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Who, What, Where: Demographics, Severity Of Presentation, And Location Of Treatment Drive Delivery Of Diabetic Limb Reconstructive Services Within The National Inpatient Survey
Elizabeth G. Zolper, BS1, Derek DeLia, PhD1,2, Cara K. Black, BA1, Jenna C. Bekeny, BA1, Tanvee Singh, MPH3, Peter Wirth, BA3, Kyle Luvisa, MPH3, David H. Song, MD, MBA1, Christopher E. Attinger, MD1, Karen K. Evans, MD1, Kenneth L. Fan, MD1.
1MedStar Georgetown University Hospital, Washington, DC, USA, 2MedStar Health Research Institute, Hyattsville, MD, USA, 3Georgetown University School of Medicine, Washington, DC, USA.

Purpose: Technical advances have been made in reconstructive diabetic limb salvage modalities. It is unknown whether these techniques are widely used. This study seeks to determine the role of patient- and hospital-level characteristics that affect use.
Methods: Admissions for diabetic lower extremity complications were identified in the 2012-2014 National Inpatient Survey (NIS) using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, limb salvage without flap techniques, or advanced limb salvage with flap techniques. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the independent contributions of factors expressed as marginal effects.
Results: Our study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, while Black patients had the lowest. Multinomial regression models revealed that when controlling for non-gas gangrene and critical limb ischemia, both of which have much greater incidence in minorities, the effect of race against receipt of reconstructive modalities was attenuated. Access to urban teaching hospitals was the strongest protective factor against amputation (9 percentage point (PP) reduction, p<0.01) and predictor of receiving limb salvage without flaps (5 PP increase, p<0.01) and with flaps (3 PP increase, p<0.01).
Conclusions: This study identified multiple patient- and hospital-level factors associated with decreased access to the gamut of reconstructive limb salvage techniques. Disparity reduction will likely require a multifaceted strategy that addresses the severity of disease presentation seen in minorities and delivery system capabilities affecting access and utilization of reconstructive limb salvage procedures.


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