A: The number is unacceptably high. And so are the potential costs to amputees’ health.

We were somewhat taken aback last winter when Dr. Kenton Kaufman, the director of the National Limb Loss and Preservation Registry, told us that as many as two-thirds of amputees never receive a prosthesis of any kind. It’s no secret that many amputees lack access to adequate prosthetic care, but we’d always assumed that most people who want at least a basic device can procure one.

Evidently we assumed wrong. The Triple A Study Act, the bipartisan Senate legislation we covered in last week’s newsletter, echoes Kaufman’s assertion that roughly two-thirds of the amputee population can’t get a prosthesis. And a new study to be published in a forthcoming issue of the Journal of Vascular Surgery (JVS) tells the same story from a slightly different angle. According to this report, only 42 percent of new lower-limb amputees are referred to a prosthetist by their surgical care team or primary care physician.

That’s a shockingly low number, given that prosthesis use correlates strongly with post-amputation health in lower-limb amputees. In essence, 58 percent of the amputees in this study were consigned to a higher-risk category by not getting referred to a prosthetist. And the most common barriers to access—cost and insurance—aren’t even relevant in this instance. We’re not talking about the procurement of a prosthetic device costing tens of thousands of dollars. This investigation focuses on a simple initial consultation with a prosthetist, which often costs nothing and almost never costs a prohibitive amount. Moreover, the patients in this particular study attended a prosthetic clinic that routinely serves uninsured and underinsured individuals.

So if cost wasn’t the issue, then what did keep these patients from getting the care that gives them the best chance to achieve good health after limb loss? The authors found that patients with the following characteristics were less likely to get referred to a prosthetist:

* Female
* Smoker
* Diabetic
* More than 70 years old
* ASA fitness score of 4 or 5

Taking these in reverse order: The ASA fitness scale was developed by the American Society of Anesthesiologists to assess patients’ fitness for surgery. Without getting too deep in the weeds, patients who score either 4 or 5 have significant life-threatening health issues aside from their amputation. Examples might include kidney impairment, intestinal obstructions, or heart problems. As the JVS authors acknowledge, there may be legitimate reasons not to refer such patients to a prosthetist; their underlying health conditions might make it ill-advised, or even impossible, to consider fitting them for a limb.

Likewise, some individuals above the age of 70 might be better served by a wheelchair or crutches, as opposed to a prosthesis, because of risks associated with balance, stamina, circulation, or other issues. Unfortunately, there are no standardized criteria for referral, so it’s impossible to know whether non-referred patients are truly unsuitable for prosthetic fitting in a clinical sense. Some of them might be, but others might be denied access to a prosthetist because of unconscious biases, geographic variation, flaws in the health care model, or other factors that have nothing to do with the individual patient and everything to do with the system that’s supposed to serve them.

The authors note that prosthetic referral was associated with better post-amputation outcomes even after controlling for other risk factors. “The risk factors for prosthetics referral following amputation have not been adequately investigated,” they conclude. Initiatives like the Limb Loss Registry and Triple A Study Act may shed some much-needed light. If the JVS findings spur further investigation, we’ll report on it here.