Assessing The Impact of Covid-19 on Lower-Limb Amputations in Underserved Populations

Dr Bill Releford
February 5, 2022

Avoidable lower-limb amputations increased in the wake of the COVID-19 pandemic. Before the virus broke out, the minority groups and underserved populations already had a hard time getting quality healthcare. The pandemic further exacerbated the state of the American healthcare system as hospitals and rehabilitation centers were filled with COVID-19 patients and the offices of doctors, therapists, and prosthetists closed.

COVID-19 Contribution to Amputation Rates

According to the Center for Disease Control and Prevention (CDC), people living with limb loss are also at a higher risk for COVID-19 infections because of underlying conditions such as diabetes and cancer. CDC adds that more than three-quarters of the people who died from COVID-19 had at least one preexisting condition, with diabetes accounting for 4 in 10 deaths.

The novel coronavirus is known to cause blood clots that restrict blood flow through arteries, including those in the lower extremity, leading to peripheral arterial disease (PAD). In turn, PAD often results in amputation and premature death.

COVID-19 causes restricted flow of oxygen into the lungs. When there’s little flow of oxygen in the lungs, the body naturally takes oxygen to the most precious organs such as the brain, heart, and lungs. It then robs oxygen from the limbs for more urgent needs and can result in gangrene, which may require amputation if not treated early.

Impact of COVID-19 in Preventive Care

Preventive care procedures such as using stents, balloons, or bypass surgery to improve blood flow are effective in preventing lower-limb amputations. However, Black Americans are more likely to get an amputation and less likely to receive amputation prevention preventive procedures than whites. As lockdowns and more measures were put in place, many medical clinics temporarily shut down and elective surgeries halted. The situation worsened for those patients that needed specialized and continuous care.

Managing PAD to prevent ulcers or restricted blood flow requires constant checkups. But even in normal times, many patients from underserved communities don’t get comprehensive medical care. Many people in communities of color either don’t know they need care or lack a good medical insurance cover despite advances in treatment and Medicaid expansion. Unfortunately, the pandemic only escalated existing disparities related to poor access to healthcare and lack of specialized treatment.

Concerns about contracting the virus also add to the challenges of preventive care during the pandemic. Many people were scared of in-person meetings with their healthcare providers and therefore skipped their checkup appointments.  

Early in the pandemic, services such as treatment for ulcers were considered “nonessential” by many hospitals. A national survey found that 90% of patients canceled elective surgeries during the pandemic. This led to increased hospital death for patients with urgent limb problems during the COVID surges. Also, those that visited hospitals were mostly non-whites exhibiting more advanced disease than pre-pandemic.

Missing “The Window of Opportunity” For Rehabilitation

Patients who undergo lower-limb amputations require a period of regular physical therapy for recovery. This period is referred to as the “critical window” and should be started immediately after hospital discharge. Research shows that getting good rehab care early increases the likelihood of surviving more than a year.

Lack of access to rehabilitation facilities by underserved Black and African American people has been a problem even before the COVID-19 pandemic. The situation worsened during the COVID-19 pandemic since too often, these facilities either closed their doors to amputees or became “overflow” units amid viral surges. Most of the amputees opted to go home and wait.

Delays in rehabilitation have been linked to repeat amputations and a lower likelihood of walking in the long term. Without physical therapy, the muscles may go unused, shorten and tense up, and eventually freeze up the residual limb leading to repeat lower-limb amputation. 

Poverty is also a major factor affecting amputees of color. Amputation post-care requires sterile bandages, cleaning supplies, and other safety equipment that these individuals can hardly afford.

Surveys done by the American Physical Therapy Association (APTA) show that as of May 2021, 30% of therapists were either laid off, furloughed, or resigned in the past year. Also, at that time, half of the outpatient clinics had closed at some point.

In recent years, there has been a surge of private surgical centers known as “office-based labs” (OBLs) that offer amputation prevention procedures.  A study found that African-Americans are less likely to be prescribed prosthetics than white patients in these privately-owned centers.

Inequalities in Telehealth

Telehealth at its best offers a worthy substitute for in-person care. It proved essential once the COVID-19 lockdowns began in March 2020 and patients couldn’t go for in-person checkups. As the world turned virtual, so did healthcare.

Many specialists scheduled virtual clinics with a nurse who is physically present with the patient assisting. However, for underserved populations, such an arrangement proved inadequate. Some of these people struggle with language and technology barriers, and have a bad internet connection. This way, telehealth may propagate disparities to an already dysfunctional healthcare system for those facing health inequalities.

Bottom Line

Many healthcare injustices put underserved communities at an even higher risk of amputations. Lower-limb amputations continue to signify the disparities in healthcare, since the large portion of the amputees is disproportionately Black and African American patients. Unprecedented medical emergencies such as COVID-19 have further indicated the danger that lies ahead if the health disparities are not addressed.