Diabetes-related amputations are often referred to as “preventable,” because they can be avoided with timely medical treatment. But according to a new study from the Journal of the American Medical Association, some medical facilities are better at prevention than others. Per this analysis, health systems differ widely in how they treat diabetic foot ulcers, leading to broad variation in amputation rates among facilities.
Conducted by researchers from the University of Iowa, University of Wisconsin, and Veterans Affairs Office of Rural Health, the research examined 140 VA hospitals over a six-year period (2016-2021). More than 86,000 patients at these facilities were diagnosed with diabetic foot ulcers (DFUs) during those years, and 3,279 (3.8 percent) required leg amputation within a year of their DFU diagnosis.
Within this large sample, the authors found, “the odds of major leg amputation were 1.85 times higher between two randomly selected facilities for an average patient.” In other words, if you sent two identical DFU patients to separate VA facilities, the patient sent to Hospital A would be nearly twice as likely to lose a limb as the patient sent to Hospital B.
The authors went out of their way to control for patient-specific factors that are known to affect amputation rates in DFU patients. A well-established body of research shows that individuals from low-income communities and rural areas are more likely to lose a limb after a DFU diagnosis; so are Black, Latino, and Native American patients. Ditto for people with chronic health challenges such as kidney disease, vascular disease, heart failure, high blood pressure, obesity, and rheumatoid arthritis.
But the authors controlled for all of those factors in their analysis. They even controlled for the drive time from the patient’s home to the nearest VA hospital. And they found that facility-level variation was more profound than most of the patient-level variables (race, geography, income, comorbidities) that influence amputation rates. “This suggests that the facilities caring for patients with DFU are important determinants of the likelihood of major leg amputation,” they conclude.
The study didn’t examine the specifics of DFU treatment among the 140 hospitals under consideration. But the authors hypothesize that any number of facility-level factors might explain the wide variation in amputation rates: ”These health care system factors [could] include access to primary care and appropriate specialty care, degree of coordination across specialties and settings (including presence of multidisciplinary teams), and local health care policies.” Facilities might also differ in their approach to limb-preserving approaches such as glycemic control, vascular disease management, revascularation, drainage surgery, and minor amputation.
The authors acknowledge a handful of limitations to their study. First and foremost, it only encompassed VA hospitals; a study encompassing a broader range of medical facilities might not yield identical results. Relatedly, the 86,000-plus patient cohort in this study was overwhelmingly male (98 percent), which doesn’t match the profile of the overall DFU population. The data set used in this analysis omitted some details about patient status (such as smoking habits) and wound status (size, extent of infection) that can impact amputation outcomes.
Even with these caveats, the authors conclude that the wide variation in amputation rates among health-care facilities can only be explained by inconsistencies in DFU care: “Health service–based interventions might be particularly impactful for standardizing high-quality care across facilities and potentially reducing disparities by offsetting social drivers of health.”
