Using the National Institute on Minority Health and Health Disparities framework to better understand disparities in major amputations

Spanish Translation and Validation of the LIMB-Q: A Patient-reported Outcome Measure for Lower Extremity Trauma

Background

Hispanic patients represent a notable portion of the adult trauma population in the United States, yet their participation in studies collecting patient-reported outcome measure data following lower extremity injuries is limited. This study aims to translate and linguistically validate the LIMB-Q in Spanish for use in this population.

Methods

We followed guidelines from the World Health Organization and the Professional Society for Health Economics and Outcomes Research to conduct this translation. Two independent translators conducted a blind forward translation of the LIMB-Q from English to Spanish, followed by a back translation to confirm the conceptual preservation of each LIMB-Q item. Five patients then participated in cognitive debriefing interviews to collect feedback on comprehension, interpretation, and language.

Results

Translators occasionally differed in the vocabulary they used in their forward translations. All conflicts were resolved by discussion and selection of the option with the greatest colloquial recognition and medical relevance. Back translation identified 25 differences, including items that did not fully convey semantics (n = 12), were missing parts (n = 9), or were listed out of order (n = 4). All items with inadequate semantics were revised to ensure full retention of their original meaning. Five patients participated in cognitive debriefing interviews, resulting in 5 revisions for diction and syntax.

Conclusions

The Spanish (US) translation of LIMB-Q is now available. This instrument may be used in both clinical and research settings to better understand the quality of life and satisfaction of Hispanic patients after traumatic lower extremity injury.

Association between Regional Market Competition and Early Femoropopliteal Interventions for Claudication

BACKGROUND

Regional market competition is known to impact practice patterns in surgical care. We aimed to investigate the association of regional market competition with the utilization of early peripheral vascular interventions (PVIs) for the treatment of claudication, and the subsequent impact on clinical outcomes.

METHODS

We conducted a retrospective analysis of 100% Medicare fee-for-service claims data from January 2019 to December 2021 to identify patients with a new diagnosis of claudication. We calculated the Herfindahl-Hirschman Index for all sites of service performing PVI according to Health Service Area. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of regional market competition with early (<6 months) PVI for claudication, and progression to chronic limb-threatening ischemia, repeat PVI, and major amputation.

RESULTS

We identified 300,492 patients with a new diagnosis of claudication (mean age 73.8 years, 51.6% male, 11.1% Black), of which 6.1% underwent an early PVI for claudication. Most patients (72.4%) were treated in low-competition markets. After adjusting for patient characteristics, patients treated in moderate-competition markets had the highest odds of receiving an early PVI. Regional market competition was not associated with conversion to chronic limb-threatening ischemia or repeat PVI (P > 0.05), but patients treated in high- (adjusted hazard ratio [aHR] 0.70, 95% confidence interval [CI] 0.56-0.86) and moderate- (aHR 0.82, 95% CI 0.69-0.92) competition markets had lower hazards of major amputation compared to patients treated in low-competition markets. Early PVI was significantly associated with worse clinical outcomes after adjusting for all factors including market competition (all, P < 0.05).

CONCLUSIONS

There is a complex interplay between regional market competition, early PVI utilization, and subsequent clinical outcomes for patients with claudication. Early PVI continues to demonstrate a strong association with unfavorable clinical outcomes even when accounting for market competition.

Spatial associations between measures of public transportation and diabetic foot ulcer outcomes in the state of Georgia: 2016-2019

INTRODUCTION

There are limited data regarding the associations between public transportation reliance, availability, and diabetic foot ulcer (DFU)-related amputations.

RESEARCH DESIGN AND METHODS

We used visit-level data from the Georgia 2016-2019 Healthcare Cost and Utilization Project database and obtained transportation variables from open sources. Using Bayesian spatial-temporal models, we assessed the associations between transportation and DFU-related amputations within each quartile of poverty status indicators at the ZIP code tabulation area (ZCTA) level. We used the proportion of adults who use public transportation to commute, distance to nearest transit stop, and per capita expense on public transportation as proxies for public transportation reliance, availability, and both, respectively.

