Evaluation of revascularization benefit quartiles using the Wound, Ischemia, and foot Infection classification system for diabetic patients with chronic limb-threatening ischemia.

OBJECTIVE: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system was developed to stratify the risk of 1-year major amputation. Recently, the WIfI scores were used to define the estimated revascularization benefit quartiles ranging from high benefit (Q1) to questionable benefit (Q4). The aim of our study was to evaluate the revascularization benefit quartiles in a cohort of diabetic patients presenting with chronic limb-threatening ischemia (CLTI). METHODS: All diabetic patients presenting to our multidisciplinary diabetic foot and wound clinic (June 2012 to May 2020) who underwent lower extremity revascularization for CLTI were included. The affected limbs were graded using the WIfI system and assigned to an estimated benefit of revascularization quartile as previously published. One-year major amputation, complete foot healing, secondary patency, and amputation-free survival were calculated among the quartiles using Kaplan-Meier curve analyses and compared using Cox proportional hazards models. RESULTS: Overall, 136 diabetic patients underwent revascularization of 187 limbs (mean age, 64.9 ± 11.2 years; 63.2% male; 58.8% black). The limbs were revascularized using an endovascular approach for 66.8% and open surgery for 33.2%. Of the 187 limbs, 27.3% had a high estimated benefit of revascularization (Q1), 31.6% had a moderate estimate benefit of revascularization (Q2), 20.3% had a low estimated benefit of revascularization (Q3), and 20.9% had a questionable benefit of revascularization (Q4). The estimated 1-year major amputation rates were 7.2% ± 4.1% for Q1, 3.8% ± 2.6% for Q2, 7.0% ± 4.8% for Q3, and 25.7% ± 7.5% for Q4 (P = .006). The estimated 1-year foot healing rates were 87.3% ± 5.7% for Q1, 84.8% ± 5.6% for Q2, 83.8% ± 7.4% for Q3, and 68.2% ± 9.1% for Q4 (P = .06). The overall secondary patency (P = .23) and amputation-free survival (P = .33) did not significantly differ among the groups. Using Cox proportional hazard modeling, the Q4 group had a significantly greater risk of major amputation compared with Q1 (hazard ratio, 4.26; 95% confidence interval, 1.15-15.70). Of the 14 limbs requiring major amputation, 9 (56.3%) had a patent revascularization at the time of amputation, including one of three limbs in Q1, two of two limbs in Q2, no limb in Q3, and six of nine limbs in Q4. CONCLUSIONS: The questionable estimated revascularization benefit quartile using the WIfI classification system is significantly associated with 1-year major amputation in diabetic patients presenting with CLTI. Limbs with a questionable benefit of revascularization (Q4) will frequently require major amputation despite a patent revascularization, suggesting that the wound size and infection burden are the driving factors behind the elevated risk of major amputation in this group. Our findings support the previously described use of the WIfI classification system to predict revascularization benefit among diabetic patients with CLTI.

Impact of Geographic Socioeconomic Disadvantage on Minor Amputation Outcomes in Patients With Diabetes.

BACKGROUND: Socioeconomic disadvantage is a known contributor to adverse events and higher admission rates in the diabetic population. However, its impact on outcomes after lower extremity amputation is unclear. We aimed to assess the association of geographic socioeconomic disadvantage with short- and long-term outcomes after minor amputation in patients with diabetes. MATERIALS AND METHODS: Geographic socioeconomic disadvantage was determined using the area deprivation index (ADI). All patients from the Maryland Health Services Cost Review Commission database (2012-2019) who underwent minor amputation with a concurrent diagnosis of diabetes were included and stratified by the ADI quartile. Associations of the ADI quartile with 30-day readmission and 1-year reamputation were evaluated using Kaplan-Meier survival analyses and multivariable logistic regression models adjusting for baseline differences. RESULTS: A total of 7415 patients with diabetes underwent minor amputation (70.1% male, 38.7% black race), including 28.1% ADI1 (least deprived), 42.8% ADI2, 22.9% ADI3, and 6.2% ADI4 (most deprived). After adjusting for demographic and clinical factors, the odds of 30-day readmission were greater in the intermediate ADI groups than those in the ADI1 group, but not among the most deprived. Adjusted odds of 1-year reamputation were greater among ADI4 than those among ADI1. Kaplan-Meier analysis confirmed a greater likelihood of reamputation with an increasing ADI quartile over a 1-year period (P < 0.001). CONCLUSIONS: Geographic socioeconomic disadvantage is independently associated with both short- and long-term outcomes after minor diabetic amputations in Maryland. A targeted approach addressing the health care needs of deprived regions may be beneficial in optimizing postoperative care in this vulnerable population.

