Clinical Studies
Institutionalization Following Diabetes-Related Lower Extremity Amputation

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Abstract

PURPOSE: We are unaware of any report in the medical literature that has discussed risk factors for both mortality and discharge disposition following lower extremity amputation (LEA). Our aim was to report risk factors associated with in-hospital mortality and the need for institutional care in diabetics with LEAs.

PATIENTS AND METHODS: We abstracted data for every hospitalization for a LEA from January 1 to December 31, 1993 in six metropolitan statistical areas in South Texas. Amputation level was categorized as foot, leg, or thigh. Discharge status categories were: home, nursing home, rehabilitation facility, and death. We used the Kaplan scale of cogent comorbidities to determine the relationship of 12 disease categories and their association with discharge status.

RESULTS: There were 1,043 LEAs in South Texas in 1993. Although only 2.3% of the population was admitted from an institutional care facility, over 25% were discharged to one. Of the total population, 18.5% were discharged to a nursing home and 7.0% to a rehabilitation facility, and 5.1% died within the period of hospitalization. We performed a univariate analysis. Factors with a P <0.25 were included in a stepwise logistic regression analysis with an α of 0.05. High level (leg or thigh) amputation, peripheral vascular disease, male gender, and absence of advanced locomotor impairment were associated with discharge to a rehabilitation facility. For discharge to a nursing home, significant associations were found with: female gender, advanced age (>65 years), single marital status, high level amputation, and advanced cerebrovascular disease and locomotor impairment. Death following LEA was strongly associated with female gender, high level amputation, advanced renal disease, anemia, and congestive heart failure.

CONCLUSION: A significant number of patients either die or require long-term care following a diabetes-related LEA, thus further adding to the burden of this sequela. Several clinical parameters are significantly associated with discharge status after this procedure. More prospective clinical research is needed to verify the associations and to clarify their application in practice.

Section snippets

Materials and Methods

We abstracted the medical records for each hospitalization for a lower extremity amputation from January 1 to December 31, 1993, in six metropolitan statistical areas (MSAs) in South Texas: San Antonio, Corpus Christi, Brownsville, McAllen, Laredo, and Victoria. Each hospital in the study areas, including military and Veterans Administration Hospital facilities, provided a list of patients that had amputations in 1993. We also abstracted medical records at the nearest state hospital facility,

Results

A total of 1,043 diabetic persons, 616 male and 427 female, with a mean age of 64.8 ± 12.5 years, underwent a lower extremity amputation in 1993. Of these amputations, 45.7% were performed at the level of the foot, 32.3% at the level of the leg, and 22.0% at thigh level. Of foot level amputations, 84.5% were digital or ray amputations, 15.1% were at the transmetatarsal level, and 0.4% were performed proximal to the transmetatarsal level but distal to the ankle.

Of all amputees, 1,019 (97.3%)

Discussion

The results of this study suggest that the vast majority of patients that were institutionalized following lower extremity amputation were living at home prior to amputation. Patients discharged to nursing homes were more likely to be single, elderly females with high level amputations and advanced cerebrovascular disease and locomotor impairment. Patients who were discharged to a rehabilitation facility were more likely to be male high-level amputees with advanced peripheral vascular disease

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