Economic value of podiatry service in limb salvage alliance (2022)


RegisterSign in


  • Access throughyour institution

Journal of Vascular Surgery

Volume 75, Issue 1,

January 2022

, Pages 296-300

(Video) Avoiding Amputation - Temple Limb Salvage Center - Eric T. Choi, MD

Presented at the Thirty-fifth Annual Meeting of the Western Vascular Society, Santa Monica, Calif, September 26-29,2020.



Over the past decade, multidisciplinary “toe and flow” programs have gained great popularity, with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States.


An administrative database that captured monthly operating room (OR) cases, clinic encounters, in-patient volume, and total work relative value units (wRVUs) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of 3years, there was a significant change in the number of podiatrists (from 1 to 4) within the program, whereas the clinical full-time employees for vascular surgeons remained relatively stable.


The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of 4years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic, and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P< .01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40%, respectively (P< .01) in the past 3years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite the fact that that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs.


This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrists in a vascular surgery practice is clearly demonstrated.

Section snippets


During a period of 5years, there was a significant fluctuation in the composition of the Southern Arizona Limb Salvage Alliance (SALSA), an established integrated “toe and flow” team. Although there was an incremental increase in the number of vascular surgeons from 2 in 2015 and 2016 to a full complement of 4 in 2018, the clinical full-time employee (cFTE) remained relatively stable. The podiatry cFTE, however, changed from 1 in 2017 to 4 in 2019, and 50% of podiatric surgeons have advanced


A total of 35,591 patient encounters in the SALSA clinic and 5535 operative procedures were performed during the period of 5years. The entire department experienced >100% of growth in clinic visits, operative cases, and total wRVU by 2019 compared with 2015 (P< .01; Table). With the equal number of podiatric and vascular surgeons in 2019, podiatry contributes to 40% of total OR cases andin-patient encounters, as well as 70% of clinic encounters.

The initial significant growth of clinic volume


Podiatry plays a central role in DFU prevention and limb preservation.7 Many systematic reviews have shown that multidisciplinary teams have lower major amputation rates10, 11, 12 as well as the clinical benefits of a podiatrist in a diabetic limb salvage team.13, 14, 15, 16 In our SALSA “toe and flow” model, podiatric surgeons are recruited into a vascular surgery division. We have previously showed that this alliance has improved clinical outcomes and decreased lower extremity amputations.17


In conclusion, DFUs and PAD are complex pathologies that require a team approach to achieve optimal outcomes. This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome and that a “toe and flow” model is financially viable for a hospital system. This study contributes to the paucity of literature that helps to justify podiatric recruitment in a health care system.

Author contributions

Conception and design: NP, WZ

Analysis and interpretation: WZ

Data collection: NP, TT, CW, AHR, AR, JP, KG, WZ

(Video) Lower extremity limb salvage 3

Writing the article: NP, WZ

Critical revision of the article: NP, TT, CW, AHR, AR, JP, KG, WZ

Final approval of the article: NP, TT, CW, AHR, AR, JP, KG, WZ

Statistical analysis: WZ

Obtained funding: Not applicable

Overall responsibility: WZ

References (20)

  • A.J. Boulton et al.The global burden of diabetic foot disease



  • L.A. Lavery et al.Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations

    Diabetes Res Clin Pract


  • J. Musuuza et al.Asystematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

    JVasc Surg


  • R.H. Albright et al.

    Diabetes Res Clin Pract


  • P.J. Kim et al.Role of the podiatrist in diabetic limb salvage

    JVasc Surg


  • L.C. Rogers et al.Toe and flow: essential components and structure of the amputation prevention team

    JVasc Surg


  • S.S. Virani et al.

    Heart disease and stroke statistics-2020 update: a report from the American Heart Association



  • D.M. Olinic et al.

    Epidemiology of peripheral artery disease in europe: VAS educational paper

    Int Angiol


    (Video) Limb salvage vs Amputation and Prosthesis in Limb Injures

  • J. Apelqvist et al.

    What is the most effective way to reduce incidence of amputation in the diabetic foot?

    Diabetes Metab Res Rev


  • D.G. Armstrong et al.

    Diabetic foot ulcers and their recurrence

    NEngl J Med


There are more references available in the full text version of this article.

Cited by (0)

Recommended articles (6)

  • Research article


    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, p. 37

  • Research article

    Non–guideline-compliant endovascular abdominal aortic aneurysm repair in women is associated with increased mortality and reintervention compared with men

    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, pp. 118-125.e1

    Sex-based disparities in surgical outcomes have emerged as an important focus in contemporary healthcare delivery. Likewise, the appropriate usage of endovascular abdominal aortic aneurysm repair (EVAR) in the United States remains a subject of ongoing controversy, with a significant number of U.S. EVARs failing to adhere to the Society for Vascular Surgery (SVS) clinical practice guideline (CPG) diameter thresholds. The purpose of the present study was to determine the effect of sex among patients undergoing EVAR that was not compliant with the SVS CPGs.

    All elective EVAR procedures for abdominal aortic aneurysms without a concomitant iliac aneurysm (≥3.0cm) in the SVS Vascular Quality Initiative were analyzed (2015-2019; n= 25,112). SVS CPG noncompliant repairs were defined as a size of<5.5cm for men and<5.0cm for women. The primary endpoint was 30-day mortality. The secondary endpoints were all-cause mortality, complications, and reintervention. Logistic regression was performed to control for surgeon- and patient-level factors. Freedom from the endpoints was determined using the Kaplan-Meier method.

