Quantifying and Addressing Racial and Ethnic Disparities in Lower-Limb Prosthesis Prescriptions Among US Veterans

BACKGROUND: Black and Hispanic Veterans undergo lower-limb amputations at higher rates than White Veterans, yet it remains unclear whether they receive equitable access to prosthetic devices within the Veterans Health Administration (VHA). OBJECTIVE: To quantify racial and ethnic disparities in lower-limb prosthesis (LLP) prescriptions among Veterans and identify factors contributing to these disparities. RESEARCH DESIGN: Retrospective cohort study using generalized Kitagawa-Oaxaca-Blinder decomposition and prescriptive disparity analysis with double/debiased machine learning. SUBJECTS: Veterans who underwent major lower-limb amputation within the VHA from 2010 to 2022 (n=16,157; 66.2% White, 27.4% Black, 6.4% Hispanic). MEASURES: Prescription of any LLP and advanced LLP within 12 months postamputation. RESULTS: Black and Hispanic Veterans were 5.7 percentage points (pp) [95% confidence limits (CLs): 4.0, 7.5] and 5.6 pp (95% CLs: 2.4, 8.8) less likely than White Veterans to receive any LLP prescription, respectively. For advanced LLPs, disparities were 1.7 pp (95% CLs: 0.8, 2.6) for Black Veterans and 3.0 pp (95% CLs: 1.5, 4.5) for Hispanic Veterans. Facility-level factors explained 58.2% of the White-Black disparity in any LLP prescriptions. Measured factors fully explained the White-Black disparity in advanced LLP prescription, with preamputation clinical factors contributing most. Prescriptive analysis revealed that targeted quality improvement at facilities serving high proportions of Black Veterans could reduce disparities by 32.5%, while interventions addressing end-stage renal disease could reduce advanced LLP disparities by 33.6%. CONCLUSIONS: Targeted resource allocation to facilities serving high proportions of racial and ethnic minority Veterans and integrated care pathways for Veterans with complex comorbidities represent actionable interventions for reducing prosthetic care inequities.