patterns of amputation (all levels) among veterans who were identified as at-risk and to examine factors that predict greater risks for a major (below-knee, above-knee) amputation. Design: Database approach, secondary data analysis. Setting: Veterans Affairs medical centers (VAMCs). Participants: 451,824 were selected if they had diagnoses of diabetes mellitus or peripheral vascular disease, and were at-risk for lower-extremity amputation. These patients were followed for 4 years (1997-2000) to determine the occurrence of amputation. Interventions: Not applicable. Main Outcome Measures: Differences in frequency and level of amputation were assessed among 132 VAMCs with different Preservation of Amputation Care and Treatment (PACT) rankings. Regression techniques were used to identify factors associated with increased risk. Results: Over the 4-year period, 10,258 patients had at least 1 amputation (2.3%). Highly ranked VAMCs had greater amputation rates and performed more above-knee amputations than less well ranked VAMCs. Factors that increase risk for a major amputation include race, skin ulcers, gangrene, and prior amputation. Conclusion: High-PACT VAMCs are often located in an urban setting, affiliated with academic medical programs, and have higher volume of patients. Higher amputation rate at high-PACT facilities may reflect a movement toward centers of excellence for prevention of and treatment for lower-extremity amputations.