Temporal Trends in Incidence Rates of Lower Extremity Amputation and Associated Risk Factors Among Patients Using Veterans Health Administration Services From 2008 to 2018

This cohort study examines temporal trends and risk factors associated with lower extremity amputation among veterans using Veterans Health Administration services. Question What are the temporal trends of lower extremity amputation (LEA) among US veterans and what risk factors are associated with the changes? Findings In this cohort study of 6 493 141 veterans using Veterans Health Administration services, rates of LEA increased between 2008 and 2018. Changes in demographic composition and lower smoking rates were associated with a reduction in LEA incidence rates, but these reductions were more than offset by increased rates of diabetes, peripheral artery disease, and chronic kidney disease. Meaning These findings suggest that strategies targeting prevention of diabetes, peripheral artery disease, and chronic kidney disease, as well as further reduction in smoking rates, might contribute to reducing the burden of LEA. Importance Lower extremity amputation (LEA) is associated with significant morbidity and mortality. However, national temporal trends of LEA incidence rates among US veterans and associated factors have not been well characterized. Objective To describe the temporal trends of LEA, characterize associated risk factors, and decompose the associations of these risk factors with changes in temporal trends of LEA among US veterans using Department of Veteran Affairs (VA) services between 2008 and 2018. Design, Setting, and Participants This cohort study used VA data from 2008 to 2018 to estimate incidence rates of LEA among veterans using VA services. Cox regression models were used to identify risk factors associated with LEA. Decomposition analyses estimated the associations of changes in prevalence of risk factors with changes in LEA rates. Data were analyzed from October 1, 2007, to September 30, 2018. Main Outcomes and Measures Toe, transmetatarsal, below-knee, or above-knee LEA. Results A total of 6 493 141 veterans were included (median [interquartile range] age, 64 [54-76] years; 6 060 390 [93.4%] men). Veterans were studied for a median (interquartile range) of 10.9 (5.6-11.0) years. Between 2008 and 2018, rates of LEA increased from 12.89 (95% CI, 12.53-13.25) LEA per 10 000 persons to 18.12 (95% CI, 17.70-18.54) LEA per 10 000 persons, representing a net increase of 5.23 (95% CI, 4.68-5.78) LEA per 10 000 persons. Between 2008 and 2018, toe amputation rates increased by 3.24 (2.89-3.59) amputations per 10 000 persons, accounting for 6