Health Services Research & Development

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2007 HSR&D National Meeting Abstract

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National Meeting 2007

3097 — Evaluation of Regional Footcare Programs: Uses of Initial and Repeat Lower Extremity Amputation Rates as Quality Improvement Indicators

Tseng C (REAP-East Orange) , Sambamoorthi U (REAP-East Orange), Rajan M (REAP-East Orange), Helmer D (REAP-East Orange), Tiwari A (REAP-East Orange), Findley P (REAP-East Orange ), Wrobel J (Center of Lower Extremity Ambulatory Research (CLEAR)), Pogach L (REAP-East Orange)

Objectives:
Healthy People 2010 sets a goal of decreasing diabetes related lower extremity amputation (LEA) rates by 55%. Distinguishing initial LEA (ILEA) from repeat LEA (RLEA) can enable clinical administrators to evaluate the effectiveness of different foot care coordination programs (e.g., screening/surveillance and limb salvage). Our objective was to evaluate the uses of ILEA, and RLEA in assessing regional variation among Veterans Integrated Service Networks (VISNs) as quality improvement indicators.

Methods:
Retrospective longitudinal cohort study of 363,538 veteran clinical users with diabetes who were either Veterans Health Administration (VHA) or dual VHA-Medicare-fee-for-service enrollees and alive in fiscal year (FY) 2000. We ascertained baseline risks (age, sex, race, foot risk factors, and medical comorbidities) in FY1999 and LEA occurring either in the VHA or private sector in FY 2000. ILEA was determined based on no evidence of prior amputation by procedure codes, post-amputation codes, and lower limb prosthetic codes within the prior 24 months. Other amputations were considered to be RLEAs. We used multinomial logistic regression for risk-adjustment and calculated risk-adjusted observed/expected(O/E) amputation ratio to rank the VISNs.

Results:
Overall, 2,988 (8.2 per 1,000, 5.7-10.9 by VISNs) veterans experienced an amputation in fiscal year 2000. Of these, 2,171 had ILEA (6.0/1000; 3.8-7.4), and 807 had RLEA (2.2/1000; 1.4-3.5). The Spearman statistic for correlation between risk-adjusted VISN ranks for ILEA and LEA was 0.94 (p<0.001), and between RLEA and LEA was 0.82 (p<0.001). ILEA and RLEA ranks were moderately related (coefficient=0.59, p=0.004). Of the 10 VISNs ranked as high outliers (higher rate) by ILEA, five were also high outliers by RLEA, four were non-outliers, and one was a low outlier (lower rate) by RLEA. Of the 8 non-outliers by ILEA, five were non-outliers and three were low outliers by RLEA. Two were lower outliers by both ILEA and RLEA.

Implications:
Application of ILEA and RLEA results in different rankings and outlier status of VHA regional areas.

Impacts:
ILEA and RLEA rates provide more specific information than LEA alone, and may permit VHA Preservation-Amputation Care and Treatment (PACT) programs to target resources more appropriately to tertiary prevention and/or limb salvage efforts as well as assist for quality improvement.