Disparities in outcomes of patients admitted with diabetic foot infections

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Abstract

Objective

The purpose of this study was to evaluate the disparities in the outcomes of White, African American (AA) and non-AA minority (Hispanics and Native Americans (NA)), patients admitted in the hospitals with diabetic foot infections (DFIs).

Research design and methods

The HCUP-Nationwide Inpatient Sample (2002 to 2015) was queried to identify patients who were admitted to the hospital for management of DFI using ICD-9 codes. Outcomes evaluated included minor and major amputations, open or endovascular revascularization, and hospital length of stay (LOS). Incidence for amputation and open or endovascular revascularization were evaluated over the study period. Multivariable regression analyses were performed to assess the association between race/ethnicity and outcomes.

Results

There were 150,701 admissions for DFI, including 98,361 Whites, 24,583 AAs, 24,472 Hispanics, and 1,654 Native Americans (NAs) in the study cohort. Overall, 45,278 (30%) underwent a minor amputation, 9,039 (6%) underwent a major amputation, 3,151 underwent an open bypass, and 8,689 had an endovascular procedure. There was a decreasing incidence in major amputations and an increasing incidence of minor amputations over the study period (P < .05). The risks for major amputation were significantly higher (all p<0.05) for AA (OR 1.4, 95%CI 1.4,1.5), Hispanic (OR 1.3, 95%CI 1.3,1.4), and NA (OR 1.5, 95%CI 1.2,1.8) patients with DFIs compared to White patients. Hispanics (OR 1.3, 95%CI 1.2,1.5) and AAs (OR 1.2, 95%CI 1.1,1.4) were more likely to receive endovascular intervention or open bypass than Whites (all p<0.05). NA patients with DFI were less likely to receive a revascularization procedure (OR 0.6, 95%CI 0.3, 0.9, p = 0.03) than Whites. The mean hospital length of stay (LOS) was significantly longer for AAs (9.2 days) and Hispanics (8.6 days) with DFIs compared to Whites (8.1 days, p<0.001).

Conclusion

Despite a consistent incidence reduction of amputation over the past decade, racial and ethnic minorities including African American, Hispanic, and Native American patients admitted to hospitals with DFIs have a consistently significantly higher risk of major amputation and longer hospital length of stay than their White counterparts. Native Americans were less likely to receive revascularization procedures compared to other minorities despite exhibiting an elevated risk of an amputation. Further study is required to address and limit racial and ethnic disparities and to further promote equity in the treatment and outcomes of these at-risk patients.

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Most cited references 30

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National trends in lower extremity bypass surgery, endovascular interventions, and major amputations.

Philip P Goodney, Adam W Beck, Jan Nagle … (2009)

Advances in endovascular interventions have expanded the options available for the invasive treatment of lower extremity peripheral arterial disease (PAD). Whether endovascular interventions substitute for conventional bypass surgery or are simply additive has not been investigated, and their effect on amputation rates is unknown. We sought to analyze trends in lower extremity endovascular interventions (angioplasty and atherectomy), lower extremity bypass surgery, and major amputation (above and below-knee) in Medicare beneficiaries between 1996 and 2006. We used 100% samples of Medicare Part B claims to calculate annual procedure rates of lower extremity bypass surgery, endovascular interventions (angioplasty and atherectomy), and major amputation between 1996 and 2006. Using physician specialty identifiers, we also examined trends in the specialty performing the primary procedure. Between 1996 and 2006, the rate of major lower extremity amputation declined significantly (263 to 188 per 100,000; risk ratio [RR] 0.71, 95% confidence interval [CI] 0.6-0.8). Endovascular interventions increased more than threefold (from 138 to 455 per 100,000; RR = 3.30; 95% CI: 2.9-3.7) while bypass surgery decreased by 42% (219 to 126 per 100,000; RR = 0.58; 95% CI: 0.5-0.7). The increase in endovascular interventions consisted both of a growth in peripheral angioplasty (from 135 to 337 procedures per 100,000; RR = 2.49; 95% CI: 2.2-2.8) and the advent of percutaneous atherectomy (from 3 to 118 per 100,000; RR = 43.12; 95% CI: 34.8-52.0). While radiologists performed the majority of endovascular interventions in 1996, more than 80% were performed by cardiologists and vascular surgeons by 2006. Overall, the total number of all lower extremity vascular procedures almost doubled over the decade (from 357 to 581 per 100,000; RR = 1.63; 95% CI: 1.5-1.8). Endovascular interventions are now performed much more commonly than bypass surgery in the treatment of lower extremity PAD. These changes far exceed simple substitution, as more than three additional endovascular interventions were performed for every one procedure declined in lower extremity bypass surgery. During this same time period, major lower extremity amputation rates have fallen by more than 25%. However, further study is needed before any causal link can be established between lower extremity vascular procedures and improved rates of limb salvage in patients with PAD.

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Long-term prognosis for diabetic patients with foot ulcers.

