Timing of Lower Limb Amputation After Diabetic Foot Ulcer Linked Between Race, Sex

Shane R. Wurdeman, PhD

Within 1 year of diabetic foot ulcer (DFU) diagnosis, new data suggest that Black/African-American individuals are more likely to receive an earlier lower limb amputation (LLA) compared with non-Hispanic individuals.

These disparate patterns continued when examining only patients with DFU who received an amputation and identified as Black/African-American, Hispanic, Asian, Native American, or other.

“This would suggest the non-Black/AA population may have access to and increased use of conservative wound management techniques or there is less access to and adherence to such treatment options within the Black/AA population,” wrote study author Shane R. Wurdeman, PhD, Hanger Institute for Clinical Research and Education.

Differences in sex additionally suggest women had a greater likelihood of delayed amputation, compared with men.

“The increased likelihood for delayed amputation may contribute to the overall increased prevalence of amputation for men as women may die before amputation is provided,” Wurdeman added.

Previous findings on amputation secondary to DFU and disparities relative to race/ethnicity or sex were mixed. Although there is evidence that disparities exist, there are limited findings on when these differences begin to occur along the care pathway.

The goal of Wurdeman and colleagues’ investigation was to examine variations on the timing of LLAs across race and ethnicity and sex among older adults with a DFU. They hypothesized that a higher proportion of Black/Afircan-American individuals were more likely to have LLA post-DFU earlier than non-Hispanic/Whites and more men would receive LLA earlier post-DFU.

The retrospective cohort analysis used eligible Medicare beneficiaries enrolled in the fee-for-service (FFS) beneficiaries with a diagnosis of DFU during the study period (2012 - 2017), up to 5 years post-DFU.

The individuals were placed into mutually exclusive groups based on timing of LLA for the primary outcome. Investigators applied multinomal logistic regression to assess the likelihood of membership into a group post-DFU based on sex and race and ethnicity.

Their final analytic sample contained 643,287 individuals enrolled in Medicare fee-for-service. The subanalysis included 68,633 beneficiaries who experienced an LLA within the 5 year study period, of whom 49.7% survived >5 years after the index DFU.

Regression results from the full sample showed that the odds of LLA within a year of DFU were significantly higher across all race categories, compared with non-Hispanic White beneficiaries. Data show Black/African-American beneficiaries had 2.18 (95% CI, 2.13 - 2.23) times the odds of receiving an LLA within 1 year of the DFU diagnosis.

Investigators noted the increased odds of LLA sustained across race/ethnicity category for Black/African-American beneficiaries to receive an LLA between 1 and 3 years post-DFU diagnosis, with an odds ratio (OR) of 1.38 (95% CI, 1.33 - 1.44).

Additionally, female beneficiaries were found to have increased odds of receiving an LLA later than men when controlling for covariates (OR, 1.07; 95% CI, 1.02 - 1.11 between 1 and 3 years and OR, 1.08; 95% CI, 1.03 - 1.12 in ≥3 years group).

“This evidence allows for more targeted, evidence-based decision making to change potentially problematic care decisions made based on non health-related factors,” Wurdeman concluded.

The study,"Racial Disparities in Health Care With Timing to Amputation Following Diabetic Foot Ulcer,” was published in Diabetes Care.