Ethnicity and diabetic foot complications

NewsBot · May 30, 2019

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Racial factors and inpatient outcomes among patients with diabetes hospitalized with foot ulcers and foot infections, 2003-2014.
Harris CM et al
PLoS One. 2019 May 29;14(5):e0216832

BACKGROUND:
In patients with diabetes, foot amputations among Black patients have been historically higher compared with White patients. Using the National Inpatient Sample database, we sought to determine if disparities in foot amputations and resource utilization have improved over time. We hypothesized there would be improvements and reduced differences in foot amputations between the two races as quality of care and access to healthcare has improved.

METHODS AND FINDINGS:
Patients over 18 years old with a principal diagnosis of diabetic foot complications and secondary diagnosis of Diabetes Mellitus were selected. We compared the primary outcome of foot amputations between Black and White patients. Adjusted rates, odds ratios (aOR) and trends of foot amputations among Black and White patients were studied. Healthcare utilization was measured via length of hospital stay (LOS). Of 262,924 patients, 18% were Black. Following adjustment for confounders, major foot amputations decreased among Whites (1.5% in 2003 to 1.1% in 2014) and Blacks (2.1% in 2003 to 0.9% in 2014). On pooled analysis, Black patients had higher adjusted odds of major foot amputations in 2003-2004 [aOR 1.7; (1.16-2.57), p<0.01]. Disparities in major foot amputations disappeared in 2013-2014 [aOR: 0.92 (0.58-1.44), p = 0.70]. Black patients had declining but persistently longer LOS (adjusted mean difference (aMD): 1.1 days (0.52-1.6) p<0.01 in 2003-2004 and 0.46 days (0.18-0.73) p<0.01 in 2013-2014). The main limitation of the study was that the NIS uses ICD-9 and ICD-10 CM codes, and hence prone to incorrect or missing codes.

CONCLUSIONS:
Major foot amputations declined among Black and White patients hospitalized with Diabetic foot complications between 2003 and 2014. The observed difference for amputations in 2003-2004 was absent by 2013-2014. Future research to determine specific contributors for this reduction in health disparities is needed for ongoing improvements and sustainability.
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NewsBot · Sep 8, 2020

Association between race/ethnicity and the risk of amputation of lower extremities among medicare beneficiaries with diabetic foot ulcers and diabetic foot infections
BMJ Open Diabetes Res Care. 2020 Aug;8(1):e001328. doi: 10.1136/bmjdrc-2020-001328.

INTRODUCTION: This study aimed to examine the association of race and ethnicity on the risk of lower extremity amputations among Medicare beneficiaries with diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs).

RESEARCH DESIGN AND METHODS: A retrospective study included 2011-2015 data of a 5% sample of fee-for-service Medicare beneficiaries with a newly diagnosed DFU and/or DFI. The primary outcome was the time to the first major amputation episode after a DFU and/or DFI were identified using the diagnosis and procedure codes. We used multivariable Cox proportional hazards models to estimate the risk of time to the first major amputation across races, adjusting for sociodemographic and health status factors. Adjusted hazard ratios (aHRs) with a 95% CI were reported.

RESULTS: Among 92 929 Medicare beneficiaries newly diagnosed with DFUs and/or DFIs, 77% were whites, 14.3% African Americans (AAs), 3.3% Hispanics, 0.7% Native Americans (NAs), and 4.0% were other races. The incidence rates of major amputation were 0.02 person-years for NAs, 0.02 person-years for AAs, 0.01 person-years for Hispanics, 0.01 person-years for other races, and 0.01 person-years for whites (p<0.05). Multivariable analysis showed that AAs (aHR=1.9, 95% CI 1.7 to 2.2, p<0.0001) and NAs (aHR=1.8, 95% CI 1.3 to 2.6, p=0.001) were associated with an increased risk of major amputation compared with whites. Beneficiaries with DFUs and/or DFIs diagnosed by a podiatrist or primary care physician (aHR=0.7, 95% CI 0.6 to 0.8, p<0.0001, specialists as reference) or at an outpatient visit (aHR=0.3, 95% CI 0.3 to 0.3, p<0.0001, inpatient stay as reference) were associated with a decreased risk of major amputation.

