Despite evidence that improved outcomes are associated with more distal lower extremity amputations (LEA), the impact of recent advances in the orthopedic approach to diabetic foot ulcer (DFU) on the use and anatomic level of LEAs is unknown.
Methods:
We queried the complete Medicare Part B claims database (2000-2010) for volume and reimbursement of all codes designating LEAs (hip and below) as well as a selection representing orthopedic treatments for DFU. Procedures were grouped for analysis; utilization rates per 100,000 Medicare enrollees and compound annual growth rates (CAGRs) of payments were calculated. Data are presented in the context of national health care spending trends.
Results:
LEA utilization rates declined from 282.5 to 201.0 per 105 enrollees (−28.8%) over the decade. In general, declines were greatest for the most proximal levels and smallest for the most distal sites. Use of orthopedic treatments for DFUs, including Achilles tendon release and total contact casting, rose from 26.0 to 63.3 per 105 enrollees (+143.3%). Payment trends mirrored utilization data. During this period, total health care spending in the United States increased at a CAGR of 6.5%, whereas total Medicare payments rose at a CAGR of 8.9%.
Conclusion:
The last decade saw a marked decline in the use of LEA in the Medicare population, despite unfavorable demographic changes. Furthermore, it became more likely for LEAs to occur at distal, limb-conserving locations. Over the same period, use of orthopedic treatments for DFU increased sharply.
Level of Evidence:
Level III, retrospective comparative database analysis.
AttlingerCEBrownBJ. Amputation and ambulation in diabetics: function is the goal. Diabetes Metab Res Rev. 2012;28(suppl 1):93-96.
2.
BirkeJAHorswellRPatoutCAChenSL. The impact of a staged management approach to diabetes foot care in the Louisiana public hospital system. J La State Med Soc. 2003;155:37-42.
3.
BusSAValkGDvan DeursenRW. The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review. Diabetes Metab Res Rev. 2008;24(suppl 1):S162-S180.
DriverVRMadsenJGoodmanRA. Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model. Diabetes Care. 2005;28:248-253.
11.
GoodneyPPBeckAWNagleJ. National trends in lower extremity bypass surgery, endovascular interventions, and major amputations. J Vasc Surg. 2009;50(1):54-60.
12.
GrantWPSullivanRSonenshineDEAdamM. Electron microscopic investigation of the effects of diabetes mellitus on the Achilles tendon. J Foot Ankle Surg. 1997,36:272-278.
13.
HoVWirthlinDYunH. Physician supply, treatment, and amputation rates for peripheral arterial disease. J Vasc Surg. 2005;42(1):81-87.
14.
HoergerTJSegelJEGreggEW. Is glycemic control improving in U.S. adults?Diabetes Care. 2008;31(1):81-86.
15.
HuangEBasuAO’GradyM. Projecting the future diabetes population size and related costs for the U.S. Diabetes Care. 2009;32(12):2225-2229.
16.
ImperatoreGCadwellBLGeissL. Thirty-year trends in cardiovascular risk factor levels among US adults with diabetes: National Health and Nutrition Examination Surveys, 1971-2000. Am J Epidemiol. 2004;160(6):531-539.
17.
International Working Group on the Diabetic Foot. Epidemiology of diabetic foot infections in a population-based cohort. Paper presented at: International Consensus on the Diabetic Foot; May 22-24, 2003; Noordwijkerhout, the Netherlands.
18.
IzumiYSatterfieldKLeeS. Risk of reamputation in diabetic patients stratified by limb and level of amputation: a 10-year observation. Diabetes Care. 2006;29(3):566.
19.
JeansKABrownRHKarolLA. Effect of amputation level on energy expenditure during overground walking by children with an amputation. J Bone Joint Surg Am. 2011;93(1): 49-56.
20.
KearneyTPHuntNALaveryLA. Safety and effectiveness of flexor tenotomies to heal toe ulcers in persons with diabetes. Diabetes Res Clin Pract. 2010;89(3):224-226.
LiYBurrowsNGreggE. Declining rates of hospitalization for non-traumatic lower-extremity amputation in the diabetic population aged 40 years or older. Diabetes Care. 2012;35(2):273-277.
25.
LinSSLeeTHWapnerKL. Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: the effect of tendo-Achilles lengthening and total contact casting. Orthopedics. 1996;19:465-475.
26.
MargolisDJMalayDSHoffstadOJ. Prevalence of diabetes, diabetic foot ulcer, and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: data points #1. February 17, 2011. In: Data points publication series [Internet]. Rockville, MD: Agency for Healthcare Research and Quality; 2011. http://www.ncbi.nlm.nih.gov/books/NBK63602/.
27.
MayfieldJAReiberGEMaynardCCzernieckiJMCapsMTSangeorzanBJ. Survival following lower-limb amputation in a veteran population. J Rehabil Res Dev. 2001;38(3):341-345.
28.
MirelSWheatcroftGParkerJD. Health characteristics of the Medicare traditional fee-for-service and Medicare advantage enrollees: 1999-2004 National Health and Nutrition Examination Survey linked to 2007 Medicare data. Natl Health Stat Rep. 2012;53:1-12.
29.
MoxeyPWGogalniceanuPHinchliffeR. Lower extremity amputations—a review of global variability in incidence. Diabet Med. 2011;28(10):1144-1153.
30.
MuellerMJSinacoreDRHastingsMKStrubeMJJohnsonJE. Effect of Achilles tendon lengthening on neuropathic plantar ulcers. J Bone Joint Surg Am. 2003;85(8):1436-1445.
31.
PatoutBirkeJAHorswellRWilliamsDCeriseFP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care. 2000; 23:1339-1342.
32.
PinzurMS. The metabolic cost of lower extremity amputation. Clin Podiatr Med Surg. 1997;14(4):599-602.
33.
SpencerS. Pressure relieving interventions for preventing and treating diabetic foot ulcer. Cochrane Database Syst Rev. 2000;(3):CD002302.
34.
TaylorSMKalbaughCBlackhurstDW. Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. J Vasc Surg. 2005(42):227-235.
