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Diabetics accounted for 64.1% of all study admissions. Hospitals in highly competitive markets performed more flaps for chronic lower extremity wounds than noncompetitive markets. Controlling for other factors, hospitals in highly competitive markets, relative to those in highly concentrated markets, were 2.48 percentage points more likely to perform limb salvage with flaps ( 0.01). Other factors were less predictive. Increased hospital competition is the strongest systems-level predictor of receipt of lower extremity flaps among p