J. Apelqvist, J. Larsson, C.-D. Agardh (1993)

To evaluate the recurrence of foot ulcers as well as the cumulative amputation and mortality rates in diabetic patients with previous foot ulcers. A prospective study of consecutively presenting diabetic patients admitted to the Department of Internal Medicine because of foot ulcer with a median follow-up of 4 years. A multidisciplinary foot-care team. Five-hundred-and-fifty-eight consecutive diabetic patients with foot ulcers treated between 1 July 1983 and 31 December 1990 were followed to final outcome. Out of these patients, 468 healed either primarily (n = 345) or after minor or major amputations (n = 123) and 90 died before healing had occurred. Those 468 patients who healed were included in this prospective study from the time of healing. Patients were followed according to a standardized protocol with registration of foot lesions, amputation, morbidity and mortality. Clinical examination was performed twice yearly. After 1, 3 and 5 years of observation 34%, 61% and 70% of the patients, respectively, had developed a new foot ulcer. The recurrence rate of foot lesions was slightly higher among patients who previously had had an amputation (P < 0.05, P < 0.01 and non-significant, respectively). Among patients with previous primary healing the cumulative amputation rates were 3%, 10% and 12% after 1, 3 and 5 years of follow-up compared with 13%, 35% and 48% among those who previously healed after amputation, irrespective of previous amputation level (P < 0.001 at all time-points). All amputations except three were initiated by a foot ulcer deteriorating to deep infection or progressive gangrene. The long-term survival ratio was lower among patients healed after previous amputation (80%, 59%, 27%) compared with patients with previously primary healing (92%, 73%, 58%) after 1, 3 and 5 years of observation, respectively (P < 0.001, P < 0.01 and P < 0.001 respectively). The mortality rate was twice as high among primarily healed and four times as high among patients with amputation compared to an age- and sex-matched Swedish population. These findings stress the need for life-long surveillance of the diabetic foot at risk and the necessity of preventive foot care among diabetic patients with previous foot lesions, and particularly among those who had had a previous amputation.

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Increased mortality associated with diabetic foot ulcer.

E.J. Boyko, J.H. Ahroni, D.G. Smith … (1996)

The objective of this study was to evaluate the relationship between foot ulceration and short-term mortality in veterans of the American military services with diabetes mellitus. A total of 725 diabetic subjects participated in a prospective study of risk factors for lower extremity complications between 1990 and 1994. Mean follow-up was 691.8 days (+/-SD 339.9, range 28-1436 days). Subjects who died during follow-up (n = 72) had a similar mean duration of diabetes to those who survived (12.6 years vs 11.2), but their mean age was greater (65.9 years vs 63.2, p = 0.026). The relative risk (RR) of death was 2.39 (95% confidence interval (CI) 1.13 to 4.58) in the subjects who developed foot ulcer (n = 88) compared to those who did not. The risk of death for those with foot ulcer was 12.1 per 100 person-years of follow-up compared to 5.1 in those without foot ulcer. Cox regression analysis demonstrated a greater than two-fold increased risk of death in ulcerated subjects after adjustment for age; diabetes type, duration, and treatment; glycosylated hemoglobin level; history of lower extremity amputation; and cumulative pack years smoked. Higher ankle-arm index was significantly related to lower mortality risk, independent of foot ulcer occurrence. We conclude that foot ulcer and lower extremity vascular disease are related to a higher risk of death in diabetic subjects. The reasons for this excess mortality require further investigation.

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Author and article information

Contributors

Tze-Woei Tan:

ORCID: http://orcid.org/0000-0002-6658-9482

Role: ConceptualizationRole: Data curationRole: Formal analysisRole: MethodologyRole: Project administrationRole: SupervisionRole: ValidationRole: Writing – original draftRole: Writing – review & editing

Chia-Ding Shih:

ORCID: http://orcid.org/0000-0001-9203-1899

Role: ValidationRole: Writing – review & editing

Kirsten C. Concha-Moore: Role: MethodologyRole: Writing – original draftRole: Writing – review & editing

Muhanad M. Diri:

ORCID: http://orcid.org/0000-0003-0035-5357

Role: InvestigationRole: Writing – original draftRole: Writing – review & editing

Bo Hu: Role: Data curationRole: Formal analysisRole: InvestigationRole: MethodologyRole: Writing – review & editing

David Marrero: Role: MethodologyRole: ResourcesRole: SupervisionRole: Writing – review & editing

Wei Zhou: Role: ConceptualizationRole: ResourcesRole: SupervisionRole: Writing – review & editing

David G. Armstrong: Role: ConceptualizationRole: ResourcesRole: SupervisionRole: Writing – review & editing

Bijan Najafi: Role: Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 4 February 2019

Publication date Collection: 2019

Volume: 14

Issue: 2

Electronic Location Identifier: e0211481

Affiliations

[1 ] University of Arizona College of Medicine, Tucson, AZ, United States of America

[2 ] Southwest Academic Limb Salvage Alliance (SALSA), Los Angeles, CA, United States of America

[3 ] Keck School of Medicine at University of Southern California, Los Angeles, CA, United States of America

[4 ] Cleveland Clinic Foundation, Cleveland, OH, United States of America

Baylor College of Medicine, UNITED STATES

Author notes

Competing Interests: The authors have declared that no competing interests exist.

* E-mail: ttan@ 123456surgery.arizona.edu

Author information

Tze-Woei Tan http://orcid.org/0000-0002-6658-9482

Chia-Ding Shih http://orcid.org/0000-0001-9203-1899

Muhanad M. Diri http://orcid.org/0000-0003-0035-5357

Article

Publisher ID: PONE-D-18-24788

DOI: 10.1371/journal.pone.0211481

PMC ID: 6361439

PubMed ID: 30716108

SO-VID: a0d9c256-effb-45d7-a67f-8ab3ba26f2fd

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

History

Date received : 22 August 2018

Date accepted : 15 January 2019

Page count

Figures: 5, Tables: 3, Pages: 12

Funding

The author(s) received no specific funding for this work.

Custom metadata

Data Availability All relevant data are within the manuscript and its Supporting Information files.

Disparities in outcomes of patients admitted with diabetic foot infections

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Abstract

Objective

Research design and methods

Results

Conclusion

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PLOS Climate

Most cited references 30

National trends in lower extremity bypass surgery, endovascular interventions, and major amputations.

Long-term prognosis for diabetic patients with foot ulcers.

Increased mortality associated with diabetic foot ulcer.

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