Amputation 'Hot Spots' Track With Low-Income Neighborhoods

August 07, 2014

Amputation rates for people with diabetes were twice as high in low-income as in high-income neighborhoods in California in 2009, a new study indicates.

The report detailing these amputation "hot spots" was published in the August issue of Health Affairs by Carl D. Stevens, MD, clinical professor in health sciences at the David Geffen School of Medicine at the University of California, Los Angeles, and colleagues.

California has enrolled at least 2 million more people in Medicaid under the Affordable Care Act (ACA), so the disparities found in 2009 may have lessened somewhat, says Dr. Stevens. However, healthcare coverage is only part of the equation, with shortages of primary-care providers for preventive care and patient factors such as low health literacy also playing a big role, he told Medscape Medical News.

"It's complicated, and there's no single solution, but the result itself is disturbing enough that we should probably take whatever action that we personally can." He added, "Most of the complications of our unequal healthcare system are hidden from sight. When you bring them out into view as we have in our paper, I think that can generate a consensus across the political spectrum that we do need to act and do something differently."

Philip Goodney, MD, assistant professor of surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, who was not involved in this study, agrees. "These results, I'm afraid, are not surprising...Diabetes affects many of our poorest citizens, and amputation often focuses on those with the fewest resources and most difficult access to care."

Dr. Goodney, who has studied regional variation in amputation prevention measures, told Medscape Medical News that amputation often relegates patients to nursing homes and keeps them from living independently.

 
Patients faced with amputation almost universally want us to do everything we can to try to 'save their leg.'
 

"Patients faced with amputation almost universally want us to do everything we can to try to 'save their leg.' They know that the ability to walk independently is critical to their life and their independence, no matter what the cost. We have effective treatments that are inexpensive when compared with living in a nursing home — offloading shoes, wound care, revascularization, preventive diabetic care. But we need better ways to deliver these measures to these high-risk patients."

Amputation "Hot Spots"

Using statewide facility discharge data for California, Dr. Stevens and colleagues identified 6763 people with diabetes who underwent at least 1 amputation in 2009. They mapped amputation rates by the patients' home zip codes and used census data to map poverty rates.

The primary outcome measure was the percentage of people with diabetes aged 45 years and older who underwent 1 or more nontraumatic lower-extremity amputation in 2009. The age cutoff was chosen in order to maximize the likelihood of the amputation being due to potentially preventable diabetes complications, he told Medscape Medical News.

Across the state, there was up to a 10-fold variation in amputation rates between the highest- and lowest-income neighborhoods. Amputation rates per 1000 residents with diabetes were 0 to 1.9 for the highest-income quartile, 2.0 to 3.3 for the second quartile, 3.4 to 5.0 for the third, and 5.1 to 14.4 in the quartile of lowest-income neighborhoods.

Overall, the amputation rate for people with diabetes in low-income neighborhoods (those in which more than 40% of households have incomes below 200% of poverty) was about double the rate for people in higher-income neighborhoods (those in which fewer than 10% of households have incomes below 200% of poverty).

Multifaceted Problem

Dr. Stevens told Medscape Medical News that the problem in these amputation "hot spots" is a lack of good-quality primary care combined with patient-related factors such as language barriers and low health literacy.

As a result, patients will often wait to seek care and then end up in the emergency department after a foot infection has progressed too far for salvage.

"There's a tendency to say poor people can always go to the emergency department, that it's a safety net. To me, the lower-extremity amputations in diabetics is a dramatic example of a big hole in that safety net. The way the system is configured it actually won't catch people in time to save their limbs," he stressed.

 
"I don't think it's too strong to say they're costing their citizens limbs."
 

Regarding the 21 states that have chosen not to expand Medicaid under the ACA, he said, "I don't think it's too strong to say they're costing their citizens limbs."

However, he added that California shares with other states a "dramatic, desperate" shortage of primary-care providers in both urban and rural low-income areas.

"That's a tougher problem to solve. That requires changing the incentives to make it more attractive to practice in those low-income areas and opening up more residency training slots in family medicine and general medicine. All of those are longer-term, bigger challenges."

But primary-care physicians are just part of the solution. Both Dr. Stevens and Dr. Goodney note that the ideal approach to preventing amputations is a multidisciplinary team approach involving many specialists.

Dr. Goodney told Medscape Medical News, "Teams encompassing all of these specialties — primary care, diabetic expertise, podiatric and wound care, and vascular care — will be key elements in limiting amputation in the high-risk cohorts these authors have so eloquently delineated."

Dr. Stevens has no disclosures. Disclosures for the coauthors are listed in the article. Dr. Goodney's group has received funding from the National Heart, Lung, and Blood Institute to study ways to limit amputation.

Health Affairs. 2014;33:1383-1390. Abstract

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