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Geographic Region and Insurance Status Predict Access to Salvage Procedures for Diabetic Lower Extremity Wounds in the United States
Alexander J. Kammien
*, Brogan G. Evans, Haripriya Ayyala, David L. Colen
Division of Plastic and Reconstructive Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT
Purpose: The current study assessed factors associated with limb salvage and subsequent amputations for patients with diabetic lower extremity wounds in the United States.
Methods: Using national administrative data from 2010-2022, adults undergoing amputation or salvage procedures (skin graft, local flap or free flap) for diabetic lower extremity wounds were identified. Patient age, sex, Elixhauser comorbidity index, geographic region and insurance status (private, Medicare, Medicaid) were extracted. Insulin dependence, tobacco use, end-stage renal disease, peripheral vascular disease, prior amputation, preoperative lower extremity infection and preoperative vascular testing or intervention were also extracted. Subsequent amputations following limb salvage were identified. Factors associated with salvage procedures and subsequent amputation were analyzed with multivariable logistic regression controlling for all patient and clinical factors.
Results: The final cohorts included 97,472 patients with amputation and 62,850 patients with salvage. Average follow-up was 3.9 years. Many patient and clinical factors were associated with limb salvage (Figure 1). Most notably, patients in the Northeast had substantially greater odds of undergoing salvage (relative to those in the West, OR 1.73, 95CI 1.67-1.80), and relative to privately insured patients, those with Medicare (0.71, 0.70-0.73) and Medicaid (0.61, 0.59-0.64), were substantially less likely to undergo salvage. Of patients who underwent salvage, 11,595 (18%) underwent subsequent amputation at an average time of 1.7 years. Geographic region was not associated with subsequent amputation, and patients with Medicare (1.12, 1.06-1.18) and Medicaid (1.16, 1.08-1.24) were only slightly more likely to undergo a subsequent amputation.
Conclusions: There are significant disparities in access to limb salvage procedures in the United States based on region and insurance status despite only minor differences in progression to subsequent amputation for these patients.
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