NEW YORK (Reuters Health) - People with diabetes who live in the poorest areas of California are about twice as likely to end up with their legs or feet amputated than those living in the wealthiest areas, according to a new study.
Black people and those who spoke Spanish appeared to be at a considerable disadvantage when it came to the likelihood of diabetes-related amputations, the researchers found.
“I think our findings show that the medical safety net has big holes in it and people are often falling through those holes and losing their limbs to diabetes when those complications could have been prevented with better care,” Dr. Carl D. Stevens said.
That so-called safety net includes emergency rooms and government-backed insurance programs, said Stevens, the study’s lead author from the David Geffen School of Medicine at the University of California, Los Angeles.
He and his colleagues write in the journal Health Affairs that in past studies, low-income people with diabetes tended to receive worse care for their disease, but no study had looked at overall poverty and amputations of legs and feet.
People with poorly controlled diabetes are at risk for a loss of feeling and poor blood flow in their extremities - conditions that increase their risk for foot ulcers and infections. Left untreated, they can worsen to the point where legs, feet or toes may need to be removed.
For the new study, the researchers linked databases of community-level poverty, diabetes prevalence and diabetes-related amputations for the U.S. state of California in 2009.
They had information on nearly 1.9 million people with diabetes age 45 and older, including 6,828 people who had 7,973 amputations of their lower extremities in 2009.
People living in the poorest areas of California were on average about twice as likely to have diabetes-related amputation of their lower extremities, compared to those living in the wealthiest regions, they found.
The differences were even more striking between individual cities, Stevens said.
“If you take the poorest town and compared it to the wealthiest, you get about a ten-time increase in risk,” he said.
What’s more, the researchers found, black people accounted for only about 6 percent of all people in the state with diabetes, but they represented about 13 percent of diabetes-related amputations.
Spanish-speaking people made up about 9 percent of all people with diabetes in California but accounted for 17 percent of all amputations.
“This is what I would have expected to see,” said Carolyn Jenkins, a nurse scientist at the Medical University of South Carolina in Charleston.
Jenkins, who was not involved with the new study, has done research on how to reduce diabetes-related disparities.
“Through our REACH coalition we know that those amputation rates can be reduced, but it truly takes a village,” she said. The REACH coalition is an organization dedicated to eliminating disparities related to diabetes and other conditions among African Americans living in the Southern U.S.
Jenkins said that to reduce amputation rates, doctors and other healthcare providers must work together to improve care and education.
Also, communities must work to provide culturally appropriate care and to build trust in the healthcare system, she said, adding that individuals and families need to help identify problems early.
“Patients who live in low-income neighborhoods have less awareness of the disease and consequences,” Stevens said.
He added that access to healthcare through insurance like Medicaid, the U.S. insurance for the poor, is also important. He’d like policymakers in states that chose not to expand their Medicaid programs under the Affordable Care Act to see these findings.
“While expanding health insurance is not the whole solution, it’s definitely part of the solution,” he said.
SOURCE: bit.ly/1oIsxHf Health Affairs, online August 4, 2014.