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Considering Distance To Hospitals As A Factor In Limb Salvage Outcomes

Excellent work published by colleagues at Baylor College of Medicine’s Save the Extremity program (STEP) suggests that the distance a patient must travel to seek care may influence hospital choice.1

Noting that surgical outcomes may differ between low- and higher-volume facilities, the study authors collected data on patients with peripheral arterial disease (PAD) and amputations or foot complications. They included geocoding to identify patients in areas more remote to hospitals with more experience or resources with limb salvage.

Patients living further from hospitals had 18.6 percent of the over 4,000 amputations studied. These remote patients were more often Caucasian and received Medicare and/or Medicaid. Within the remote grouping of patients, those at lower-volume hospitals tended to be older, were more often Hispanic, and more often received Medicaid. Emergency room admission was more common as was an admitting diagnosis of foot infection.1

The study authors also identified five geographic areas where a higher-volume facility was more than 50 miles away and recommended further study to identify ways to decrease amputations for these specific patients.1

This study brings to light the question of how patients choose a hospital. Convenience and accessibility, especially in patients with diabetes, PAD, mobility issues or advanced age, might play a role. This could cause patients to choose a facility close by as opposed to one with more experience in limb salvage.

One may also say this study opens a discussion on not only access to medical care but access to the highest echelons of care. The bottom line is that care should be stratified based on skill set. In 2010, we published information on stratifying diabetic foot centers into the equivalent of trauma centers.2

As far as improving options for care in the five “less served” geographic areas identified in this study, there are many we might consider. Perhaps these could include more training for currently lower-volume hospitals to improve current levels of care, improving transportation options for affected populations or even improving patient education on care options outside of their immediate area.

Dr. Armstrong is a Professor of Surgery at the Keck School of Medicine at the University of Southern California. He is the Director of the Southwestern Academic Limb Salvage Alliance (SALSA). 

Editor’s Note: This blog originally appeared at: is adapted with permission from the author.


  1. Barshes NR, Uribe-Gomez A, Sharath SE, Mills JL, Rogers SO. Leg amputations among texans remote from experienced surgical care. J Surg Res. 2019. doi: 10.1016/j.jss.2019.09.074.
  2. Rogers LC, Andros G, Caporusso J, Harkless LB, Mills JL, Armstrong DG. Toe and flow: essential components and structure of the amputation prevention team. J Am Podiatr Med Assoc. 2010;100(5):342-348.
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