Outcomes and Predictors of Wound Healing among Patients with Complex Diabetic Foot Wounds Treated with a Dermal Regeneration Template (Integra).

BACKGROUND: The utility of dermal regeneration templates for treating high-risk diabetic foot wounds is unclear. The authors report wound healing and major amputation outcomes among a cohort of diabetic patients with complex diabetic foot wounds treated in a multidisciplinary setting. METHODS: All patients with complex diabetic foot wounds treated with a dermal regeneration template (March of 2013 to February of 2019) were captured in a prospective institutional database. Wound severity was classified according to the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system to determine limb salvage prognosis at baseline. Wound healing and major amputation rates were reported using Kaplan-Meier analyses. A stepwise Cox proportional hazards model was used to identify independent characteristics associated with wound healing. RESULTS: Eighty-five patients with 107 complex diabetic foot wounds were treated (mean age, 61.2 ± 3.3 years; 63.5 percent male and 61.2 percent African American). Most diabetic foot wounds were high-risk (wound, ischemia, and foot infection stage 3 or 4, 93.5 percent), corresponding to a predicted 25 to 50 percent risk of major amputation at 1 year. Dermal regeneration template use resulted in successful wound granulation in 66.7 percent of cases, with a mean time to complete wound healing of 198 ± 18 days. Twelve- and 18-month wound healing rates were 79.0 ± 5.0 percent and 93.0 ± 3.3 percent, respectively. Major amputation was required in 11.2 percent of patients. Independent predictors of poor wound healing included lack of bone involvement, higher WIfI stage, and prior dermal regeneration template failure. CONCLUSION: Application of a dermal regeneration template to complex diabetic foot wounds at high risk for major amputation results in good wound healing and excellent limb salvage outcomes among diabetic patients treated in a multidisciplinary setting. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Glycemic control and diabetic foot ulcer outcomes: A systematic review and meta-analysis of observational studies.

OBJECTIVE: To evaluate the association between glycemic control (hemoglobin A1C, fasting glucose, and random glucose) and the outcomes of wound healing and lower extremity amputation (LEA) among patients with diabetic foot ulcers (DFUs). RESEARCH DESIGN AND METHODS: Medline, EMBASE, Cochrane Library, and Scopus were searched for observational studies published up to March 2019. Five independent reviewers assessed in duplicate the eligibility of each study based on predefined eligibility criteria and two independent reviewers assessed risk of bias. Ameta-analysis was performed to calculate a pooled odds ratio (OR) or hazard ratio (HR) using random effects for glycemic measures in relation to the outcomes of wound healing and LEA. Subgroup analyses were conducted to explore potential source of heterogeneity between studies. The study protocol is registered with PROSPERO (CRD42018096842). RESULTS: Of 4572 study records screened, 60 observational studies met the study eligibility criteria of which 47 studies had appropriate data for inclusion in one or more meta-analyses(n = 12,604 DFUs). For cohort studies comparing A1C >7.0 to 7.5% vs. lower A1C levels, the pooled OR for LEA was 2.04 (95% CI, 0.91, 4.57) and for studies comparing A1C ≥ 8% vs. <8%, the pooled OR for LEA was 4.80 (95% CI 2.83, 8.13). For cohort studies comparing fasting glucose ≥126 vs. <126 mg/dl, the pooled OR for LEA was 1.46 (95% CI, 1.02, 2.09). There was no association with A1C category and wound healing (OR or HR). There was high risk of bias with respect to comparability of cohorts as many studies did not adjust for potential confounders in the association between glycemic control and DFU outcomes. CONCLUSIONS: Our findings suggest that A1C levels ≥8% and fasting glucose levels ≥126 mg/dl are associated with increased likelihood of LEA in patients with DFUs. A purposively designed prospective study is needed to better understand the mechanisms underlying the association between hyperglycemia and LEA.