CONCLUSIONS: Racial and ethnic disparities in the risk of lower extremity amputations appear to exist among fee-for-service Medicare beneficiaries with diabetic foot problems. AAs and NAs with DFUs and/or DFIs were associated with an increased risk of major amputations compared with white Medicare beneficiaries.
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NewsBot · Oct 5, 2021

Is ethnicity an appropriate measure of health care
marginalization? A systematic review
and meta-analysis of the outcomes of diabetic
foot ulceration in Aboriginal populations
David Isa, David Pace
Can J Surg 2021 September 22;

Background: Aboriginal people have higher prevalence rates of diabetes than nonAboriginal people in the same geographic locations, and diabetic foot ulcer (DFU)
complication rates are also presumed to be higher. The aim of this systematic review
and meta-analysis was to compare DFU outcomes in Aboriginal and non-Aboriginal
populations.
Methods: We searched PubMed, Embase, CINAHL and the Cochrane Library
from inception to October 2018. Inclusion criteria were all types of studies comparing the outcomes of Aboriginal and non-Aboriginal patients with DFU, and
studies from Canada, the United States, Australia and New Zealand. Exclusion criteria were patient age younger than 18 years, and studies in any language other
than English. The primary outcome was the major amputation rate. We assessed
the risk of bias using the ROBINS-I (Risk Of Bias In Non-randomized Studies – of
Interventions) tool. Effect measures were reported as odds ratio (OR) with 95%
confidence interval (CI).
Results: Six cohort studies with a total of 244 792 patients (2609 Aboriginal,
242183 non-Aboriginal) with DFUs were included. The Aboriginal population was
found to have a higher rate of major amputation than the non-Aboriginal population
(OR 1.85, 95% CI 1.04–3.31). Four studies were deemed to have moderate risk of
bias, and 2 were deemed to have serious risk of bias.
Conclusion: Our analysis of the available studies supports the conclusion that DFU
outcomes, particularly the major amputation rate, are worse in Aboriginal populations
than in non-Aboriginal populations in the same geographic locations. Rurality was
not uniformly accounted for in all included studies, which may affect how these outcome differences are interpreted. The effect of rurality may be closely intertwined
with ethnicity, resulting in worse outcomes.
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NewsBot · Sep 26, 2022

Racial Disparities in Health Care With Timing to Amputation Following Diabetic Foot Ulcer
Taavy A Miller et al
Diabetes Care. 2022 Oct 1;45(10):2336-2341

Objective: To examine variations in timing of lower-limb amputation (LLA) across race/ethnicity and sex among older adults with a diabetic foot ulcer (DFU). It was hypothesized Black/African Americans were more likely to have LLA post-DFU earlier compared with non-Hispanic/Whites, and more men would receive LLA earlier post-DFU compared with women.

Research design and methods: This was a retrospective cohort analysis of enrolled Medicare fee-for-service (FFS) beneficiaries with a diagnosis of DFU during the study period (2012-2017), allowing up to 5 years post-DFU. Final analytic sample contained 643,287 individuals; the subsample consisted of 68,633 individuals with LLA only. The primary outcome was mutually exclusive groups based on timing of LLA. Multinomial logistic regression was applied to assess likelihood of membership into a group post-DFU based on characteristics such as sex and race/ethnicity.

Results: Black/African American beneficiaries had 1.98 (95% CI 1.93-2.03) times the odds of receiving an LLA within 1 year of DFU diagnosis compared with non-Hispanic/White beneficiaries relative to no amputation. Female beneficiaries had increased odds (odds ratio [OR] 1.07, 95% CI 1.02-1.11] between 1 and 3 years and OR 1.08 [95% CI 1.03-1.12] in ≥3 years) of a delayed LLA compared with men among those that underwent LLA.

Conclusions: Notably, these results present novel evidence on timing of LLA between racial groups and sex for Medicare FFS beneficiaries post-DFU. Results may be generalizable to individuals with Medicare FFS and DFU. Clinically more targeted, evidence-based decision making informs care decisions with opportunities to address inequities related to the social determinants of health that may lead to LLA.
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NewsBot · Apr 4, 2023

Geographic and Ethnic Inequalities in Diabetes-Related Amputations
Alfonso Bellia et al
Front Clin Diabetes Healthc. 2022 Mar 11

