Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION Act

Hiroyuki Suzuki; Mary Vaughan-Sarrazin; Michael Ohl; Bradley Mecham; Kimberly McCoy; Daniel J Livorsi

doi:10.1111/iwj.71039

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Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION Act

Journal article

Open access

Peer reviewed

Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION Act

Hiroyuki Suzuki, Mary Vaughan-Sarrazin, Michael Ohl, Bradley Mecham, Kimberly McCoy and Daniel J Livorsi

International wound journal, Vol.23(9), e71039

09/08/2026

DOI: 10.1111/iwj.71039

PMCID: PMC13554705

PMID: 42712013

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Abstract

ABSTRACT The Veterans Affairs (VA) Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act expanded eligibility for community‐based care particularly for Veterans facing geographic or capacity‐related barriers. Patients with diabetic foot ulcers (DFU) require timely specialty management and are vulnerable to fragmented care, yet little is known about how the MISSION Act reshaped patterns of DFU‐related specialty care within and outside the VA. We conducted a retrospective cohort study of Veterans aged 65 or older with a new DFU diagnosis in VA between 2016 and 2022. We identified DFU‐related specialty encounters (podiatry, vascular surgery, infectious diseases and endocrinology) and categorised community encounters as VA‐paid or Medicare‐paid. We assessed annual trends in community specialty care and changes in the proportion and payer type of care before and after the MISSION Act. Among 76 398 patients, VA‐paid community specialty care increased substantially following the MISSION Act, with larger relative growth among rural Veterans (rural: +119%; urban: +96%). In contrast, Medicare‐paid DFU specialty care declined during the same period (rural: −12%; urban: −13%). Following the MISSION Act, reliance on VA‐paid community specialty care increased markedly for Veterans with DFU, particularly in rural areas, while reliance on Medicare‐paid care decreased.

cost shift

diabetic foot ulcer

disconnected care

MISSION act

veterans affairs

UIOWA OA Agreement

Details

Title: Subtitle: Changing Patterns of Specialty Care for Diabetic Foot Ulcers Among Rural and Urban Veterans Following the VA MISSION Act
Creators: Hiroyuki Suzuki - University of Iowa
Mary Vaughan-Sarrazin - University of Iowa
Michael Ohl - University of Iowa
Bradley Mecham - Iowa City VA Health Care System
Kimberly McCoy - Iowa City VA Health Care System
Daniel J Livorsi - University of Iowa
Resource Type: Journal article
Publication Details: International wound journal, Vol.23(9), e71039
DOI: 10.1111/iwj.71039
PMID: 42712013
PMCID: PMC13554705
NLM abbreviation: Int Wound J
ISSN: 1742-4801
eISSN: 1742-481X
Publisher: Wiley
Grant note: VA Office of Rural Health: NOMAD:03806
This work was supported by VA Office of Rural Health (NOMAD:03806).
Language: English
Date published: 09/08/2026
Academic Unit: Psychiatry; Infectious Diseases; Health Management and Policy; General Internal Medicine; Internal Medicine
Record Identifier: 9985222683402771

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