Community Care Consultations for Veterans with Diabetic Foot Ulcers

ABSTRACT

Objectives: To quantify community care consultations for patients with newly diagnosed diabetic foot ulcers (DFUs), identify associated patient- and facility-level characteristics, and measure time to specialty care within and outside the Veterans Health Administration (VHA).

Study Design: A retrospective cohort study.

Methods: This study included patients 65 years and older with newly diagnosed DFUs who received specialty care between 2019 and 2023. Data were sourced from the VHA Corporate Data Warehouse and linked Medicare data. Community care consultation was defined as receiving specialized consultations (ie, podiatry, vascular surgery, infectious disease, endocrinology) at a community health care system within 1 year of DFU diagnosis. Patient demographics, comorbidities, and facility characteristics were analyzed with multivariable mixed-effects logistic regression models to assess factors associated with community care consultation while controlling for facility-level clustering.

Results: A total of 60,121 patients with a new diagnosis of DFU were included. Of these, 29.2% had a community care consultation. Those receiving community care were more often older, White, living in a rural area, and cared for in lower-complexity facilities. Patients were more frequently referred to community care for vascular surgery, infectious disease, and endocrinology consultations than for podiatry. For all specialties, the time to a new consultation was longer for community care than for a consultation within the VHA.

Conclusions: Community care consultations for patients with DFUs in the VHA system were substantial but varied significantly across facilities. Rural and lower-complexity facilities relied more on community care, particularly for vascular surgery, infectious disease, and endocrinology. Future research should explore the impact of community care on DFU outcomes and strategies to enhance multidisciplinary care coordination.

Am J Manag Care. 2026;32(9):e309-e315.

doi:10.37765/ajmc.2026.90009

Takeaway Points

• This retrospective cohort study of patients with newly diagnosed diabetic foot ulcers within the Veterans Health Administration found substantial but variable use of community care consultations for specialty care (podiatry, vascular surgery, infectious disease, endocrinology).
• Community care consultations were more often used by smaller and rural facilities.
• The time to a new consultation for all specialties was significantly longer for a community care consultation vs a consultation within the Veterans Health Administration.
• Future research is needed to further assess the impact of community care consultation on the outcomes of these patients and to identify strategies for optimizing multidisciplinary diabetic foot ulcer care across various health care settings.

A diabetic foot ulcer (DFU) occurs in up to 34% of patients with diabetes. Approximately 50% to 60% of these ulcers become infected, and within 5 years, up to 30% of affected patients will undergo lower limb amputation (LLA), which is a serious life event.¹

We recently reported a 12-fold difference across Veterans Health Administration (VHA) facilities in the proportion of patients with newly diagnosed DFUs between 2016 and 2021 who underwent major LLA within 1 year, even after adjusting for patient-level factors.² We hypothesized that facility-level variation in LLA is mainly driven by interfacility differences in DFU-specific care, particularly in the coordination of care across disciplines. A multidisciplinary team approach is considered standard of care for patients with a DFU. Within the VHA system, the Prevention of Amputation in Veterans Everywhere program has provided a model of DFU care, including multidisciplinary teams, to all VHA facilities since 1983.³ However, some VHA facilities may be more successful than others at implementing these teams. For example, small and rural facilities may not be able to assemble a multidisciplinary team due to the lack of specialists, resulting in more specialty consultations at community hospitals.

The increasing use of community outpatient care among VHA enrollees through the Veterans Choice Program⁴ and Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018⁵ may further complicate the multidisciplinary management of DFUs.^6-8 Although community care could improve veterans’ access to necessary care, a major concern is that veterans who use both the VHA and community health care systems may experience poor care coordination between their providers.

Disconnected care, in turn, can lead to worse outcomes and care experiences.^9-11 The challenges for coordinated care may be much greater in patients with complicated chronic diseases like DFU because care coordination is not only needed between VHA primary care physicians and community-based specialists but also between VHA specialists (eg, podiatrists) and community-based specialists (eg, infectious disease [ID] specialists).

To date, no study has described how often VHA patients with DFUs were referred to a community care health care system to receive specialty care. To begin understanding these needs and improve care coordination across systems, we aimed to (1) quantify community care consultations for veterans with DFUs, (2) identify patient- and facility-level characteristics associated with community care consultation, and (3) measure time to specialty care within and outside the VHA. Our data may be useful when designing future interventions and policies to improve care coordination and resource allocation for these patients and others with complex chronic diseases.

