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Access To Care Affects Level Of Diabetic Amputation In American Hospitals
Jenna C. Bekeny, BA1, Christopher J. Kennedy, DPM1, Elizabeth G. Zolper, BS1, John S. Steinberg, DPM1, Christopher E. Attinger, MD1, Karen K. Evans, MD1, Derek DeLia, PhD1,2, Kenneth L. Fan, MD1.
1Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC, USA, 2MedStar Health Research Institute, Hyattsville, MD, USA.

PURPOSE: Diabetic lower extremity disease is the primary driver of mortality among patients with diabetes. Functional foot amputation (FFA) at the forefoot or ankle preserves limb length, increases function, and reduces deconditioning and mortality. In cases in which amputation is necessary, lower level amputations should be preferentially pursued versus their higher level, higher morbidity counterparts. We sought to examine the risk factors and disparities that are predictive against receiving a FFA.
METHODS: Diabetic lower extremity admissions were extracted from the 2012-2014 National Inpatient Survey (NIS) using ICD-9-CM diagnosis codes. The main outcome was a 2-level variable consisting of FFAs (e.g., transmetataral amputation, Symes, and Choparts) versus below the knee amputations (BKA). Logistic regression analysis was used to determine the contributions of patient- and hospital-level factors to relative risk of receipt of FFA.
RESULTS: Our study cohort represented 110,355 admissions nationally, comprising of 42,375 FFAs and 67,980 BKAs. Compared to all diabetic admissions from 2012-2014, our population was overrepresented by males and minorities. Controlling for other factors, living in an urban area (RRR=1.48, 1.3-1.7, p<0.0001), and having vascular intervention in the same hospital stay (RRR=2.96, 2.71-3.24, p<0.0001) were predictive of FFA. Patients from rural localities but treated in urban centers were more likely to receive BKAs. Minorities were more likely to present with severe disease, limiting delivery of FFAs. A high Elixhauser comorbidity score was predictive of not receiving a FFAs.
CONCLUSION: Although multidisciplinary care delivers functional amputations, this study identifies delivery biases facing patients without access to large, urban hospitals. Nevertheless, rural patients seeking care in these centers are more likely to receive below the knee amputations. Minorities present with more severe disease, perhaps as a lack of access to care. Further detailed examination is required to examine which method is more effective at reducing rates of BKAs: earlier referral to multidisciplinary centers in a centralized approach versus satellite centers in rural localities in a decentralized approach.


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