Adjuvant and Salvage Radiotherapy after Prostatectomy: ASTRO/AUA Guideline Amendment 2018-2019.

PURPOSE: The purpose of this amendment is to incorporate newly-published literature into the original ASTRO/AUA Adjuvant and Salvage Radiotherapy after Prostatectomy Guideline and to provide an updated clinical framework for clinicians. MATERIALS AND METHODS: The original systematic review yielded 294 studies published between January 1990 and December 2012. In April 2018, the guideline underwent an amendment and incorporated 155 references that were published from January 1990 through December 2017. Two new key questions were added. One on the use of genomic classifiers and the other on the treatment of oligo-metastases with radiation post-radical prostatectomy. RESULTS: A new statement on the use of hormone therapy with salvage radiotherapy after radical prostatectomy was added and long-term data was used to update an existing statement on adjuvant radiotherapy. The balance of the guideline statements were re-affirmed and references were added to the existing literature base. A discussion on the use of genomic classifiers as a risk stratification tool was added to the future research discussion. No relevant data on oligo-metastases was found. CONCLUSIONS: Hormone therapy should be offered to patients who have had radical prostatectomy and who are candidates for salvage radiotherapy. The clinician should discuss possible short- and long-term side effects with the patient as well as the potential benefits of preventing recurrence. The decision to use hormone therapy should be made by the patient and a multi-disciplinary team of providers with full consideration of the patient's history, values, preferences, quality of life, and functional status.

Adjuvant and Salvage Radiation Therapy After Prostatectomy: ASTRO/AUA Guideline Amendment, Executive Summary 2018.

PURPOSE: The purpose of this amendment is to incorporate newly published literature into the original American Society for Radiation Oncology/American Urological Association Adjuvant and Salvage Radiotherapy After Prostatectomy Guideline and provide an updated clinical framework for clinicians. METHODS AND MATERIALS: The original systematic review yielded 294 studies published between January 1990 and December 2012. In April 2018, the guideline underwent an amendment and incorporated 155 references that were published between January 1990 and December 2017. Two new key questions were added: one on the use of genomic classifiers and the other on the treatment of oligo-metastases with radiation after radical prostatectomy. RESULTS: A new statement on the use of hormone therapy with salvage radiation therapy (RT) after radical prostatectomy was added, and long-term data were used to update an existing statement on adjuvant RT. The balance of the guideline statements were reaffirmed, and references added to the existing literature base. A discussion on the use of genomic classifiers as a risk stratification tool was added to the future research discussion. No relevant data on oligo-metastases were found. CONCLUSIONS: Hormone therapy should be offered to patients who have had radical prostatectomy and who are candidates for salvage RT. Clinicians should discuss possible short- and long-term side effects with patients in addition to the potential benefits of preventing recurrence. The decision to use hormone therapy should be made by the patient and a multidisciplinary team of providers with full consideration of the patient's history, values, preferences, quality of life, and functional status.

"Halo effect" in trauma centers: does it extend to emergent colectomy?

BACKGROUND: Trauma centers (TCs) have been demonstrated to improve outcomes for some nontrauma surgical conditions, such as appendicitis, but it remains unclear if this extends to all emergency general surgery procedures. Using emergent colectomy in patients with diverticulitis as index condition, this study compared outcomes between TCs and nontrauma centers (NTCs). MATERIALS AND METHODS: The Nationwide Emergency Department Sample (2006-2011) was queried for patients ≥16 y with diverticulitis who underwent emergency surgical intervention. Outcomes included mortality, total charges, and length of stay (LOS). Mortality in TC and NTC was compared using logistic regression, controlling for patient, procedure, and hospital-level characteristics. Adjusted total charges and LOS were analyzed using generalized linear models with gamma and Poisson distributions, respectively. RESULTS: A total of 25,396 patients were included, 5189 (20.4%) were treated at TC and 20,207 (79.6%) at NTC. Median age and sex distribution were similar. Unadjusted proportional in-hospital mortality did not differ between TC and NTC; median charges and LOS were greater in TC. After adjusting, the odds of mortality were significantly higher in TC (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.02-1.51; P = 0.003) as were mean charges and LOS (P < 0.001). CONCLUSIONS: The improved outcomes reported for other nontrauma conditions in TC were not observed for patients undergoing an emergent colectomy for diverticulitis after accounting for patient, procedure, and hospital-level characteristics. Future research is needed to assess differences in case mix between TC versus NTC and possible case-mix effects on outcomes to elucidate potential benefit of surgical care in a TC across the breadth of emergency general surgery conditions.

Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs.

BACKGROUND: Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes mellitus (DM) on foot ulcer admissions in the United States, and to investigate potential explanations for rising hospital costs. METHODS: The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM versus non-DM. RESULTS: In total, 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM versus non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; P < 0.001). Neuropathy and infection accounted for 90% of DFU admissions, while peripheral vascular disease accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; P < 0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; P < 0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared with all other causes ($11,290 vs. $8,145; P < 0.001). CONCLUSIONS: Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.

Thirty-day readmission after lower extremity bypass in diabetic patients.

BACKGROUND: Lower extremity bypass (LEB) for peripheral vascular disease is a common procedure in diabetics and is associated with readmission. Thus, we hypothesized that diabetes might be a predictor of 30-d unplanned readmission after LEB. METHODS: Patients undergoing infrainguinal LEB in the 2011-12 American College of Surgeons National Surgery Quality Improvement Program database were divided into nondiabetics mellitus (NDM), non-insulin-dependent diabetics mellitus (NIDDM), and insulin-dependent diabetic mellitus (IDDM). Univariate and multivariate analyses were used to evaluate the influence of diabetes on 30-d readmission. RESULTS: A total of 9207 patients (5155 [56%] NDM, 1690 (18%) NIDDM, and 2362 (26%) IDDM) underwent LEB. Unplanned readmission was observed in 1448 patients (16%). IDDM had significantly higher crude postoperative complication (43% versus 30% NDM, 36% NIDDM; P < 0.001) and unplanned readmission rates (20% versus 14% NDM, 16% NIDDM; P < 0.001). Concomitant cardiac disease significantly modified the association between diabetes and unplanned readmission. On multivariable analysis, IDDM was an independent predictor of unplanned readmission in the absence of cardiac disease (odds ratio [OR] = 1.23; 95% confidence interval [CI], 1.03-1.47; P = 0.01). However, this association did not remain significant in the presence of cardiac disease (OR = 0.70; 95% CI, 0.48-1.01; P = 0.56). On subgroup analysis of those without cardiac disease, cardiac complications were a significant risk factor for readmission in IDDM (OR = 2.00; 95% CI, 1.12-3.57; P = 0.02) but not NDM (P = 0.31) or NIDDM (P = 0.10). CONCLUSIONS: Although post-LEB unplanned readmission was more common among diabetics, IDDM was independently associated with unplanned readmission only in those without cardiac disease. This was driven, in part, by increased cardiac complications. Therefore, a more stringent preoperative cardiac workup in this group should be considered before LEB.

Investigating the relationship between weather and violence in Baltimore, Maryland, USA.

BACKGROUND: It is a common refrain at major urban trauma centers that caseloads increase in the heat of the summer. Several previous studies supported this assertion, finding trauma admissions and crime to correlate positively with temperature. We examined links between weather and violence in Baltimore, MD, through trauma presentation to Johns Hopkins Hospital and crime reports filed with the Baltimore Police Department. METHODS: Crime data were obtained from the Baltimore City Police Department from January 1, 2008 to March 31, 2013. Trauma data were obtained from a prospectively collected registry of all trauma patients presenting to Johns Hopkins Hospital from January 1, 2007 to March 31, 2013. Weather data were obtained from the National Climatic Data Center. Correlation coefficients were calculated and negative binomial regression was used to elucidate the independent associations of weather and temporal variables with the trauma and crime data. RESULTS: When adjusting for temporal and meteorological factors, maximum daily temperature was positively associated with total trauma, intentional injury, and gunshot wounds presenting to Johns Hopkins Hospital along with total crime, violent crime, and homicides in Baltimore City. Associations of average wind speed, daily precipitation, and daily snowfall with trauma and crime were far weaker and, when significant, nearly universally negative. CONCLUSION: Maximum daily temperature is the most important weather factor associated with violence and trauma in our study period and location. Our findings suggest potential implications for hospital staffing to be explored in future studies.

Awareness of racial/ethnic disparities in surgical outcomes and care: factors affecting acknowledgment and action.