METHODS

Study Cohort

We conducted a retrospective cohort study of patients 65 years and older who were newly diagnosed with DFUs in the VHA and received specialty care (ie, podiatry, vascular surgery, ID, or endocrinology) between 2019 and 2023 using the VHA Corporate Data Warehouse, including inpatient and outpatient encounter files, and linked Medicare data. The cohort was limited to those 65 years and older because most of these individuals are enrolled in Medicare, thereby providing data on care not paid for by the VHA. We also limited the cohort to veterans who received any VHA care within the 2 years prior to their DFU diagnosis to ensure adequate capture of previous diagnoses and medical services. The diagnosis of DFU was identified using validated International Statistical Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes for DFU (eAppendix [available at ajmc.com]). We excluded veterans who had ICD-10 codes for DFU in 2018 to ensure that only new DFU diagnoses were included in the study.

Variables

Additional patient-level variables collected included patient demographics (age, sex, race, and ethnicity), Social Vulnerability Index (SVI), rurality (urban or rural/highly rural), drive time to the nearest VHA tertiary hospital, comorbidities, and complicated DFU at the time of diagnosis. The SVI was obtained from the CDC home page and was used as an area-level measure of socioeconomic disadvantage and linked to patient records by the census tract of residence.¹² Rurality was determined by the geocoded location of residence.¹³ Patients were considered as having a complicated DFU if they had an ICD-10 code for osteomyelitis or gangrene within 2 weeks before or 1 week after the DFU diagnosis (eAppendix); otherwise, they were considered as having an uncomplicated DFU. In addition to patient-level variables, we collected facility complexity—a rating based on health services provided, patient population served, and the teaching and research activities of the facility.¹⁴ In this rating scale, a level 1 rating indicates high complexity (subdivided into 1a, 1b, 1c), a level 2 rating indicates medium complexity, and a level 3 rating indicates low complexity.

Objectives

The primary objectives were to describe the frequency of community care consultation within 1 year of DFU diagnosis and to identify factors associated with community care consultation. Community care consultation was defined as receiving podiatry, vascular surgery, ID, or endocrinology inpatient or outpatient consultation in a community health care system within 1 year of a DFU diagnosis. These 4 specialties were chosen because of their pivotal roles in meeting the core responsibilities of a multidisciplinary team managing DFUs, namely glycemic control, wound management and off-loading, peripheral artery disease (PAD) care, and infection treatment.¹⁵ Consultations in a community health care system were captured through the VHA Corporate Data Warehouse (consultation tables and Integrated Veteran Care Consolidated Data Set), Medicare fee-for-service claims, and Medicare Advantage encounters data. VHA-only care was defined as receiving these consultations within the VHA without community
care consultation.

Secondary objectives were to describe facility-level variation in community care consultation, assess the types and patterns of specialties utilized for community care consultation, and measure the time to a new consultation. Time to a new consultation was defined as the number of days from DFU diagnosis to the consultation visit, after excluding consultations that happened before the DFU diagnosis. We also measured major LLA within 12 months of the DFU diagnosis; this outcome was identified using ICD-10 codes and Current Procedural Terminology codes (eAppendix).

Statistical Analysis

Patient demographics, comorbidities, and facility complexity level were summarized as frequencies and percentages for the overall cohort. Comparisons of variables between VHA-only care and community care consultation groups were conducted using the χ² test or Wilcoxon rank sum test, as appropriate. Variables significantly associated with community care consultation were used in the multivariable mixed-effects logistic regression model with a facility random intercept to assess factors associated with community care consultation while controlling for facility-level clustering in community care consultation practices. We estimated ORs and 95% CIs to examine the associations between patient-level risk factors and community care consultations. Facility-specific random intercepts were exponentiated to derive ORs and 95% CIs for community care consultations at each facility relative to the average facility. The median OR was calculated to quantify between-facility variation in the use of community care consultation among patients with DFUs. All statistical tests were 2 sided with statistical significance defined as α less than .05. Analyses were performed using SAS version 9.4 (SAS Institute Inc).

Ethics

This study was approved by the institutional review boards (IRBs) of the University of Iowa and the Iowa City Veterans Affairs Health Care System Research and Development Committee (IRB ID #202303655). Informed consent was waived.

RESULTS

During the study period, 68,371 patients 65 years and older were newly diagnosed with DFUs. After excluding 8250 patients who did not receive a podiatry, ID, vascular surgery, or endocrinology consultation, 60,121 patients from 139 VHA facilities were included in the analysis.

Characteristics of the study cohort after applying exclusion criteria are shown in Table 1. The mean (SD) age was 75.3 (7.0) years. Most patients were male (> 95%) and White (> 75%). Approximately one-third of patients resided in rural or highly rural areas, and approximately 80% received care at level 1 facilities. The most common comorbidities were hypertension (86.8%), PAD (38.3%), and chronic kidney disease (CKD; 34.9%).

