Geographic Variation in Prosthesis Prescription Disparities Between White and Black Veterans After Major Lower Limb Amputation: A Retrospective Cohort Analysis: Geographic Variation in Lower Limb Prosthesis Prescription Disparities.

Abstract

Objective: To examine racial disparities in lower limb prosthesis (LLP) prescription practices between White and Black Veterans across different geographic levels within the United States Veterans Health Administration (VHA) and explore how racial disparities in LLP prescription practices differ by amputation level.

Design: Retrospective cohort study.

Setting: VHA facilities across the United States.

Participants: A total of 12,143 White and 4,711 Black Veterans who underwent major lower limb amputation between 2010 and 2022 in a VHA facility, including 4,885 with transfemoral amputations (TFA) and 11,969 with transtibial amputations (TTA).

Interventions: Not applicable.

Main outcome measures: Age-standardized percentage point (pp) differences in LLP prescriptions between White and Black Veterans within 12 months post-amputation, analyzed at national, regional, and Veterans Integrated Service Network (VISN) levels. A positive pp difference indicates a racial disparity, meaning a higher proportion of White Veterans were prescribed LLPs compared to Black Veterans.

Results: Nationally, 54.5% of Veterans received an LLP prescription within 12 months post-amputation, with the age-standardized pp difference in LLP prescriptions favoring White Veterans by 5.06 pp (95% CI: 2.51, 7.61). Regional analysis revealed variations, with the Continental region showing the largest disparity (9.10 pp; 95% CI: 4.48, 13.71) and the Pacific region the smallest (3.27 pp; 95% CI: -3.87, 10.42). The VISN-level analysis uncovered greater variations, ranging from -9.26 to 14.54 pp. Disparities were more pronounced for Veterans with TFA (5.25 pp; 95% CI: 1.91, 8.59) compared to TTA (4.52 pp; 95% CI: 1.54, 7.50).

Conclusions: Significant geographic variations exist in racial disparities for LLP prescriptions across the VHA, with most areas favoring White Veterans. Disparities were more pronounced for Veterans with transfemoral amputations, highlighting the need for targeted interventions to improve equity in access to prosthetic care, especially for Veterans with more proximal amputations and in regions and VISNs with the largest disparities.