BACKGROUND: Studies have demonstrated racial/ethnic disparities in surgical outcomes and care. Surgeon awareness and its association with institutional action remain unclear. The study sought to assess surgeons' awareness of racial/ethnic disparities, ascertain whether demographic and practice factors influence acknowledgement of disparities, and determine whether surgeons are seeking to mitigate disparities. METHODS: Anonymous online survey was administered to a random sample of American College of Surgeons (ACS) general surgeons (July 2013 to March 2014). Responses were weighted for nonresponse and risk-adjusted using logistic regression. RESULTS: 172 surgeons completed the survey. Levels of acknowledged disparities were low. Less than one half reported institutional efforts to address disparities, and less than one fourth had taken efforts to investigate disparities in their personal practice. Several respondent factors including Academic Medical Center affiliation, awareness of the ACS statement on optimal access, and year of medical school graduation significantly associated with expressed acknowledgment of disparities. CONCLUSIONS: Such associations speak to the need for continued efforts to promote enhanced provider awareness and participation. As the field of surgical disparities moves from understanding to action, we must acknowledge the contributing role that providers play.

From understanding to action: interventions for surgical disparities.

BACKGROUND: Health care disparities are a well-documented phenomenon. Despite the development and implementation of multiple interventions, disparities in surgery have proven persistent. Thought to arise from a combination of patient, provider, and system-level factors, the objective of this study was to identify what is currently known about factors that influence surgical disparities and elucidate possible interventions to address them across four intervention-based themes: (1) condition-specific targeted interventions; (2) increased reliance on quantitative factors; (3) doctor-patient communication; and (4) cultural humility. DATA SOURCES: Articles were abstracted from PubMed, EMBASE, and the Cochrane Library using controlled keyword vocabulary. CONCLUSIONS: There are various forms of interventions to address surgical disparities, spanning knowledge from disparate fields. Promising efforts have emerged towards the successful alleviation of disparities. In order to move the field of surgery from understanding of disparities towards actions to mitigate them, continued development of meaningful quality improvement initiatives are needed.

Traumatic Spinal Cord Injury Emergency Service Triage Patterns and the Associated Emergency Department Outcomes.

Paralysis is an indication for trauma patients to be preferentially triaged by emergency services to designated level I or II trauma centers (TC). We sought to describe triage practices for patients with acute traumatic spinal cord injury (TSCI) and its associated emergency department (ED) outcomes. Adults ages ≥ 18 years with a diagnosis of acute TSCI (International Classification of Diseases-9: 806 and 952) in the 2006-2011 United States Nationwide Emergency Department Sample were included in these analyses. Outcomes assessed include triage to non-trauma centers (NTC), which is referred to as "under-triage," and ED mortality. Of 117,444 adults with TSCI, 33.4% were under-triaged to NTC. Under-triage was more prevalent with increasing age. Among patients under-triaged to NTC, 37.4% had new injury severity score (NISS) >15, representing severe injuries or polytrauma. Among patients with NISS >15, the odds of ED mortality in NTC were four-fold greater compared to level I trauma centers (TC-I) (adjusted odds ratio [AOR] = 4.06; 95% confidence interval = 1.87-8.79; p < 0.001). In conclusion, under-triage of adults with acute TSCI occurred in at least one-third of the cases. Patients triaged to NTC rather than TC-I experienced higher likelihood of death in the ED even after controlling for personal and injury characteristics. Further research is necessary to elucidate detailed clinical and logistical factors that may be associated with under-triage of acute TSCI, to facilitate interventions aimed at improving patient experience and outcomes.

Undertriage of older trauma patients: is this a national phenomenon?

BACKGROUND: Older age is associated with high rates of morbidity and mortality after injury. Statewide studies suggest significantly injured patients aged ≥55 y are commonly undertriaged to lower level trauma centers (TCs) or nontrauma centers (NTCs). This study determines whether undertriage is a national phenomenon. MATERIALS AND METHODS: Using the 2011 Nationwide Emergency Department Sample, significantly injured patients aged ≥55 y were identified by diagnosis and new injury severity score (NISS) ≥9. Undertriage was defined as definitive care anywhere other than level I or II TCs. Weighted descriptive analysis compared characteristics of patients by triage status. Multivariable logistic regression determined predictors of undertriage, controlling for hospital characteristics, injury severity, and comorbidities. RESULTS: Of 4,152,541 emergency department (ED) visits meeting inclusion criteria, 74.0% were treated at lower level TCs or NTCs. Patients at level I and II TCs more commonly had NISS ≥9 (22.2% versus 12.3%, P < 0.001), but among all patients with NISS ≥9, 61.3% were undertriaged to a lower level TC or a NTC. On multivariable logistic regression, factors independently associated with higher odds of being undertriaged were increasing age, female gender, and fall-related injuries. A subgroup analysis examined urban and suburban areas only where access to a TC is more likely and found that 55.8% of patients' age were undertriaged. CONCLUSIONS: There is substantial undertriage of patients aged ≥55 y nationwide. Over half of significantly injured older patients are not treated at level I or II TCs. The impact of undertriage should be determined to ensure older patients receive trauma care at the optimal site.

