A new paper from Ioana Popescu and colleagues — including Aksone Nouvong and Vincent Rowe at UCLA Geffen, with the RAND Corporation team — just landed in JAMA Network Open. It is, to my eye, the strongest population-level evidence yet that access to podiatry is access to limb preservation.
The setup: 707,971 Medicare fee-for-service beneficiaries (66+) with diabetic lower-extremity (DLE) wounds, aggregated across 306 hospital referral regions, 2017–2019, modeled with spatial-temporal Bayesian methods. The outcome: HRR-year proportion of DLE wounds undergoing major amputation within 12 months.
The headline may surprise no one in our field — but the magnitude should.
Of all the health-system variables tested — primary care supply, endocrinology supply, revascularization-performing specialist supply, hospitals with wound management programs — only HRR-level podiatrist supply was associated with fewer major amputations.
OR 0.74 (95% CrI 0.66–0.82) per +1 podiatrist per 10,000 Medicare beneficiaries.
Translated: a 19.1% reduction in amputation odds in low-supply markets, 6.6% in medium-supply, 3.2% in higher-supply. The dose–response curve flattens as you would expect, but the inflection at the lower end is where the most lives — and limbs — are on the line.
The disparities side of this paper is equally important, and equally consistent with what we have been documenting for two decades:
— % Black patients in the HRR: OR 5.19 (CrI 3.78–7.12)
— % Hispanic patients: OR 2.39 (CrI 1.73–3.29)
— Economic deprivation index: OR 1.29 (CrI 1.02–1.62)
Not modest signals. Floodlights. And they sit alongside our recent TriNetX work with Mittal and Wukich pointing in exactly the same direction.
What this paper says, plainly: when you increase the supply of clinicians trained to look, touch, and intervene early on the diabetic foot, fewer people lose their legs. Not all clinicians. Not generic “wound programs.” Podiatrists.
This is the Toe-and-Flow thesis — the SALSA thesis — the entire reason we built DFCon and ALPS — distilled into 306 referral regions and a Bayesian model. The policy implication is uncomfortable but unavoidable: in regions where podiatry is scarce, amputation is more common, and the gradient is steep enough to matter at the population level.
Worth the read. Worth the share. Worth a conversation with anyone who still treats the diabetic foot as an afterthought.
Popescu I, Hernandez H, Plasencia G, Schutz S, Birnbaum D, Gurvey J, Nouvong A, Rowe V, Damberg CL. “Geographic Variation in Amputations for Medicare Patients With Diabetic Lower-Extremity Wounds.” JAMA Netw Open. 2026 May 1;9(5):e2613616. doi:10.1001/jamanetworkopen.2026.13616
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#DiabeticFoot #LimbPreservation #Podiatry #HealthDisparities #Medicare #ToeAndFlow #SALSA #JAMANetworkOpen #Amputation #DFU #VascularSurgery #HealthPolicy
PAPER LINK:
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PMID: 42154463
PMC: PMC13187873
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