Individuals with diabetes mellitus are at increasing risk for major lower-extremity amputations (LEAs). Poor quality of life and remarkable disabilities are associated with LEAs, determining a high economic burden for the healthcare systems. Reducing LEAs is therefore a primary marker of quality of care of the diabetic foot. At global level, between-countries comparisons of LEAs rates are basically hampered by differences in criteria used for data collection and analysis among studies. Significant variability in amputation rates exists between geographic areas, and also within specific regions of a country. Overall 5-year mortality rate after major amputations is reported to vary substantially across countries, from 50 to 80%. The odds of LEAs are substantially higher for Black, Native American and Hispanic ethnicities compared with White groups, with similar figures observed in the economically disadvantaged areas compared to more developed ones. Such discrepancies may reflect differences in diabetes prevalence as well as in financial resources, health-care system organization and management strategies of patients with diabetic foot ulcers. Looking at the experience of countries with lower rates of hospitalization and LEAs worldwide, a number of initiatives should be introduced to overcome these barriers. These include education and prevention programs for the early detection of diabetic foot at primary care levels, and the multidisciplinary team approach with established expertise in the treatment of the more advanced stage of disease. Such a coordinated system of support for both patients and physicians is highly required to reduce inequalities in the odd of diabetes-related amputations worldwide.
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NewsBot · Apr 20, 2023

Association of rurality and identifying as black with receipt of specialty care among patients hospitalized with a diabetic foot ulcer: a Medicare cohort study
Lindsay Taylor et al
BMJ Open Diabetes Res Care. 2023 Apr;11(2)

Introduction: Rural patients with diabetic foot ulcers, especially those identifying as black, face increased risk of major amputation. Specialty care can reduce this risk. However, care disparities might beget outcome disparities. We aimed to determine whether a smaller proportion of rural patients, particularly those identifying as black, receive specialty care compared with the national proportion.

Research design and methods: This 100% national retrospective cohort examined Medicare beneficiaries hospitalized with diabetic foot ulcers (2013-2014). We report observed differences in specialty care, including: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, or vascular surgery. We used logistic regression to examine possible intersectionality between rurality and race, controlling for sociodemographics, comorbidities, and ulcer severity and including an interaction term between rurality and identifying as black.

Results: Overall, 32.15% (n=124 487) of patients hospitalized with a diabetic foot ulcer received specialty care. Among rural patients (n=13 100), the proportion decreased to 29.57%. For patients identifying as black (n=21 649), the proportion was 33.08%. Among rural patients identifying as black (n=1239), 26.23% received specialty care. This was >5 absolute percentage points less than the overall cohort. The adjusted OR for receiving specialty care among rural versus urban patients identifying as black was 0.61 (95% CI 0.53 to 0.71), which was lower than that for rural versus urban patients identifying as white (aOR 0.85, 95% CI 0.80 to 0.89). This metric supported a role for intersectionality between rurality and identifying as black.

Conclusions: A smaller proportion of rural patients, particularly those identifying as black, received specialty care when hospitalized with a diabetic foot ulcer compared with the overall cohort. This might contribute to known disparities in major amputations. Future studies are needed to determine causality.
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NewsBot · Oct 4, 2023

Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens
Virginie Blanchette et al
Front Endocrinol (Lausanne). 2023 Aug 14;14:1177020

Introduction: Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens.

Methods: A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR).

Results: Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA.

Discussion: This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare.

Conclusion: Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting.
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NewsBot · Oct 4, 2023

Racial and Ethnic Disparities in the Management of Diabetic Feet
Elizabeth O Clayton et al
Curr Rev Musculoskelet Med. 2023 Sep 21

Purpose of review: Diabetes mellitus is a chronic medical condition affecting many individuals worldwide and leads to billions of dollars spent within the healthcare system for its treatment and complications. Complications from diabetes include diabetic foot conditions that can have a devasting impact on quality of life. Diabetic foot ulcers and amputations occur in minority individuals at an increased rate compared to Caucasian individuals. This review provides an update examining the racial and ethnic disparities in the management of diabetic foot conditions and the differences in rates of amputation.

Recent findings: Current research continues to show a disparity as it relates to diabetic foot management. There are novel treatment options for diabetic foot ulcers that are currently being explored. However, there continues to be a lack in racial diversity in new treatment studies conducted in the USA. Individuals from racial and ethnic minority groups have diabetes at higher rates compared to Caucasian individuals, and are also more likely to develop diabetic foot ulcers and receive amputations. Over the last few years, more efforts have been made to improve health disparities. However, there needs to be an improvement in increasing racial diversity when investigating new therapies for diabetic foot ulcers.
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