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05-23-2022 | Diabetic foot ulcers | News

Diabetic foot ulcer amputation, death rates highest among rural Black people

Author: Lynda Williams


medwireNews: The risk for major leg amputation or death after hospitalization for diabetic foot ulcers is elevated in Black people and those living in rural areas, with a 10.4% absolute increase among patients with both risk factors compared with the national rate, US researchers have found.

“We assert these differences are clinically and socially meaningful, particularly given the use of a complete Medicare population, which eliminates selection bias and ensures internal validity,” say Meghan Brennan (University of Wisconsin, Madison, USA) and co-workers.

“We urge using an intersectionality approach to address this disparity,” they write in JAMA Network Open.

The team collated data for the US National Medicare Claims Data Database for all 124,487 adults hospitalized with diabetic foot ulcers between 2013 and 2014. The patients were aged an average of 71.5 years, 57.3% were men, 17.4% identified as being Black, and 10.5% lived in a rural setting.

Analysis showed that 17.6% of patients required major leg amputation or died during their hospital stay or within 30 days of discharge.

The rate of this outcome was higher among individuals identifying as Black than those who identified as White (21.9 vs 16.5%) and among rural or suburban residents versus urban residents (18.3 and 18.2 vs 17.3%, respectively). Major leg amputation or death was also more common among individuals living in disadvantaged versus non-disadvantaged neighborhoods (19.0 vs 17.2%).

Furthermore, the rate of major leg amputation or death increased to 28.0% among individuals identifying as Black who lived in a rural setting versus 25.7% and 20.7% for those living in suburban and urban settings, respectively. The corresponding rates for individuals identifying as White were 17.1%, 17.1%, and 16.1%.

Brennan and co-workers emphasize that the rate of major leg amputation or death in Black rural-dwelling individuals “exceeded the expected excess” of 5.0 percentage points calculated on the basis of Black identity plus rural residency by “more than 2-fold.”

Social identity metric modeling confirmed there was a significant interaction between Black identity and rural residency, with an odds ratio (OR) for major leg amputation or death of 1.34, “indicating that the associations of these 2 social identities were amplified,” the authors say.

Noting that the link between rural residency and major leg amputation was strengthened after taking comorbidity into consideration, the team suggests that other factors may be involved, such as the “eroding rural health care infrastructure,” and that improving access to multidisciplinary triage may be a “particularly effective” approach among Black rural residents.

Moreover, recognizing that Black patients were almost twice as likely to present at hospital with a gangrenous ulcer than their White counterparts (20.5 vs 10.5%), the researchers postulate that “[f]ocusing efforts to improve care further upstream in ambulatory – as opposed to hospital – settings will likely prove to be particularly effective.”

medwireNews is an independent medical news service provided by Springer Healthcare Ltd. © 2022 Springer Healthcare Ltd, part of the Springer Nature Group

JAMA Netw Open 2022; 5: e228399


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