Who, What, Where: Demographics, Severity of Presentation, and Location of Treatment Drive Delivery of Diabetic Limb Reconstructive Services within the National Inpatient Sample

Abstract

Background: 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 to 2014 National Inpatient Sample using International Classification of Diseases, Tenth Revision, Clinical Modification 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 National Inpatient Sample was used to determine the independent contributions of factors expressed as marginal effects. Results: The authors’ study cohort represented 155,025 admissions nationally. White non-Hispanic patients had the highest proportion of reconstruction without and with flaps, whereas black patients had the lowest. Multinomial regression models revealed that controlling for nongas gangrene and critical limb ischemia, both of which have a 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 percent reduction; p < 0.01) and predictor of receiving limb salvage without flaps (5 percent increase; p < 0.01) and with flaps (3 percent 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 use of reconstructive limb salvage procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Expanding Criteria for Limb Salvage in Comorbid Patients with Nonhealing Wounds: The MedStar Georgetown Protocol and Lessons Learned after 200 Lower Extremity Free Flaps

“…Despite the rising incidence of these wounds, at many qualified centers, only a handful are performed annually. 12,13 There is a steep learning curve associated with establishing an effective limb salvage team, but combined with standardized perioperative protocols, a skilled microsurgeon can safely and consistently achieve high free flap success rates. Our institutional limb salvage protocol includes a standardized thrombophilia assessment to determine thrombotic risk, in addition to arterial and venous vascular studies to evaluate recipient vessel integrity.…”

“…11 Previously, few patients were eligible for free tissue transfer, even at qualified centers. 12,13 Comorbidities such as diabetes mellitus and peripheral vascular disease were thought to be contraindications for microvascular reconstruction because of both the technical and medical complexity of this patient population. 11 Atherosclerotic disease is 20 times more likely in patients with diabetes mellitus type 2 as compared to the general population.…”

A Systematic Review of Health Disparities Research in Plastic Surgery

“…This review did not include studies on disparities in lower extremity reconstruction, for which there have been several articles recently published. [2][3][4] This is of particular importance, as lower extremity function is an area of focus at large tertiary care centers and one that requires disparities-improving interventions. Lower extremity outcomes are 1068e Plastic and Reconstructive Surgery • December 2021 tightly linked to both quality of life and mortality, and as plastic surgeons, we play a pivotal role on limb salvage teams.…”

“…Numerous medical organizations, including the American Society of Plastic Surgeons, actively opposed these legislations. 3 Although research can augment such advocacy efforts, novel strategies are needed to ensure that evidence is translated into meaningful policy. Perhaps we should append the "detect, understand, reduce" framework for combatting inequity with "disseminate," to confirm that evidence-based interventions are implemented and maintained.…”

Risk Factors for Loss to Follow-Up in the Lower Extremity Limb Salvage Population

“…Patients with access to urban hospitals have disproportionately greater odds of receiving advanced limb salvage modalities. 9 At the same time, patients with chronic lower extremity wounds are often of a lower socioeconomic level, with limited education, and several chronic comorbidities. 10–12…”