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

Underrepresentation of African Americans in Plastic Surgery: Examining Demographics, Specialty Factors, and Medical School Experiences

BACKGROUND

Racial representation among medical trainees translates into physicians that are able to communicate with diverse patient populations and are perceptive to health disparities. This is important within plastic surgery where an optimal physicianpatient relationship is essential to health outcomes.

OBJECTIVE

The purpose of this study is to address underrepresentation of African Americans (AA) in plastic surgery through improving understanding of factors that may contribute to AA medical student interest in plastic surgery.

DESIGN

This was a voluntary, cross-sectional survey. An online survey was designed to collect information on demographics, specialty factor importance, medical school experiences, and plastic surgery interest among medical students. The survey was distributed to medical students within three national medical organizations between August 2018 and February 2019. The following groups of respondents were statistically COMPARED: AAs interested vs. AAs not interested in plastic surgery and AA vs. Caucasian medical students both interested in plastic surgery.

SETTING

Online survey for medical students in the United States.

PARTICIPANTS

All 428 participants were medical students that belonged to at least 1 of the 3 national medical organizations between August 2018 and February 2019.

RESULTS

The survey was completed by 428 participants of which 142 were excluded for incomplete surveys, leaving 286 (66.8%) participants to be included in the study. Among AA medical students, 128 (75.3%) were not interested in Plastic Surgery and 42 (24.7%) were interested. The 2 groups were similar demographically but differed significantly across multiple specialty factors and medical school experiences (p < 0.05). When compared to interested Caucasian medical students (n = 30), interested AA medical students differed significantly in demographics, specialty factors, and medical school experiences (p < 0.05).

CONCLUSIONS

This study supports the implementation of medical school interventions emphasizing specialty factors and medical school experiences unique to AA medical students interested in plastic surgery to promote their application into the specialty.

Disparities in limb preservation and associated socioeconomic burden among patients with diabetes and/or peripheral artery disease in the United States

Racial, ethnic, socioeconomic, and geographic disparities in limb preservation and nontraumatic lower extremity amputation (LEA) are consistently demonstrated in populations with diabetes and peripheral artery disease (PAD). Higher rates of major LEA in disadvantaged groups are associated with increased health care utilization and higher costs of care. Functional decline that often follows major LEA confers substantial risk of disability and premature mortality, and the burden of these outcomes is more prevalent in racial and ethnic minority groups, people with low socioeconomic status, and people in geographic regions where limited resources or distance from specialty care are barriers to access. We present a narrative review of the existing literature on estimated costs of diabetic foot disease and PAD, inequalities in care that contribute to excess costs, and disparities in outcomes that lead to a disproportionate burden of diabetes- and PAD-related LEA on systematically disadvantaged populations.

Multidisciplinary approach to decreasing major amputation, improving outcomes, and mitigating disparities in diabetic foot and vascular disease

Major nontraumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease. Incidence of major LEAs consistently declined during the 1990s and 2000s, but rates have plateaued or increased in many regions during the past decade. Marked racial, ethnic, socioeconomic, and geographic disparities in risk of LEA persist and are related to inequalities in access to care and differential rates of attempted limb preservation. Multidisciplinary diabetic foot care (MDFC) is increasingly recognized as a necessary model for optimal management of patients with diabetic foot and vascular disease. This article reviews the role of MDFC in reducing major LEAs and the specific ways in which MDFC can mitigate disparities in care delivery and limb preservation outcomes. Access to MDFC among vulnerable populations remains a significant barrier to systematic reduction in major LEAs.

Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.

Effect of Function-Based Approach to Nontraumatic Major Lower Extremity Amputation on 5-Year Mortality

BACKGROUND

Five-year mortality rates after lower extremity amputation in the chronic wound population have long been regarded as high and inevitable. We theorize that function-based surgical technique and multidisciplinary care improve mortality and assess our institution's mortality rates after major lower extremity amputation (MLEA).

STUDY DESIGN

We performed a retrospective review of patients who underwent primary nontraumatic MLEA at our institution from 2010 to 2013. Major amputations included below knee amputation, through knee amputation, and above knee amputation. Our function-based surgical approach to MLEA is guided by 4 tenets: (1) optimization of limb biomechanics, (2) maximal soft tissue preservation, (3) multidisciplinary team approach, and (4) addressing nerves during primary amputation to prevent postamputation pain. Kaplan-Meier analysis and Cox regression were performed to estimate cumulative 5-year mortality and to identify predictors of 5-year mortality, respectively.