    Noncompliant EVAR was performed in 9675 patients (38.5%). Although men were significantly more likely to undergo such procedures (90% vs 10%; odds ratio [OR], 3.1; 95% confidence interval [CI], 2.9-3.4; P< .0001), the 30-day mortality was greater for the women than the men (1.8% vs 0.5%; P= .0003). Women also experienced significantly higher rates of multiple complications, including postoperative myocardial infarction (1% vs 0.3%; P= .006), respiratory failure (1.4% vs 0.6%; P= .01), intestinal ischemia (0.7% vs 0.2%; P= .003), access vessel hematoma (3% vs 1.2%; P= .0006), and iliac access vessel injury (2.4% vs 0.8%; P< .0001). Additionally, women experienced increased overall 1-year reintervention rates (11.5% vs 5.8%; P< .0001). In the adjusted analysis, 30-day mortality and any in-hospital complication risk remained significantly greater for the women (30-day death: OR, 3.1; 95% CI, 1.6-5.8; P= .0005; in-hospital complication: OR, 1.9; 95% CI, 1.4-2.6; P< .0001). Women also experienced increased reintervention rates over time compared with men (OR, 1.5; 95% CI, 1.1-2.2; P= .02).

    Although men were more likely to undergo non–CPG compliant EVAR, women experienced increased short-term morbidity and 30-day mortality and higher rates of reintervention when undergoing non–CPG compliant EVAR. These unanticipated findings necessitate increased scrutiny of current U.S. sex-based EVAR practice and should caution against the use of non–CPG compliant EVAR for women.

    (Video) Embracing a Limb Salvage Team

  • Research article

    It is time for a deep dive on our business model

    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, p. 385

  • Research article


    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, pp. 193-194

  • Research article

    The tangled story of carotid disease, carotid revascularization, and Alzheimer's disease: The plot thickens

    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, p. 229

  • Research article

    A statewide quality improvement collaborative significantly improves quality metric adherence and physician engagement in vascular surgery

    Journal of Vascular Surgery, Volume 75, Issue 1, 2022, pp. 301-307

    Quality improvement national registries provide structured, clinically relevant outcome and process-of-care data to practitioners—with regional meetings to disseminate best practices. However, whether a quality improvement collaborative affects processes of care is less clear. We examined the effects of a statewide hospital collaborative on the adherence rates to best practice guidelines in vascular surgery.

    A large statewide retrospective quality improvement database was reviewed for 2013 to 2019. Hospitals participating in the quality improvement collaborative were required to submit adherence and outcomes data and meet semiannually. They received an incentive through a pay for participation model. The aggregate adherence rates among all hospitals were calculated and compared.

    A total of 39 hospitals participated in the collaborative, with attendance of surgeon champions at face-to-face meetings of >85%. Statewide, the hospital systems improved every year of participation in the collaborative across most “best practice” domains, including adherence to preoperative skin preparation recommendations (odds ratio [OR], 1.83; 95% confidence interval [CI], 1.76-1.79; P< .001), intraoperative antibiotic redosing (OR, 1.09; 95% CI, 1.02-1.17; P= .018), statin use at discharge for appropriate patients (OR, 1.18; 95% CI, 1.16-1.2; P< .001), and reducing transfusions for asymptomatic patients with hemoglobin >8mg/dL (OR, 0.66; 95% CI, 0.66-0.66; P< .001). The use of antiplatelet therapy at discharge remained high and did not change significantly during the study period. Teaching hospital and urban or rural status did not affect adherence. The adherence rates exceeded the professional society mean rates for guideline adherence.

    The use of a statewide hospital collaborative with incentivized semiannual meetings resulted in significant improvements in adherence to “best practice” guidelines across a large, heterogeneous group of hospitals.

View full text

© 2021 by the Society for Vascular Surgery. Published by Elsevier Inc.

(Video) Venita Chandra, MD - Limb Salvage: Multidisciplinary Care and Advanced Endovascular Techniques


1. vascularPODCAST | Ep 3: The Diabetic Foot
2. Limb Loss Due to PAD and DM - Misty Humphries, MD
(UC Davis Department of Surgery)
3. Ask Me Anything - Professor, Researcher, CEO, and Podiatric Physician!
(Student Doctor Network)
4. Chronic Limb-Threatening Ischemia
(UAB Medicine)
5. Innovation Day 2013 Honorees, Dr. Manish Bharara and Dr. David Armstrong
(University of Arizona Center for Innovation)
6. APMA Limb Salvage Briefing: David Armstrong, DPM, MD, PhD
(APMA Professional Education)

You might also like

Latest Posts

Article information

Author: Moshe Kshlerin

Last Updated: 06/02/2022

Views: 6379

Rating: 4.7 / 5 (57 voted)

Reviews: 80% of readers found this page helpful

Author information

Name: Moshe Kshlerin

Birthday: 1994-01-25

Address: Suite 609 315 Lupita Unions, Ronnieburgh, MI 62697

Phone: +2424755286529

Job: District Education Designer

Hobby: Yoga, Gunsmithing, Singing, 3D printing, Nordic skating, Soapmaking, Juggling

Introduction: My name is Moshe Kshlerin, I am a gleaming, attractive, outstanding, pleasant, delightful, outstanding, famous person who loves writing and wants to share my knowledge and understanding with you.