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Poor People with Diabetes up to Ten Times Likelier to Lose a Limb than Wealthier Patients

Most Amputations Are Preventable with Earlier Medical Care, Researchers Say

It’s no secret that poverty is bad for your health. Now a new University of California, Los Angeles (UCLA) study demonstrates that people with diabetes in California who live in low-income neighborhoods are up to ten times more likely to lose a toe, foot, or leg than patients residing in more affluent areas of the state. Earlier diagnosis and proper treatment could prevent many of these amputations, the researchers say.

The study authors hope their findings, published in the August issue of Health Affairs, will motivate public agencies and medical providers to reach out to patients at risk of late intervention and inspire policymakers to adopt legislation to reduce barriers to care.

“I’ve stood at the bedsides of diabetic patients and listened to the surgical residents say, ‘We have to cut your foot off to save your life,'” said lead author Carl Stevens, MD, MPH, a clinical professor of medicine at the David Geffen School of Medicine at UCLA. “These patients are often the family breadwinners and parents of young children-people with many productive years ahead of them.

“When you have diabetes, where you live directly relates to whether you’ll lose a limb to the disease,” added Stevens, an emergency medicine doctor for 30 years at Harbor-UCLA Medical Center. “Millions of Californians have undergone preventable amputations due to poorly managed diabetes. We hope our findings spur policymakers nationwide to improve access to treatment by expanding Medicaid and other programs targeting low-income residents, as we did in California in 2014.”

The authors used data from the UCLA Center for Health Policy Research’s California Health Interview Survey, which estimated the prevalence of diabetes among low-income populations by ZIP code. They blended these statistics with household-income figures from the U.S. Census Bureau and hospital discharge data from the Office of Statewide Health Planning and Development that tracked diabetes-related amputations by ZIP code.

The result was a detailed set of maps showing diabetic amputation rates by neighborhood for patients 45 and older-the age range at greatest risk for amputation from disease complications.

“Neighborhoods with high amputation rates clustered geographically into hot spots with a greater concentration of households falling below the federal poverty level,” said co-author Dylan Roby, director of health economics at the UCLA Center for Health Policy Research and an assistant professor at the UCLA Fielding School of Public Health.

The findings paint a grim picture.

In 2009, California doctors surgically removed nearly 8,000 legs, feet, and toes from 6,800 people with diabetes. Roughly 1,000 of these patients underwent two or more amputations. On average, 20 Californians with diabetes were wheeled into the operating room each day for an amputation.

The researchers found that not only did diabetic residents of low-income neighborhoods like San Fernando have a tenfold higher risk of at least one amputation, compared with patients in, say, tonier Hermosa Beach, but that race also played a significant role.

Less than 6 percent of Californians with diabetes are African-American, yet blacks accounted for nearly 13 percent of the patient population undergoing one or more amputations in 2009. Conversely, 12 percent of Californians with diabetes are Asians yet this population underwent less than 5 percent of diabetes-related amputations that year.

Patients undergoing amputation were most likely to be black or non-English speaking, male, and older than 65.

People with poorly managed diabetes often suffer from a compromised immune system. As a result, a blister or other foot injury may rapidly progress to a serious, even life-threatening infection. Early diagnosis, antibiotics, and expert wound care can stop the process, but patients lacking access to treatment risk gangrene and blood infections that require immediate amputation.

The UCLA researchers’ next step will be to tease out the most important factors contributing to amputation and to develop strategies for lowering the risk for people with diabetes living in impoverished neighborhoods.

This article was adapted from information provided by UCLA, Health Sciences.

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