Advancing Health Policy and Systems Approaches to Improved Delivery of Surgical Limb Salvage Procedures for Severe Chronic Wounds

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PROJECT SUMMARY/ABSTRACT In the United States, 2.4-4.5 million people suffer from chronic lower extremity wounds, costing the health system up to $31.7 billion annually. A multidisciplinary approach is necessary for amputation reduction in severe wounds, as nontraumatic amputation leads to a 5-year mortality rate of 50-75%. It has been demonstrated that the establishment of limb salvage centers reduces amputation rates, improves provider to provider education resulting in earlier referral, improves prevention measures and increases global functioning of patients. Currently, little is known about the state of limb salvage adoption by hospitals in the United States, including which surgical modalities are most commonly used, their spread across regions and over time, and the scale of operations relative to community-based need. Even less is known about how this care is organized within local hospital markets and how the structure of these markets affects which patients receive limb salvage versus amputations. This lack of fundamental knowledge stands as a barrier to improvements in the organization and distribution of resource-intensive wound care teams to treat chronic wounds in the U.S. As a result, limb salvage is characterized by fragmented delivery, inequitable provision, few quality standards, and pervasive fee-for-service payment mechanisms with their well-known lack of incentives for quality or efficiency. These issues are likely to grow in importance during the COVID-19 pandemic, as delays in care will likely lead to more patients developing severe chronic wounds before seeking treatment. This project will address these gaps by conducting the first large-scale assessment of limb salvage spread, provision, and market effects for lower extremity wounds in the United States. Under Aim 1, will use the 2005-2017 Healthcare Cost and Utilization Project (HCUP) – State Inpatient Database (SID) linked to the American Hospital Annual (AHA) Survey to examine the role of hospital market structure, hospital factors, and patient factors in the adoption and spread of limb salvage procedures and its effects on disparities in care. Under Aim 2, we will engage an Expert Advisory Panel to help translate the findings from Aim 1 into a set of actionable health system and policy strategies, disseminate findings to practitioners, and develop a research agenda for advancing much-needed healthcare payment and delivery reforms in the provision of severe chronic wound care. This study will advance AHRQ’s priority to spread evidence-based practices and develop the foundation to address other priorities including comparative performance of systems and providers, and development of performance-improvement incentives. These findings will be especially important to AHRQ priority populations, including low-income, minority, rural, and people with chronic illnesses.