SLR - October 2022 - Caleb Thomas, DPM
Reference: Brennan MB, Powell WR, Kaiksow F, et al. Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers. JAMA Netw Open. 2022;5(4):e228399. doi:10.1001/jamanetworkopen.2022.8399Scientific Literature Review – October 2022
Reviewed By: Caleb Thomas, DPM
Residency Program: Geisinger Community Medical Center – Scranton, PA
Podiatric Relevance: Limb salvage is an integral part of the podiatric profession, and podiatric surgeons are often presented with difficult decisions when it comes to the surgical management of their limb salvage patients. Understanding how race, ethnicity, rurality, and/or neighborhood disadvantage can be associated with limb salvage outcomes is important not only to better serve our patient population, but to recognize which of these patients are particularly at-risk.
Methods: A retrospective cohort study used data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Race was categorized using variables from the Research Triangle Institute. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index. The main outcome being evaluated was a patient either having a major leg amputation or dying, be it during their hospitalization or within 30 days of hospital discharge. Interactions between race, ethnicity, rurality, neighborhood disadvantage, comorbidities, and severity of the diabetic foot ulcer were all evaluated.
Results: The study included a total of 124,487 patients, with a mean (SD) age of 71.5 (13.0) years. Of these, 71,286 (57.3%) were men, 13,100 (10.5%) were rural, and 21,649 (17.4%) identified as Black. Overall, 17.6% of the total participants (n = 21,919), 18.3% of rural patients (2,402 of 13,100), and 21.9% of patients identifying as Black (4,732 of 21,649) underwent major leg amputation or expired. Among the 1,239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% − 17.6% = 0.7%) plus those identifying as Black (21.9% − 17.6% = 4.3%) by more than twofold (28.0% − 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%). A significant interaction between race and rurality was noted.
Conclusions: When it comes to Medicare patients with diabetic foot ulcers, a significant interaction between race and rurality exists. Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests a synergistic interaction between racial and rural disparities, further amplifying risk for patients that identify as black and that live in a rural area. To better investigate and address the disparities in major leg amputation and mortality for patients with diabetic foot ulcers, the study’s findings support the use of an intersectionality lens. This a concept or framework that aims to explain why every person sees the world in a unique way and is the compilation of all the influences and unique experiences in our lives that come together to shape our worldview. Incorporating this mindset into our podiatric practices can help us better understand and serve our patients.