Emergency department presentation, admission, and surgical intervention for colonic diverticulitis in the United States.

BACKGROUND: Diverticulitis in admitted inpatients is well reported. This study examined colonic diverticulitis treated in the emergency department (ED). METHODS: The 2010 Nationwide Emergency Department Sample was used to examine relationships among patient age and inpatient admission, surgical intervention, and in-hospital mortality among ED patients with a primary diagnosis of diverticulitis. RESULTS: Of 310,983 ED visits for primary diverticulitis, 53% resulted in hospitalization and 6% in surgical intervention. Most patients 65+ years old were female (69%), and most were hospitalized (63%). Seven percent of ED patients aged 65+ underwent surgery and .96% died in hospital. Patients aged less than 40 years (13% of all admissions) were mostly male (63%), 42% were hospitalized, 4% underwent surgery, and less than .01% died. Compared with patients aged less than 40 years, those 65+ demonstrated greater odds of admission (odds ratio 1.53, 95% confidence interval 1.43 to 1.64) and surgical intervention (odds ratio 1.45, 95% confidence interval 1.27 to 1.65). CONCLUSIONS: Half of ED patients were hospitalized and 6% of ED visits resulted in colectomy. Fully 13% of ED patients were less than 40 years old. Future studies examining outpatient services may further illuminate the epidemiology of diverticulitis.

Trends in incidence and severity of sports-related traumatic brain injury (TBI) in the emergency department, 2006-2011.

OBJECTIVE: To characterize and identify trends in sports-related traumatic brain injury (TBI) emergency department (ED) visits from 2006-2011. METHODS: This study reviewed data on sports-related TBI among individuals under age 65 from the Nationwide Emergency Department Sample from 2006-2011. Visits were stratified by age, sex, injury severity, payer status and other criteria. Variations in incidence and severity were examined both between groups and over time. Odds of inpatient admission were calculated using regression modelling. RESULTS: Over the period examined, 489 572 sports-related TBI ED visits were reported. The majority (62.2%) of these visits occurred among males under the age of 18. The average head Abbreviated Injury Severity score among these individuals was 1.93 (95% CI = 1.93-1.94) and tended to be lowest among those in middle school and high school age groups; these were also less likely to be admitted. The absolute annual number of visits grew 65.9% from 2006 until 2011, with the majority of this growth occurring among children under age 15. Hospitalization rates dropped 35.6% over the same period. CONCLUSION: Changes in year-over-year presentation rates vs. hospitalization rates among young athletes suggest that players, coaches and parents may be more aware of sports-related TBI and have developed lower thresholds for seeking medical attention.

Traumatic brain injury in the elderly: morbidity and mortality trends and risk factors.

An estimated 1.7 million people sustain a traumatic brain injury (TBI) annually in the United States. We sought to examine factors contributing to mortality among TBI patients aged ≥65 y in the United States. TBI data from the Nationwide Inpatient Sample were combined from 2000-2010. Patients were stratified by age, sex, mechanism of injury, payer status, comorbidity, injury severity, and other factors. Odds of death were explored using an adjusted multivariable logistic regression. A total of 950,132 TBI-related hospitalizations and 107,666 TBI-related deaths occurred among adults aged ≥65 y from 2000-2010. The most common mechanism of injury was falling, and falls were more common among the oldest age groups. Logistic regression analysis showed highest odds of death among male patients, those whose mechanism of injury was motor vehicle related, patients with three or more comorbidities, and patients who were designated as self-paying.

Fenestrated endovascular repair of abdominal aortic aneurysms is associated with increased morbidity but comparable mortality with infrarenal endovascular aneurysm repair.

