People with type 2 diabetes who have low incomes or live in rural areas are significantly more likely to suffer a lower-limb amputation, largely due to limited access to preventive healthcare, according to research by the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona (UA) Department of Surgery. The study, “A Diabetic Emergency One Million Feet Long: Disparities and Burdens of Illness among Diabetic Foot Ulcer Cases within Emergency Departments in the United States, 2006-2010,” published August 6 in the journal PLoS One, also found that a system for preventive care for those patients with type 2 diabetes could cut national annual healthcare costs by billions of dollars.
In research spanning from 2006 through 2010, people living in rural areas were 51 percent more likely to have a major amputation (above the ankle) and 41 percent were more likely to die as a result of complications from diabetes-related foot ulcers than people living in urban areas where preventive care is more readily available. Medicaid beneficiaries were 21 percent more likely to have a major amputation. During the research timeframe, more than one million cases of diabetes-related foot ulcers were seen in emergency departments throughout the United States, with about 83 percent of those resulting in hospital admission. The annual cost of treating those cases was about $8.8 billion, including about $1.9 billion per year in emergency department costs alone.
The findings suggest that by the time patients with diabetes-related foot ulcers are seen for the first time in an emergency department, the condition usually is so serious patients are hospitalized, as opposed to being treated and discharged. Once they get to that point, 3.4 percent of patients have a major amputation above the ankle, 7.1 percent have an amputation below the ankle, and 1.8 percent die. The percentages increase significantly for patients with low income or who live in rural areas.
However, preventive care could keep people out of emergency departments and hospitals, where they often face expensive treatment of foot ulcers that ultimately can result in amputation, said David G. Armstrong, DPM, MD, PhD, UA professor of surgery, director and cofounder of SALSA, and a co-author of the study. Once a foot ulcer develops, he said, there’s about a 50 percent chance the ulcer will become infected. Once infected, there is a high risk of amputation.
“This problem is one of the most, if not the most, expensive complications of diabetes,” Armstrong said. “It appears to be the most common reason people are admitted to the hospital.” He suggested a three-tiered system for care could help reduce the disparity in outcomes for patients in outlying communities and for patients with low income. He proposed creating a “level 3” type of care in which a physician or nurse is in an outlying community with the training and knowledge to screen residents for type 2 diabetes and foot ulcers. A “level 2” facility could be based in a community hospital, where clinicians, vascular surgeons, and podiatric surgeons also have a focus on the condition. And a “level 1” center would be in a facility where the most complex cases could be treated.
Editor’s note: This story was adapted from materials provided by UA.