Geographic Region and Insurance Status Predict Access to Salvage Procedures for Diabetic Lower-Extremity Wounds in the United States.

[PURPOSE] The current study assessed factors associated with limb salvage and subsequent amputations for patients with diabetic lower-extremity wounds in the United States.

[METHODS] Using national administrative data from 2010 to 2022 (PearlDiver), adults undergoing amputation or salvage procedures (skin graft, local flap, or free flap) for diabetic lower-extremity wounds were identified. Patient age, sex, Elixhauser Comorbidity Index, geographic region, and insurance status were extracted. Insulin dependence, tobacco use, end-stage renal disease, peripheral vascular disease, prior amputation, preoperative lower-extremity infection, and preoperative vascular testing or intervention were also extracted. Subsequent amputations following limb salvage were identified. Factors associated with salvage procedures and subsequent amputation were analyzed with multivariable logistic regression.

[RESULTS] The final cohorts included 97,472 patients with amputation and 62,850 patients with salvage. The average follow-up was 3.9 years. Many patient and clinical factors were associated with limb salvage. Most notably, patients in the Northeast had the greatest odds of undergoing salvage, and relative to privately insured patients, those with Medicare and Medicaid were significantly less likely to undergo salvage. Of patients who underwent salvage, 11,595 (18%) underwent subsequent amputation at an average time of 1.7 years. There was minimal variation in subsequent amputation by geographic region, and patients with Medicare and Medicaid were only slightly more likely to undergo a subsequent amputation.

[CONCLUSIONS] There are significant disparities in access to limb salvage procedures in the United States based on region and insurance status despite only minor differences in progression to subsequent amputation for these patients.