OBJECTIVE: A recent prospective study found that fenestrated endovascular abdominal aortic aneurysm (AAA) repair (FEVAR) was safe and effective in appropriately selected patients at experienced centers. As this new technology is disseminated to the community, it will be important to understand how this technology compares with standard endovascular AAA repair (EVAR). The goal of this study was to compare the outcomes of FEVAR vs EVAR of AAAs. METHODS: The American College of Surgeons-National Surgical Quality Improvement Program database from 2005 to 2012 was queried for AAAs (International Classification of Diseases, Ninth Revision code 441.4). Patients were stratified according to procedure (FEVAR vs EVAR). A bivariate analysis was done to assess preoperative and intraoperative risk factors for postoperative outcomes. Thirty-day postoperative mortality and complication rates were described for each procedure type. Multivariable logistic regression was performed to assess the association between the type of procedure and the risk of postoperative complications. RESULTS: A total of 458 patients underwent FEVAR and 19,060 patients underwent EVAR for AAA. Patients undergoing FEVAR were older (P = .02) and less likely to have a bleeding disorder (P = .046). Otherwise, the incidence of comorbidities in both groups was similar. FEVAR was associated with increased median operative time (156 vs 137 minutes; P < .001), and average postoperative length of stay (3.3 vs 2.8 days; P = .03). There was a statistically significant increase in overall complications (23.6% vs 14.3%; P < .001) and postoperative transfusions (15.3% vs 6.1%, P < .001) and trends toward increased cardiac complications (2.2% vs 1.3%; P = .09) and the need for dialysis (1.5% vs 0.8%; P = .08) in the FEVAR group. Mortality (2.4% vs 1.5%; P = .12) was not statistically different. On multivariable analysis, FEVAR remained independently associated with the need for postoperative transfusions when operative time was <75th percentile (adjusted odds ratio, 1.72; 95% confidence interval, 1.09-2.72; P = .02) as well as when operative time was >75th percentile for respective procedures (adjusted odds ratio, 5.33; 95% confidence interval, 3.55-8.00; P < .001). CONCLUSIONS: Patients undergoing FEVAR are more likely than patients undergoing EVAR to receive blood transfusions postoperatively and are more likely to sustain postoperative complications. Although mortality was similar, trends toward increased cardiac and renal complications may suggest the need for judicious dissemination of this new technology. Future research with larger number of FEVAR cases will be necessary to determine if these associations remain.

Outcomes of nonelective weekend admissions for lower extremity ischemia.

OBJECTIVE: A "weekend effect" has been demonstrated for a number of diagnoses, including many cardiovascular pathologies. Whether patients with lower extremity ischemia admitted over the weekend have inferior outcomes compared with those admitted on a weekday is unknown. METHODS: Nonelective admissions for critical limb ischemia (CLI) and acute limb ischemia (ALI) from lower extremity thrombosis or embolism were identified in the 2005 to 2010 Nationwide Inpatient Sample, and outcomes were compared based on weekend vs weekday admission by using multiple logistic and linear regression. RESULTS: Of the 63,768 patients identified with lower extremity vascular emergencies, 15.4% were admitted during the weekend. Patients admitted on the weekend were less likely to have CLI than those admitted on a weekday (51.2% vs 65.4%; P < .001) and were more likely to have ALI than patients admitted during a weekday (48.8% vs 34.5%; P < .001). Weekend admission was independently associated with a lower likelihood of revascularization (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.85-0.95; P < .001), a longer time until revascularization (3.09 days vs 2.75 days; P < .001), an increased likelihood of major amputation (aOR, 1.35; 95% CI, 1.19-1.53; P < .001), in-hospital complications (aOR, 1.18; 95% CI, 1.11-1.25; P < .001), and discharge to a skilled nursing facility (aOR, 1.15; 95% CI, 1.06-1.25; P = .001), and a longer predicted length of stay (10.1 days vs 9.5 days; P < .001). There was no statistically significant association between weekend admission and in-hospital mortality (aOR, 1.15; 95% CI, 1.06-1.25; P = .10). CONCLUSIONS: Patients admitted on the weekend for lower extremity vascular emergencies are significantly more likely to experience adverse outcomes, including major amputation, than patients admitted on a weekday, independent of their presenting diagnosis with ALI or CLI. Further investigation into the etiologies of these differences is needed to address this disparity. These data raise questions about the proper staffing models to optimize urgent treatment of lower extremity vascular emergencies.