Incidence and Risk Factors Associated With Ulcer Recurrence Among Patients With Diabetic Foot Ulcers Treated in a Multidisciplinary Setting.

BACKGROUND: Recent studies demonstrate favorable diabetic foot ulcer (DFU) healing outcomes with the implementation of a multidisciplinary team. We aimed to describe the incidence of and risk factors associated with ulcer recurrence after initial complete healing among a cohort of patients with DFU treated in a multidisciplinary setting. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from 6/2012-04/2018 were enrolled in a prospective database. The incidence of ulcer recurrence after complete wound healing was assessed per limb using the Kaplan-Meier method, and a stepwise multivariable Cox proportional hazards model was created to identify independent predictors of ulcer recurrence. RESULTS: A total of 244 patients with 304 affected limbs were included. Ulcer recurrence rates at one and 3 y after healing were 30.6 ± 3.0% and 64.4 ± 5.2%, respectively. Recurrent ulcers were smaller (4.4 ± 1.1 cm2versus 8.2 ± 1.2 cm2; P = 0.04) and had a lower Wound, Ischemia, and foot Infection stage (stage 4: 7.7% versus 22.4%; P < 0.001) than initial ulcers, and wound healing time was significantly reduced (95.0 ± 9.8 versus 131.8 ± 7.0 d; P = 0.004). Independent predictors of ulcer recurrence included abnormal proprioception (HR, 1.57 [95% CI 1.02-4.43]) and younger age (HR 1.02 per year [95% CI 1.01-1.04]). CONCLUSIONS: In this prospective cohort of patients with DFU, time to diagnosis and healing was significantly lower for recurrent ulcers, and downstaging was common. These data suggest that engaging patients with DFU in a multidisciplinary care model with frequent follow-up and focused patient education may serve to decrease DFU morbidity.

Contribution of 30-day readmissions to the increasing costs of care for the diabetic foot.

OBJECTIVE: The inpatient cost of care for diabetic foot ulcers (DFUs) has been estimated to be $1.4 billion annually in the United States. We have previously demonstrated that the risk of 30-day unplanned readmission for patients with DFU is nearly 22%. Our aim was to quantify the cost of readmissions for patients admitted with DFU. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from June 2012 to June 2016 were enrolled in a prospective database. Inpatient costs and net margins were calculated overall and for index admissions vs 30-day unplanned readmissions. RESULTS: A total of 249 admissions for 150 patients were included. Of these, 206 admissions were index admissions and 43 were 30-day readmissions. The most common reason for readmission was the foot wound (49%), followed by a bypass wound (14%), renal complications (9%), and other systemic complications. Surgical interventions during readmission were common (47%) and included both podiatric (37%) and vascular (23%). The wound healing outcomes were favorable, with 78% of all wounds achieving healing by 1 year. Limb salvage was 91% overall. The median hospital cost per admission was $20,111 (interquartile range, $12,589-$33,254) and did not differ between the index and readmissions ($22,165 vs $19,408; P = .46). However, the hospital net margins were lower after readmission ($3908 vs $1975; P = .02). The overall cost of care for patients requiring readmission was significantly greater than that for patients not readmitted ($79,315 vs $28,977; P < .001). During the study period, DFU care at our institution cost $7.9 million, of which $1.2 million (16%) was attributable to readmission costs. CONCLUSIONS: Readmissions for patients with DFU are common and associated with a substantial cost burden. The cost of readmission for patients with DFU was as high as the cost of the index admission but with lower hospital net margins. When extrapolated to national data, the 15% readmission cost burden we have reported would be equivalent to $210 million hospital costs annually. Focused efforts at preventing readmissions in this high-risk patient population are essential to reducing the overall costs of care associated with DFUs.

Quantifying the costs and profitability of care for diabetic foot ulcers treated in a multidisciplinary setting.