RESULTS

A total of 188 patients underwent MLEA. Median Charlson Comorbidity Index was 4. Estimated 5-year mortality was 40% overall and 43% for diabetic patients. When stratified by amputation level, 5-year mortalities were 36.3% for below knee amputation, 60.9% for through knee amputation, and 44.0% for above knee amputation. Charlson Comorbidity Index (hazard ratio 1.24, p < 0.001) and end-stage renal disease (hazard ratio 3.38, p < 0.001) were the strongest predictors of 5-year mortality.

CONCLUSIONS

We demonstrate the lowest mortality rate reported for MLEA. Improved functional and mortality outcomes can be achieved with a function-based surgical approach to MLEA and close follow-up by a multidisciplinary team. Future studies, using standardized reporting of mortality data and incorporating patient-reported outcomes, are warranted to correlate return to function and mortality.

Disparities In Diabetes-Related Lower Extremity Amputations In The United States: A Systematic Review

Disparities in rates of peripheral diabetic neuropathy and lower extremity amputation exist in the United States. To investigate the factors linked to this disparity, we performed a systematic review of the literature on the subject published during the period 2000-20. Nineteen observational studies were included. Disparities in rates of lower extremity amputation were reported according to patient race, ethnicity, sex, and age; across hospital referral regions, residential area characteristics, and income estimates; and on the basis of payer type and hospital characteristics. Several of these factors were interrelated. There was a reduction in major lower extremity amputation rates among Black, Hispanic, and White patients with diabetes over time, suggesting narrowing disparities in the odds of this procedure among Black and White patients. There is a need for a national strategy that integrates public awareness, screening, early initiated multidisciplinary care, and quality measures for peripheral artery disease management, as well as neighborhood-level public health interventions, to reduce the disproportionate burden of lower extremity amputation in underserved communities.

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

BACKGROUND

Lower extremity salvage in the setting of nonhealing wounds requires a multidisciplinary approach for successful free tissue transfer. Patients with comorbidities including diabetes mellitus and peripheral vascular disease were previously considered poor candidates for free tissue transfer. However, amputation leads to functional decline and severely increased mortality. The authors present their institutional perioperative protocol in the context of 200 free tissue transfers performed for lower extremity salvage in a highly comorbid population.

METHODS

The authors reviewed an institutional database of 200 lower extremity free tissue transfers performed from 2011 to 2019. Demographics, comorbidities, wound cause and location, intraoperative details, flap outcomes, and complications were compared between the first and second 100 flaps. The authors document the evolution of their institutional protocol for lower extremity free tissue transfers, including standard preoperative hypercoagulability testing, angiography, and venous ultrasound.

RESULTS

The median Charlson Comorbidity Index was 3, with diabetes mellitus and peripheral vascular disease found in 48 percent and 22 percent of patients, respectively. Thirty-nine percent of patients tested positive for more than three hypercoagulable genetic conditions. The second group of 100 free tissue transfers had a higher proportion of patients with decreased vessel runoff (35 percent versus 47 percent; p < 0.05), rate of endovascular intervention (7.1 percent versus 23 percent; p < 0.05), and rate of venous reflux (19 percent versus 64 percent; p < 0.001). Flap success (91 percent versus 98 percent; p < 0.05) and operative time (500 minutes versus 374 minutes; p < 0.001) improved in the second cohort.

CONCLUSIONS

Standardized evidence-based protocols and a multidisciplinary approach enable successful limb salvage. Although there is a learning curve, high levels of salvage can be attained in highly comorbid patients with improved institutional knowledge and capabilities.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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

BACKGROUND

Limb salvage for chronic lower extremity wounds requires long-term care best delivered by specialized multidisciplinary centers. This optimizes function, reduces amputation rates, and improves mortality. These centers may be limited to urban/academic settings, making access and appropriate follow-up challenging. Therefore, the authors hypothesize that both system- and patient-related factors put this population at exceedingly high risk for loss to follow-up.

