medwireNews: The likelihood of limb amputation within a year of being diagnosed with diabetic foot ulcer (DFU) varies significantly across Veterans Health Administration (VHA) centers with the difference primarily related to disparities in diabetic foot ulcer-specific care, US study findings indicate.
The findings provide “an estimate of the extent to which limb salvage could be improved by standardizing high-quality care throughout the nation’s largest health care system,” write Hiroyuki Suzuki (Iowa City VA Health Care System) and co-authors in JAMA Network Open.
Suzuki and team examined facility-level variation in major leg amputation among 86,094 veterans (mean age 73 years, 98% men) who received a new diagnosis of DFU at one of 140 VHA facilities across the USA between 2016 and 2021.
Of these, 3.8% underwent major leg amputation within a year of DFU diagnosis and 15.6% died.
After adjusting for demographics, comorbidities, and complicated DFU at initial diagnosis, the researchers found that the median odds ratio (OR) for facility-level variation was a significant 1.85 and ranged from 0.29 to 3.53.
This indicates that two identical hypothetical patients would have a median 85% higher odds of major leg amputation if treated in one random facility versus another, they explain.
Suzuki et al point out that the magnitude of the facility-level median OR for amputation was larger than the point estimate ORs for many patient-level variables, including age, social vulnerability, and comorbidities such as myocardial infarction and chronic kidney disease. “This suggests that the facilities caring for patients with DFU are important determinants of the likelihood of major leg amputation,” the authors remark.
They continue: “We hypothesize that variation in major leg amputation is largely due to health care system factors related to organization of care in patients with DFUs in each facility because we found a much smaller degree of facility-level variation in all-cause mortality and prior studies report associations between DFU-specific care and limb salvage.”
Indeed, the median OR for facility-level variation in 1-year mortality was 1.16, ranging from 0.69 to 1.42.
The authors conclude: “The VHA should strive to minimize the odds of major leg amputation and interfacility variation.”
To do so, the investigators plan “to assess how facility-level variation in major leg amputation rates is influenced by health care organization and care processes.”
They say: “Facilities serving communities with high rates of social deprivation and excelling at limb salvage may offer insights into closing longstanding disparities. The VHA’s national program PAVE (Prevention of Amputation in Veterans Everywhere) provides an infrastructure to distribute best practices to clinicians vested in limb salvage at each facility, including identification of patients at risk for leg amputation and timely referral of the highest-risk patients to podiatrists.”
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