Diabetes-Related Lower Extremity Amputation (DRLEA): Payor and plan type matters for single-step vs. multi-step (incremental) amputations

Background: Lower extremity amputation among patients with diabetes is a little studied topic. Providers' decisions regarding a major below-knee Diabetes-Related Lower Extremity Amputation (DRLEA) single-step (one-time) amputation vs. multi-step (repeat) amputations may be driven by payer and plan type apart from clinical considerations. Major DRLEA is defined as any amputation at or above the metatarsophalangeal joint. This research will profile DRLEA procedures among adult diabetic patients from 429 member-hospitals of a large consulting and group purchasing hospital consortium. This study uniquely examines a nationwide sample of working age adults and Medicare patients. Research Objectives: 1) Analyze associations between single- vs. multi-step DRLEA and payer source/health plan type controlling for race, hospital characteristics, diabetes severity and co-morbidities, age, gender and geographic region. 2) Analyze associations between patient outcomes (mortality) and length of stay vs. the amputation approach (single vs. multi-step). We hypothesize that insurance source and plan type (fee-for-service, FFS vs. HMO or indigent) may influence the amputation approach. Methods: Retrospective claims data analysis on all 18 to 89 year old diabetic patients with a below-knee amputations discharged between January 1 2006 and December 31 2010 during 2006 through 2010 (the study population). Records of these patients were scanned for the year prior to the index discharge to identify the DRLEA as a single-step procedure (one-step) amputation or as the final step following one or more additional amputations during the prior year. Key independent variables of interest include payer source/plan type, hospital teaching status and race. Control variables include diabetes severity (comorbidities), geographic region, age, gender and hospital bed size. An AHRQ-algorithm driven patient severity measure, APR DRG was used to account for diabetes severity and co-morbidities. Binomial and multinomial logistic regression analyses are used. The association of amputation approach with patient outcomes (mortality and length of stay) will be presented. Results/Conclusion: Completed analyses show that commercial FFS is associated with significantly higher adjusted likelihood of multi-step amputations relative to HMO plans and indigent/self pay sources (ORs=1.18 and 1.57). Medicare FFS patients were the most likely of all groups to receive multi-step amputations relative to all other payers. Analyses for the remaining study objectives are underway. Findings suggest that single vs. multistep amputation decisions may be influenced by payer and health plan type. As the first study to explore this issue, our findings will serve to inform the medical professional and health policy community of the possible factors influencing DRLEA decisions.