METHODS

Records were reviewed retrospectively for 200 new patients seen at the Georgetown Center for Wound Healing in 2013. The primary outcome was loss to follow-up, defined as three consecutive missed appointments despite explicit documentation indicating the need for return visits. Demographic, clinical, and geographic data were compared. Multivariate logistic regression analysis for loss to follow-up status controlled for variables found significant in the bivariate analysis. Spatial dependency was evaluated using variograms.

RESULTS

Over a 6.5-year-period, 49.5 percent of patients followed were lost to follow-up. Male sex and increased driving distance to the limb salvage center were risk factors for loss to follow-up. Wound-specific characteristics including ankle and knee/thigh location were also associated with higher rates of loss to follow-up. There was no spatial dependency or discrete clustering of at-risk patients.

CONCLUSIONS

This study is the first of its kind to investigate the demographic and clinical characteristics that predispose chronic lower extremity wound patients to loss to follow-up. These findings inform stakeholders of the high rates of loss to follow-up and support decentralized specialty care, in the form of telemedicine, satellite facilities, and/or dedicated case managers. Future work will focus on targeting vulnerable populations through focused interventions to reduce patient and system burden.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Long-term Mortality After Nontraumatic Major Lower Extremity Amputation: A Systematic Review and Meta-analysis

Chronic wounds that lead to major lower extremity amputation have immense consequences on quality of life, and ultimately, mortality. However, mortality rates after lower extremity amputation for a chronic wound are broad within the literature and have escaped precise definition. This systematic review aims to quantify long-term mortality rates after major lower extremity amputation in the chronic wound population available in the existing literature. Ovid MEDLINE was searched for publications which provided mortality data after major, nontraumatic, primary lower extremity amputations. Lower extremity amputations were defined as below and above the knee amputation. Data from included studies was analyzed to obtain pooled 1-, 2-, 3-, 5- and 10-year mortality rates. Sixty-one studies satisfied inclusion criteria representing 36,037 patients who underwent nontraumatic major lower extremity amputation. Pooled mortality rates were 33.7%, 51.5%, 53%, 64.4%, and 80% at 1-, 2-, 3-, 5- and 10-year follow-up, respectively. Within the 8184 diabetic patients (types 1 and 2), 1- and 5-year mortality was 27.3% and 63.2%. Sources of mortality data were varied and included electronic medical records, national health and insurance registries, and government databases. Mortality after nontraumatic major lower extremity amputation is high, both in patients with diabetes as well as those without. Methods used to measure and report mortality are inconsistent, lack reliability, and may underestimate true mortality rates. These findings illustrate the need for a paradigm shift in wound management and improved outcomes reporting. A focus on amputation prevention and care within a multidisciplinary team is critical for recalcitrant ulcers.

Translating Technique into Outcomes in Amputation Surgeries

The department of surgery at Washington University is putting increased emphasis on outcomes for amputees. This multidisciplinary effort begins with choosing the correct surgery and incorporating the latest technical advances in amputation surgery.

Use of Flap Salvage for Lower Extremity Chronic Wounds Occurs Most Often in Competitive Hospital Markets

Wounds in the comorbid population require limb salvage to prevent amputation. Extensive health economics literature demonstrates that hospital activities are influenced by level of market concentration. The impact of competition and market concentration on limb salvage remains to be determined.

Methods

Admissions for chronic lower extremity wounds in nonrural hospitals were identified in the 2010-2011 National Inpatient Survey using ICD-9-CM diagnosis codes. The study cohort consisted of admitted patients receiving amputations, salvage without flap techniques (eg, skin grafts), or salvage with flap techniques. The all-service Herfindahl-Hirschman Index (HHI), which is a commonly used tool for market and antitrust analyses, was used to measure hospital competition. Multinomial regression analysis accounting for the complex survey design of the NIS was used to determine the relationship between the HHI and hospital adoption of limb salvage controlling for patient, hospital, and market factors.

Results

The study cohort represents 124,836 admissions nationally: 89,880 amputations, 26,715 salvage without flap techniques, and 8241 salvage flap techniques. Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps (P < 0.01). Other factors were less predictive.

Conclusion

Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among patients with chronic wounds. Improving access to reconstructive limb services must consider the competitive structure of hospital markets.

Telemedicine in the Wake of the COVID-19 Pandemic: Increasing Access to Surgical Care

The COVID-19 pandemic has brought seismic shifts in healthcare delivery. The objective of this study was to examine the impact of telemedicine in the disadvantaged population.