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. 2019 Mar;30(3):481-491.
doi: 10.1681/ASN.2018101002. Epub 2019 Feb 19.

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

Catherine R Butler  1 , Margaret L Schwarze  2 , Ronit Katz  3 , Susan M Hailpern  3 , William Kreuter  3 , Yoshio N Hall  3 , Maria E Montez Rath  4   5 , Ann M O'Hare  3   6
Affiliations

Lower Extremity Amputation and Health Care Utilization in the Last Year of Life among Medicare Beneficiaries with ESRD

Catherine R Butler et al. J Am Soc Nephrol. 2019 Mar.

Abstract

Background: Lower extremity amputation is common among patients with ESRD, and often portends a poor prognosis. However, little is known about end-of-life care among patients with ESRD who undergo amputation.

Methods: We conducted a mortality follow-back study of Medicare beneficiaries with ESRD who died in 2002 through 2014 to analyze patterns of lower extremity amputation in the last year of life compared with a parallel cohort of beneficiaries without ESRD. We also examined the relationship between amputation and end-of-life care among the patients with ESRD.

Results: Overall, 8% of 754,777 beneficiaries with ESRD underwent at least one lower extremity amputation in their last year of life compared with 1% of 958,412 beneficiaries without ESRD. Adjusted analyses of patients with ESRD showed that those who had undergone lower extremity amputation were substantially more likely than those who had not to have been admitted to-and to have had prolonged stays in-acute and subacute care settings during their final year of life. Amputation was also associated with a greater likelihood of dying in the hospital, dialysis discontinuation before death, and less time receiving hospice services.

Conclusions: Nearly one in ten patients with ESRD undergoes lower extremity amputation in their last year of life. These patients have prolonged stays in acute and subacute health care settings and appear to have limited access to hospice services. These findings likely signal unmet palliative care needs among seriously ill patients with ESRD who undergo amputation as well as opportunities to improve their care.

Keywords: amputation; end-of-life; end-stage renal disease; palliative care; surgery; vascular disease.

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Figures

None
Graphical abstract
Figure 1.
Figure 1.
Cohort derivation flow diagram. (A) Cohort derivation for Medicare beneficiaries with ESRD. (B) Cohort derivation for Medicare beneficiaries without ESRD. ICD-9, International Classification of Diseases, Ninth Revision.
Figure 2.
Figure 2.
Highest level and frequency of amputation during the last year of life among patients with and without ESRD. AKA, above-knee amputation; BKA, below-knee amputation.
Figure 3.
Figure 3.
Adjusted association of ESRD with amputation level and frequency during the last year of life.
Figure 4.
Figure 4.
End-of-life care for patients with ESRD stratified by receipt of amputation. Percentage of patients with ESRD admitted to different care settings in the last year of life and percentage that died in a hospital and discontinued dialysis before death (left). Median time spent in each setting (right). Note: error bars around median days spent in each setting denote IQR.
Figure 5.
Figure 5.
Adjusted association of amputation with end-of-life health care utilization in patients with ESRD.
Figure 6.
Figure 6.
End-of-life care for patients with ESRD stratified by level and frequency of amputation. Percentage of patients with ESRD admitted to different care settings in the last year of life and percentage that died in a hospital and discontinued dialysis before death (left). Median time spent in each setting (right). Note: error bars around median days spent in each setting denote IQR. AKA, above knee-amputation; BKA, below-knee amputation.
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