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Poor Californians much more likely to lose a limb to diabetes

The study authors are hopeful that their findings will encourage public agencies and medical providers to reach out to patients at risk of late intervention and stimulate policymakers to adopt legislation to reduce barriers to care
The study authors are hopeful that their findings will encourage public agencies and medical providers to reach out to patients at risk of late intervention and stimulate policymakers to adopt legislation to reduce barriers to care
Robin Wulffson, MD

Poverty can have a negative impact on one’s health in many ways. Now, a new UCLA study reports that poor individuals with diabetes up to 10 times likelier undergo an amputation of a toe, foot or leg than wealthier diabetics. Sadly, earlier diagnosis and treatment could prevent many of these amputations. The findings were published in the August issue of the journal Health Affairs.

The study authors are hopeful that their findings will encourage public agencies and medical providers to reach out to patients at risk of late intervention and stimulate 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,’” noted lead author Dr. Carl Stevens, a clinical professor of medicine at the David Geffen School of Medicine at UCLA. He added, “These patients are often the family breadwinners and parents of young children: people with many productive years ahead of them.

Dr. Stevens, an emergency physician for 30 years at Harbor-UCLA Medical Center, explained, “When you have diabetes, where you live directly relates to whether you’ll lose a limb to the disease. 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.”

For the study, the authors accessed 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 combined these statistics with household-income figures from the US Census Bureau and hospital discharge data from the Office of Statewide Health Planning and Development that tracked diabetes-related amputations by ZIP code. They developed a detailed set of maps showing diabetic amputation rates by neighborhood for patients 45 and older, which is 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,” explained 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. He added, “Amputation rates in California were 10 times higher in the poorest neighborhoods, like Compton and East Los Angeles, than in the richest neighborhoods, such as Malibu and Beverly Hills.”

In 2009, California surgeons removed nearly 8,000 legs, feet, and toes from 6,800 diabetics. Approximately 1,000 of these patients underwent two or more amputations. On average, 20 diabetic Californians were wheeled into the operating room each day for an amputation. The investigators found that not only did diabetic residents of low-income neighborhoods such as San Fernando have a tenfold higher risk of at least one amputation, compared with patients in a more affluent area such as Hermosa Beach. In addition, race also played a significant role. Amputation patients were most likely to be black or non-English speaking, male, and older than 65. Less than 6% of diabetic Californians are African American; however, that ethnic group accounted for almost 13% of the patient population undergoing one or more amputations in 2009. In contrast, Asians comprised 12% of the diabetic population butt had less than 5% of diabetes-related amputations that year.

“The US spends more healthcare dollars per person than any country in the world,” explained co-author Dr. David Schriger, a professor of emergency medicine at the Geffen School of Medicine. He added, “Yet we still can’t organize our healthcare system in a way that gives everyone adequate treatment. Should we tolerate a tenfold disparity for the loss of a limb and a patient’s ability to walk when we can prevent amputations with proper care?”

Individuals 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 halt the process, but patients lacking access to treatment risk gangrene and blood infections that require immediate amputation. The next phase of the UCLA research will be to ferret out the most important factors contributing to amputation and to develop strategies for lowering the risk for diabetic people living in impoverished neighborhoods.