OBJECTIVE: Increasing Wound, Ischemia, and foot Infection (WIfI) stage has previously been shown to be associated with prolonged wound healing time, higher number of surgical procedures, and increased cost of care in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. However, the profitability of this care model is unknown. We aimed to quantify the hospital costs and net margins associated with multidisciplinary DFU care. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service (January 2012-June 2016) were enrolled in a prospective database. Inpatient and outpatient costs and net margin (U.S. dollars) were calculated for each wound episode (initial visit until complete wound healing) overall and per day of care according to WIfI classification. RESULTS: A total of 319 wound episodes in 248 patients were captured. Patients required an average of 2.6 ± 0.2 inpatient admissions and 0.9 ± 0.1 outpatient procedures to achieve complete healing. Limb salvage at 1 year was 95.0% ± 2.4%. The overall mean cost of care per wound episode was $24,226 ± $2176, including $41,420 ± $3318 for inpatient admissions and $11,265 ± $1038 for outpatient procedures. The mean net margin was $2412 ± $375 per wound episode, including $5128 ± $622 for inpatient admissions and a net loss ($-3730 ± $596) for outpatient procedures. Mean time to wound healing was 136.3 ± 7.9 days, ranging from 106.5 ± 13.1 days for WIfI stage 1 wounds to 229.5 ± 20.0 days for WIfI stage 4 wounds (P < .001). When adjusted for days of care, the net margin ranged from $2.6 ± $1.3 per day (WIfI stage 1) to $23.6 ± $18.8 (WIfI stage 4). CONCLUSIONS: The costs associated with multidisciplinary DFU care are substantial, especially with advanced-stage wounds. Whereas hospitals can operate at a profit overall, the net margins associated with outpatient procedures performed in a hospital-based facility are prohibitive, and the overall net margins are relatively low, given the labor required to achieve good outcomes. Thus, reimbursement for the multidisciplinary care of DFUs should be re-examined.

The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds.

OBJECTIVE: Previous studies show conflicting results in wound healing outcomes based on angiosome direct perfusion (DP), but few have adjusted for wound characteristics in their analyses. We have previously shown that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing in diabetic foot ulcers (DFUs) treated by a multidisciplinary team. The aim of this study was to compare WIfI classification vs DP and pedal arch patency as predictors of wound healing in patients presenting with DFU and peripheral arterial disease. METHODS: We performed a retrospective review of a prospectively maintained database of all patients with peripheral arterial disease presenting to our multidisciplinary DFU clinic who underwent angiography. An angiosome was considered directly perfused if the artery feeding the angiosome was revascularized or was completely patent. Wound healing time at 1 year was compared on the basis of DP vs indirect perfusion, Rutherford pedal arch grade, and WIfI classification using univariable statistics and Cox proportional hazards models. RESULTS: Angiography was performed on 225 wounds in 99 patients (mean age, 63.3 ± 1.2 years; 62.6% male; 53.5% black) during the entire study period. There were 33 WIfI stage 1, 33 stage 2, 51 stage 3, and 108 stage 4 wounds. DP was achieved in 154 wounds (68.4%) and indirect perfusion in 71 wounds (31.6%). On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2% for WIfI 3/4 vs 77.3% for WIfI 1/2; P = .02), whereas DP and pedal arch patency were not (both, P ≥ .08). After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing (WIfI 3/4: hazard ratio [HR], 0.77; 95% confidence interval [CI], 0.67-0.88), whereas DP (HR, 0.82; 95% CI, 0.55-1.21) and pedal arch grade (HR, 0.85; 95% CI, 0.70-1.03) were not. CONCLUSIONS: In our population of patients treated by a multidisciplinary diabetic foot service, the Society for Vascular Surgery WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. Our results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome-directed perfusion results previously observed.

Neighborhood socioeconomic disadvantage is not associated with wound healing in diabetic foot ulcer patients treated in a multidisciplinary setting.

