Underutilization of an Objective Vascular Screening Test in Patients with Diabetic Foot Ulcers

Although current guidelines recommend ankle-brachial index (ABI) or toe-brachial index (TBI) for all diabetic foot ulcer (DFU) patients due to poor diagnostic accuracy of physical examination, adherence remains unclear. This study aimed to evaluate the performance and timeliness of ABI/TBI testing among newly diagnosed DFU patients.

We conducted a retrospective cohort study using Veterans Affairs data from January 1, 2019, to December 31, 2023. Veterans aged ≥65 years with a new DFU diagnosis were included. ABI/TBI within 1 year before or after the DFU diagnosis was recorded. Multivariable mixed-effects logistic regression with a facility random intercept evaluated factors associated with ABI/TBI and facility-level variation of vascular screening.

Among 57,265 patients, 46.0% completed ABI/TBI. The median time from DFU diagnosis to ABI/TBI was 24 days (interquartile range 3-92). Patients with complicated DFU (osteomyelitis or gangrene) were more likely to undergo ABI/TBI (74.5% vs. 43.0% for uncomplicated DFU) and had shorter wait times (median 2 days vs. 32 days for uncomplicated DFU), suggesting ABI/TBI was often reserved for complicated DFU patients. There was notable facility-level variation for ABI/TBI (median odds ratio 2.40) after adjustment for patient and facility characteristics, suggesting that systemic barriers may influence vascular screening practices.

Fewer than half of DFU patients received ABI/TBI, and testing was often delayed or reserved for advanced disease. System-level interventions to implement universal ABI/TBI screening for DFU patients are needed.