A total of 17,561 patients (29.2%) had a community care consultation. There was no obvious yearly trend in the number ofcommunity care consultations during the study period (Figure 1). Compared with patients who received VHA-only care, those who received a community care consultation were older, more likely to be White, and less likely to be Black or Hispanic. They were also more likely to reside in rural areas, live farther from the nearest VHA tertiary facility, and be cared for in complexity level 2 or 3 facilities (Table 2). Interestingly, patients presenting with complicated DFUs were more likely to receive VHA-only care. CKD and PAD were significantly associated with higher rates of community care consultation.

Facility-level ORs for community care consultation are shown in Figure 2. ORs varied greatly across facilities, ranging from 0.25 to 3.66. The median OR for community care consultation was 1.58 (95% CI, 1.49-1.69), indicating a 58% difference in the odds of consultation between 2 randomly selected facilities after adjustment for patient-level characteristics and facility complexity level.

Among patients with DFUs, podiatry was the most commonly consulted specialty (88.3%), followed by vascular surgery (40.8%), ID (25.2%), and endocrinology (16.4%). The share of community care consultations out of the total number of consultations (community care plus VHA) for a given specialty varied. Specifically, community care accounted for 8.0% of podiatry consults, 17.8% of vascular consults, 15.3% of ID consults, and 14.2% of endocrinology consults. Community care was used less frequently for podiatry compared with the other specialties (P < .001 for all 3 comparisons). Time to new consultations was significantly longer among patients who received community care consultation vs consultation within the VHA for all specialties (Table 3).

Major LLA occurred in 4.1% of patients within 12 months of their DFU diagnosis. Patients who received community care consultations had significantly higher major LLA rates compared with those who received VHA-only care (4.6% vs 3.9%; P < .001).

DISCUSSION

In this retrospective cohort study of VHA patients with newly diagnosed DFUs, nearly 30% received community care consultations for specialty care. Those who received community care consultations were older, more often White, and more likely to have CKD and/or PAD. They were also more likely to live in a rural area, reside farther from a VHA tertiary hospital, and receive care at lower-complexity hospitals. Vascular surgery, ID, and endocrinology consultations were more often referred outside the VHA, suggesting limited timely access to these specialty providers within the VHA. The time to new consultations was significantly longer for community care consultations.

The use of community care consultations can be influenced by various factors, including the type and urgency of health care needs, the availability of specialists and procedures at local VHA facilities, and patients’ personal preferences.^16-18 Previous studies show wide variation in how often community care is used depending on the condition and procedure. For example, among patients newly diagnosed with prostate cancer between 2015 and 2018, the rate of community care consultation was 66.7% among those who received radiation therapy, 37.5% among those who received radical prostatectomy, and 7.5% among those managed with active surveillance.¹⁹ More recently, after the MISSION Act was implemented in 2019, 50% to 84% of patients living far from VHA medical centers who underwent cardiac procedures (percutaneous coronary intervention, coronary artery bypass grafting, or aortic valve replacement) received the procedure outside the VHA system.⁸ Among patients with diabetes 65 years and older who were dually enrolled in the VHA and Medicare from 2008 to 2009, Radomski et al reported that 17.2% utilized Medicare outpatient services outside the VHA system.²⁰ In our study, 29.2% of patients with DFUs were referred to community care, which is higher than the rate described in Radomski’s study. Our study’s higher consultation rate may reflect the more complex needs of patients with DFUs vs diabetes. The higher rate may also reflect the expanded availability of community care during the 2010s through the Veterans Choice Program⁴ and MISSION Act.⁵

We found that patients living in rural areas, who experienced longer drive times and received care at lower-complexity facilities, were more likely to receive a community care consultation. These patients are the main target of the VHA’s effort to expand community care, and our findings are consistent with previous studies assessing factors associated with community care consultation.^8,20 CKD and PAD were also associated with community care consultations. It is possible that patients with those comorbidities were selected because they tend to need vascular surgery consultation for treatment of the conditions.

Interestingly, patients who presented with complicated DFUs were more commonly treated entirely within the VHA system. Although the exact reasons for this are unclear, a previous study that categorized patterns of VHA care use suggested that high VHA-care users, who represented only 10% of all VHA patients, were the sickest population.²¹ This group tended to concentrate care within the VHA and accounted for 90% of all inpatients at VHA hospitals.²¹ Because most patients with complicated DFUs require hospital admission, these patients might have chosen to receive all their care within the VHA system.