Cholecystectomy and wound complications: smoking worsens risk.

BACKGROUND: In the United States, approximately 800,000 cholecystectomies are performed annually. We sought to determine the influence of preoperative smoking on postcholecystectomy wound complication rates. MATERIALS AND METHODS: Using the National Surgical Quality Improvement Program database (2005-2011), patients aged ≥18 y who underwent elective open or laparoscopic cholecystectomy (LC) for benign gallbladder disease were identified using current procedural terminology codes. Multivariate regression was performed to determine the association between smoking status and wound complications, by surgical approach. RESULTS: Of 143,753 identified patients, 128,692 (89.5%) underwent LC, 27,788 (19.3%) were active smokers, and 100,710 (70.2%) were females. Active smokers were younger than nonsmokers (mean + standard deviation age: 44.2 (14.9) versus 51.6 (17.9) years); P < 0.001) and had fewer comorbidities. Within 30-d postcholecystectomy, wound complications were reported in 2011 (1.4%) patients. Compared with nonsmokers, active smokers demonstrated increased odds of wound complications after both open cholecystectomy (odds ratio 1.28; P = 0.010) and LC (odds ratio 1.20; P = 0.020) after adjustment for demographic and clinical characteristics. Having wound complications increased the average postoperative length of stay by 2-4 d (P <0.001). CONCLUSIONS: Active smokers are more likely to develop wound complications after cholecystectomy, regardless of surgical approach. Occurrence of wound complications consequently increases postoperative length of stay. Smoking abstinence before cholecystectomy may reduce the burden associated with wound complications.

Trends and determinants of costs associated with the inpatient care of diabetic foot ulcers.

OBJECTIVE: The cost of care for diabetic foot ulcers is estimated to be more than $1.5 billion annually. The aim of this study was to analyze inpatient diabetic foot ulcer cost changes over time and to identify factors associated with these costs. METHODS: The Nationwide Inpatient Sample (2005-2010) was queried using the International Classification of Diseases, Ninth Revision codes for a primary diagnosis of foot ulceration. The primary outcomes were changes in adjusted total hospital charges and costs over time. Multivariable analysis was performed to assess relative increases (RIs) in hospital charges per patient in 2005 vs 2010 adjusting for demographic characteristics, income, comorbidities (Charlson Comorbidity Index ≥3), insurance type, hospital characteristics, diagnostic imaging, revascularization, amputation, and length of stay. RESULTS: Overall, 336,641 patients were admitted with a primary diagnosis of diabetic foot ulceration (mean age, 62.9 ± 0.1 years, 59% male, 61% white race). The annual cumulative cost for inpatient treatment of diabetic foot ulcers increased significantly from 2005 to 2010 ($578,364,261 vs $790,017,704; P < .001). More patients were hospitalized (128.6 vs 152.8 per 100,000 hospitalizations; P < .001), and the mean adjusted cost per patient hospitalization increased significantly over time ($11,483 vs $13,258; P < .001). The proportion of nonelective admissions remained stable (25% vs 23%; P = .32) and there were no differences in mean hospital length of stay (7.0 ± 0.1 days vs 6.8 ± 0.1 days; P = .22). Minor (17.9% vs 20.6%; P < .001), but not major amputations (3.9% vs 4.2%; P = .27) increased over time. Based on multivariable analysis, the main factors contributing to the escalating cost per patient hospitalization included increased patient comorbidities (unadjusted mean difference 2005 vs 2010 $3303 [RI, 1.08] vs adjusted $15,220 [RI, 1.35]), open revascularization (unadjusted $15,145 [RI, 1.25] vs adjusted $30,759 [RI, 1.37]), endovascular revascularization (unadjusted $17,662 [RI, 1.29] vs adjusted $28.937 [RI, 1.38]), and minor amputations (unadjusted $9918 [RI, 1.24] vs adjusted $18,084 [RI, 1.33]) (P < .001, all). CONCLUSIONS: Hospital charges and costs related to diabetic foot ulcers have increased significantly over time despite stable hospital length of stay and proportion of emergency admissions. Risk-adjusted analyses suggest that this change might be reflective of increasing charges associated with a progressively sicker patient population and attempts at limb salvage. Despite this, the overall incidence of major amputations remained stable.