BACKGROUND: Socioeconomic deprivation is associated with poor glycemic control and higher hospital admission rates in patients with diabetes. We sought to quantify the effects of neighborhood socioeconomic deprivation on wound healing among a cohort of patients with diabetic foot ulceration (DFU) treated in a multidisciplinary setting. METHODS: Socioeconomic disadvantage was calculated for all patients using the area deprivation index (ADI) stratified by quartile (from ADI-0: least through ADI-3: most). Predictors of wound healing were assessed using Cox proportional hazards models accounting for patient demographics, wound characteristics, and ADI category. RESULTS: Six hundred twenty-one wounds were evaluated, including 59% ADI-0, 7% ADI-1, 12% ADI-2, and 22% ADI-3. After accounting for patient demographics and wound characteristics, the likelihood of wound healing was similar between groups (ADI-3 versus ADI-0: hazards ratio [HR] 1.03 [95% confidence interval 0.76-1.41]). Independent predictors of poor wound healing included peripheral arterial disease (HR 0.75), worse wound stage (stage 4: HR 0.48), larger wound area (HR 0.99), and partially dependent functional status (HR 0.45) (all, P < 0.05). CONCLUSIONS: In a multidisciplinary setting, wound healing was largely dependent on wound characteristics and vascular status rather than patient demographics or neighborhood socioeconomic disadvantage. Use of a multidisciplinary approach to the management of DFU may overcome the negative effects of socioeconomic disadvantage frequently described in the diabetic population.

Unplanned 30-day readmission in patients with diabetic foot wounds treated in a multidisciplinary setting.

OBJECTIVE: Readmission rates are known to be high for vascular surgery patients in general, but there are limited data describing the risk of surgical and nonsurgical readmission among patients with diabetic foot ulcers (DFUs). Our aim was to identify factors associated with unplanned readmission in DFU patients treated in a multidisciplinary setting. METHODS: We studied a single-center cohort of patients enrolled in a multidisciplinary diabetic foot service (July 2012-June 2017). Readmissions were stratified by planned vs unplanned and related vs unrelated to the wound and vascular status. Predictors of unplanned 30-day readmission were examined with univariable and multivariable logistic regression models including all covariates with P ≤ .10. RESULTS: There were 460 admissions in 206 patients during the study period, including 99 total readmissions (21.5%). Readmissions were categorized as planned (n = 18 [18.2%]) or unplanned (n = 81 [81.8%]) and as related (n = 67 [67.7%]) or unrelated (n = 32 [32.3%]) to the wound and vascular status. The most frequent reasons for unplanned 30-day readmission were deterioration of the foot wound (41%), vascular complications (15%), gastrointestinal complications (10%), cardiac complications (8%), and acute kidney injury (8%). The average length of stay for the initial admission was 9.0 ± 7.1 days, whereas the average unplanned readmission length of stay was 8.6 ± 9.1 days (P = .38). On univariable analysis, hypertension (odds ratio [OR], 2.80; 95% confidence interval [CI], 1.19-6.59), peripheral arterial disease (OR, 1.80; 95% CI, 1.09-2.99), and exposure to an open vascular operation (OR, 2.64; 95% CI, 1.34-5.17) were associated with a higher risk of 30-day unplanned readmission (P ≤ .02). Private, military, or self-pay insurance was protective (OR, 0.52; 95% CI, 0.28-0.97). Wound duration, location, and Wound, Ischemia, and foot Infection (WIfI) classification were not associated with readmission (P ≥ .22). After risk adjustment, only hypertension (OR, 2.80; 95% CI, 1.19-6.59) and current smoking (OR, 1.95; 95% CI, 1.02-3.73) were independently associated with 30-day unplanned readmission, but the predictive accuracy of the model was weak (C statistic = 0.69). CONCLUSIONS: We found a 17% unplanned 30-day readmission rate in this prospective cohort of DFU patients enrolled in a multidisciplinary diabetic foot service. Only current smoking and hypertension were independent predictors of readmission after risk adjustment. These findings suggest that implementation of a smoking cessation program may be beneficial to reduce unplanned readmissions in DFU patients. They also highlight the complexity involved in achieving comprehensive DFU care and the unpredictability of readmissions in this unique population of patients.

The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system correlates with cost of care for diabetic foot ulcers treated in a multidisciplinary setting.