In terms of specialty, vascular surgery, ID, and endocrinology were more commonly utilized in a community care health care system than podiatry. The facility-level variation in community care consultation is likely explained by differences in the timely availability of these 3 specialist consultations within the VHA system. Although we are lacking the exact numbers of specialists within the VHA system, facility-level variation is likely reflecting the lack of both medical and surgical specialties in rural settings compared with metropolitan health care settings.²²

We also found that the time to specialty consultation in a community health care system was longer than it was within the VHA system. This is consistent with previous findings that wait time for community specialty care was longer than wait time within the VHA in most of the Veterans Integrated Service Networks.²³ Although we lack data on how often patients were admitted to hospitals in the community, it is possible that patients seen exclusively within the VHA were more often receiving their consultations while hospitalized and, in turn, were able to receive these specialty services faster than patients waiting for outpatient visits with specialists.

Furthermore, our study’s rate of major LLA was significantly higher among patients who received community care consultations than those who completed their care within the VHA system. Although patients with complicated DFUs were more likely to receive VHA-only care, it was beyond the scope of this study to determine whether community care consultations are associated with higher major LLA rates. However, we can speculate that greater and more timely access to limb-salvaging efforts provided by podiatrists, primary care physicians, and other specialists might have led to lower major LLA rates within the VHA system.

Limitations

There are several limitations to our study. First, although our study utilized VHA data and Medicare data, we may not have captured some episodes of community care paid for by Medicaid or private insurance. Because 90% of VHA enrollees 65 years and older reported any Medicare enrollment in the 2024 survey,²⁴ we believe the number of patients utilizing Medicaid or private insurance was small. Moreover, claims for health care services would typically be submitted to Medicare in addition to alternative insurance payers. Second, we focused on 4 specialties that we believe play a major role in DFU management, but we may have overlooked other important specialties related to DFU care, including wound care specialists, orthopedics, and plastic surgery. Third, we lacked information on the reasons for community care consultations and therefore could not assess the reasons underlying the consultation decisions. Additionally, we were unable to determine who referred the patients to the specialists. Fourth, we focused on inpatient and outpatient consultations and did not include other types of community care consultations, such as diagnostic tests or medications. Fifth, although we calculated the time to consultation, we were unable to fully evaluate the quality of care delivered through community care consultations, such as the performance of pertinent care processes or outcomes. Sixth, because the study period was after implementation of the MISSION Act, we were unable to assess how this policy change may have had an impact on consultation patterns or care delivery.

CONCLUSIONS

This study found substantial but variable use of community care consultations for specialty care among patients with DFUs within the VHA. Community care consultations were more often used by smaller and rural facilities. Future research is needed to further assess the impact of community care consultation on the outcomes of these patients and to identify strategies for optimizing multidisciplinary DFU care across health care settings.

Author Affiliations: Veterans Rural Health Resource Center–Iowa City, Veterans Health Administration (VHA) Office of Rural Health (HS), Iowa City, IA; Center for Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System (HS, MVS, MO, BM, KM, DJL), Iowa City, IA; Department of Internal Medicine, University of Iowa (HS, MVS, MO, DJL), Iowa City, IA; Department of Medicine, School of Medicine and Public Health, University of Wisconsin (MBB), Madison, WI; William S. Middleton Memorial Veterans’ Hospital (MBB), Madison, WI; College of Podiatric Medicine, Kent State University (JMR), Independence, OH.

Source of Funding: This study was funded by Veterans Rural Health Resource Center–Iowa City Rural Career Development Award NOMAD:03806.

Author Disclosures: Dr Suzuki reports employment with the US Department of Veterans Affairs (VA) Iowa City Healthcare system, pending VA Merit funding, a VA Rural Health Career Development Award grant from the VHA Office of Rural Health, and attendance at the 2025 Diabetic Foot Conference. The remaining authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (HS, MVS, MO, MBB, JMR); acquisition of data (HS, BM); analysis and interpretation of data (HS, MVS, MO, KM, MBB, JMR, DJL); drafting of the manuscript (HS, MO, KM); critical revision of the manuscript for important intellectual content (MVS, MO, BM, MBB, JMR, DJL); statistical analysis (HS, MVS, KM); obtaining funding (HS, DJL); administrative, technical, or logistic support (BM, KM); and supervision (DJL).

Address Correspondence to: Hiroyuki Suzuki, MD, MSCI, Veterans Rural Health Resource Center­—Iowa City/Iowa City VA Healthcare System, 601 Highway 6, Iowa City, IA 52246. Email: hiroyuki-suzuki@uiowa.edu

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