African-Americans more likely to lose a leg to diabetes

A new study says that blacks in the United States are three times more likely to have a leg amputated as a result of disparities in the preventive care of diabetes. According to the Dartmouth Atlas Project report, overall diabetic amputation rates have decreased compared to 10 or 15 years ago, but are increasing in certain groups, especially in the Southeast, in rural areas and among Africa-Americans. “There are certain parts of the country where the disparity is larger,” director of the Center for the Evaluation of Surgical Care at Dartmouth Hitchcock Medical Center and lead author Dr. Philip Goodney told Reuters.

The researchers singled out Mississippi as having diabetes care disparities between blacks and non-blacks that were among the most far apart. Even within the southern United States where surgery rates were the highest in general, Mississippi stood out. For example, there were a little less than five surgeries for every 1,000 black patients in Columbus, Georgia, as opposed to 41.7 per 1,000 patients in Hattiesburg, Mississippi. Director of the Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change national program Dr. Marshall Chin – not involved in the study – also mentioned Chicago, where “people with diabetes who live in predominantly black areas have a much higher rate of amputation.”

Goodney and colleagues analyzed Medicare claims from 2007-2011 for patients with diabetes and peripheral arterial disease (which the data classified as black or non-black), and took into account standard facets of diabetes care, surgical procedures for related complications such as wounds and ulcers, and amputation as a last ditch effort. They found that approximately 75% of black patients received a blood lipids test – a preventive measure for diabetes – in 2010, in comparison with 82% of non-blacks. Moreover, 2% of African-American patients received surgery for complications of diabetes, compared to 1.3% of non-black patients. The authors considered surgery of this nature to be an indicator of poor preventive care.

As for leg amputations, the rate for black patients was 5.6 procedures per 1,000 patients, compared to 2 per 1,000 non-black patients. To put it in perspective, the national rate for the years 2007 to 2011 was 2.4 amputations per each 1,000 Medicare enrollees. Such a low number is a result of the availability of improved preventive measures, such as medications that lower cholesterol and diabetic foot care, “but for those with more severe disease we saw the likelihood of getting those preventive measures was low,” said Goodney. He explained that certain patients seek care only until it is too late to save their leg, while others have a plethora of other chronic conditions that makes it difficult for physicians to set time aside for diabetes preventive care.

Furthermore, although the preventive measures are there, they need to be tweaked to meet outcome drivers for specific patients. “I could say to a patient at the end of a visit, you need to eat healthy, exercise, take medications, come back in three months and we’ll see how you’re doing. Their sugar will still be out of control.” Chin said. “We need to talk to them about the challenges they have to eating healthy: maybe you live in a food desert, maybe you are using traditionally ethnic recipes high in fat or sugar. There are very specific ways that we need to understand each individual patient situation, their particular set of family and neighborhood factors.” On the plus side, Chin believes that raising awareness about these disparities through studies like the Dartmouth Atlas Project is a step in the right direction. “Almost all clinicians and organizations want to do the right thing, but if they don’t believe there’s a problem they won’t do anything,” he said.

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