OBJECTIVE: We have previously demonstrated that the Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification correlates with wound healing time in patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. Our aim was to assess whether the charges and costs associated with DFU care increase with higher WIfI stages. METHODS: All patients presenting to our multidisciplinary diabetic limb preservation service from June 2012 to June 2016 were enrolled in a prospective database. Inpatient and outpatient charges, costs, and total revenue from initial visit until complete wound healing were compared for wounds stratified by WIfI classification. RESULTS: A total of 319 wound episodes in 248 patients were captured, including 31% WIfI stage 1, 16% stage 2, 30% stage 3, and 24% stage 4 wounds. Limb salvage at 1 year was 95% ± 2%, and wound healing was achieved in 85% ± 2%. The mean number of overall inpatient admissions (stage 1, 2.07 ± 0.48 vs stage 4, 3.40 ± 0.27; P < .001), procedure-related admissions (stage 1, 1.86 ± 0.45 vs stage 4, 2.28 ± 0.24; P < .001), and inpatient vascular interventions (stage 1, 0.14 ± 0.10 vs stage 4, 0.80 ± 0.12; P < .001) increased significantly with increasing WIfI stage. There were no significant differences in mean number of inpatient podiatric interventions or outpatient procedures between groups (P ≥ .10). The total cost of care per wound episode increased progressively from stage 1 ($3995 ± $1047) to stage 4 ($50,546 ± $4887) wounds (P < .001). Inpatient costs were significantly higher for advanced stage wounds (stage 1, $21,296 ± $4445 vs stage 4, $54,513 ± $5001; P < .001), whereas outpatient procedure costs were not significantly different between groups (P = .72). Overall, hospital total revenue increased with increasing WIfI stage (stage 1, $4182 ± $1185 vs stage 4, $55,790 ± $5540; P < .002). CONCLUSIONS: Increasing WIfI stage is associated with a prolonged wound healing time, a higher number of surgical procedures, and an increased cost of care. While limb salvage outcomes are excellent, the overall cost of DFU care from presentation to healing is substantial, especially for patients with advanced (WIfI stage 3/4) disease treated in a multidisciplinary setting.

The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing but not major amputation in patients with diabetic foot ulcers treated in a multidisciplinary setting.

OBJECTIVE: The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) threatened limb classification has been shown to correlate well with risk of major amputation and time to wound healing in heterogeneous diabetic and nondiabetic populations. Major amputation continues to plague the most severe stage 4 WIfI patients, with 1-year amputation rates of 20% to 64%. Our aim was to determine the association between WIfI stage and wound healing and major amputation among patients with diabetic foot ulcers (DFUs) treated in a multidisciplinary setting. METHODS: All patients presenting to our multidisciplinary DFU clinic from July 2012 to December 2015 were enrolled in a prospective database. Wound healing and major amputation were compared for patients stratified by WIfI classification. RESULTS: There were 217 DFU patients with 439 wounds (mean age, 58.3 ± 0.8 years; 58% male, 63% black) enrolled, including 28% WIfI stage 1, 11% stage 2, 33% stage 3, and 28% stage 4. Peripheral arterial disease and dialysis were more common in patients with advanced (stage 3 or 4) wounds (P ≤ .05). Demographics of the patients, socioeconomic status, and comorbidities were otherwise similar between groups. There was a significant increase in the number of active wounds per limb at presentation with increasing WIfI stage (stage 1, 1.1 ± 0.1; stage 4, 1.4 ± 0.1; P = .03). Mean wound area (stage 1, 2.6 ± 0.6 cm2; stage 4, 15.3 ± 2.8 cm2) and depth (stage 1, 0.2 ± 0.0 cm; stage 4, 0.8 ± 0.1 cm) also increased progressively with increasing wound stage (P < .001). Minor amputations (stage 1, 18%; stage 4, 56%) and revascularizations (stage 1, 6%; stage 4, 55%) were more common with increasing WIfI stage (P < .001). On Kaplan-Meier analysis, WIfI classification was predictive of wound healing (P < .001) but not of major amputation (P = .99). For stage 4 wounds, the mean wound healing time was 190 ± 17 days, and risk of major amputation at 1 year was 5.7% ± 3.2%. CONCLUSIONS: Among patients with DFU, the WIfI classification system correlated well with wound healing but was not associated with risk of major amputation at 1 year. Although further prospective research is warranted, our results suggest that use of a multidisciplinary approach for DFUs may augment healing time and reduce amputation risk compared with previously published historical controls of standard wound care among patients with advanced stage 4 disease.