Geographic Variation in Amputations for Medicare Patients With Diabetic Lower-Extremity Wounds

Geographic variation in amputations following diabetic lower-extremity (DLE) wounds is substantial. Understanding the sociodemographic and health care factors associated with variations can inform policy to reduce amputations.

To examine associations of regional patient and health care system characteristics with major amputations following DLE wounds.

This cross-sectional study was conducted among Medicare fee-for-service beneficiaries aged 66 years and older with DLE wounds from 2017 to 2019. Data were aggregated at the hospital referral region (HRR) level. Analyses were performed between February 2025 and February 2026.

Diagnosis of a DLE wound.

The outcome was the HRR-year proportion of DLE wounds undergoing major amputation within 12 months after diagnosis. Key measures included HRR-year percentages of Black and Hispanic Medicare beneficiaries with DLE wounds, an economic deprivation index, clinician supply per 10 000 Medicare beneficiaries (primary care, endocrinology, podiatry, and revascularization-performing specialists), and the percentage of hospitals with wound management programs. Spatial-temporal bayesian models estimated associations of HRR-year amputations with these measures and were reported as odds ratios (ORs) with 95% credible intervals (CrIs).

The study cohort included 707 971 Medicare DLE wounds (median [range] age, 76 [65-11]; median [range] sex, 55.0% [44.0%-68.0%] male) in 306 HRRs with wide variation in median (range) racial composition (5.2% [0.0%-53.1% Black and 1.4% [0.0%-87.0%] Hispanic), economic deprivation index (60.6 [7.2-87.8]), specialist supply per 10 000 Medicare beneficiaries (podiatry: 4.0 [1.1-16.3]; endocrinology: 1.4 [0.2-5.4]; revascularization-performing specialties: 8.0 [3.9-28.0]) and the percentage of hospitals with wound management programs (63.4% [25.0%-100%]). The median (range) HRR-year proportion of DLE wounds followed by major amputation was 3.0% (0.3%-9.3%). In bayesian models, the percentages of Black (OR, 5.19; 95% CrI, 3.78-7.12) and Hispanic patients (OR, 2.39; 95% CrI, 1.73-3.29) and economic deprivation (OR, 1.29; 95% CrI, 1.02-1.62) had positive associations with amputations. Among health care factors, only HRR-level podiatrist supply had a negative association with amputations (OR, 0.74; 95% CrI, 0.66-0.82), corresponding to an estimated 19.1%, 6.6%, and 3.2% reduction in amputation odds with 1 additional podiatrist per 10 000 Medicare beneficiaries in low-, medium-, and higher-supply markets (approximately 1, 4, and 9 podiatrists per 10 000 beneficiaries).

In this cross-sectional study of Medicare beneficiaries with DLE wounds, beyond social determinants of health, higher podiatrist supply was associated with fewer amputations. These findings suggest that increasing access to podiatry may reduce amputations among patients with DLE wounds.