RESULTS

Of 114 606 DFUs, 21 388 (19%) were associated with a major or minor amputation. Among ZCTAs at the highest income quartile, reduced amputation risk was associated with the proportion of adults who use public transportation to commute to work (relative risk (RR)=0.29, 95% CI 0.09 to 0.97 per IQR increase of 1.13%) and per capita expense on public transportation (RR=0.78, 95% CI 0.63 to 0.78 per IQR increase of 6 cents). In metropolitan Georgia, a 1 IQR (261 m) increase in distance to the nearest transit stop was associated with lower amputation risk among ZCTAs at the lowest income quartile (RR=0.47, 95% CI 0.26 to 0.85).

CONCLUSION

In Georgia, public transportation reliance and availability are protective against DFU-related amputations in high-income but not among low-income ZCTAs. Reducing disparities in DFU-related amputations requires interventions to mitigate transportation barriers to care.

Geographic Variation in First Lower Extremity Amputations Related to Diabetes and/or Peripheral Arterial Disease

BACKGROUND

To assess trends of first cases of lower extremity amputation (LEA) related to diabetes and/or peripheral arterial disease (PAD), according to areas of residency and neighbourhood material and social deprivation quintiles, in the province of Quebec, Canada.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of first LEA (total, minor, and major) among adults 40 years of age and older with diabetes and/or PAD in fiscal years 2006 and 2019. Area of residency was compiled in 3 categories: (1) Montreal and other census metropolitan areas; (2) midsize agglomerations (10,000-100,000 inhabitants); and (3) small towns and rural areas (< 10,000 inhabitants). We also stratified according to neighbourhood material and social deprivation quintiles. One-year and 5-year all-cause mortality after first LEA were compared according to area of residency.

RESULTS

Among the 10,275 individuals who had a first LEA, age-standardized LEA rates remained stable between 2006 and 2019, whereas major LEA rates declined in all geographical areas and minor LEA rates increased (31.6%) in small towns and rural areas. In 2019, age-standardized LEA rates were higher in midsize agglomerations and small towns and rural areas compared with census metropolitan areas. Age-standardized LEA rates in 2019 were higher among the most deprived quintile compared with the most privileged quintile for material and social deprivation. No difference was observed in mortality after first LEA according to area of residency.

CONCLUSIONS

There are health disparities in the burden of diabetes and PAD related to first LEA in the province of Quebec. To improve preventive care and reduce the burden of LEA, targeted actions should be taken among the most deprived groups and rural settings.

Creation of a Limb Loss and Preservation Registry for Improving the Quality of Patient Care in the United States

Objective

To describe the development of a national Limb Loss and Preservation Registry (LLPR) designed to collect, standardize, and report patient outcomes data on limb loss and limb difference in the United States.

Design

Clinical Data Registry.

Setting

The LLPR was developed through consensus of key stakeholders from academia, industry, patient advocacy, and payers as well as the available scientific evidence. Data are collected from multiple sources, including hospitals, providers, and patients.

Participants

Data are collected from all 50 states.

Interventions

Not applicable.

Main Outcome Measures

More than 1100 trigger codes are used to identify patients who have limb difference or have received a limb preservation or amputation procedure. Once a patient is identified, all subsequent episodes of care are collected for the life of the patient. An integrated model is used for collecting, validating, cleaning, transforming, aggregating, and storing the data received from all sources. The information contained is then provided in a thorough and easily comprehensible manner.

Results

To date, the LLPR has captured data from >435,000 patients and >11.5 million episodes of care.

Conclusions

The LLPR creates opportunities to apply large-data analytical methodologies to provides caregivers, researchers, manufacturers, payers, and policy makers the tools needed to improve the quality of clinical care, quantify patient-centric outcomes, develop clinical practice guidelines, assess patient quality of life, identify appropriate technology, and guide creation of national policies to allocate scarce sources appropriately.

Residential Address Amplifies Health Disparities and Risk of Infection in Individuals With Diabetic Foot Ulcers

OBJECTIVE

To determine the association between social determinants of health (SDOH) and a diagnosis of diabetic foot ulcer (DFU) infection.

RESEARCH DESIGN AND METHODS

Targeted interrogation of electronic health record data using novel search engines to analyze individuals with a DFU infection during a 5-year period (2013-2017) was performed. We extracted geolocated neighborhood data and SDOH characteristics from the National Neighborhood Data Archive and used univariate and multiple logistic regression to evaluate associations with outcomes in the population with diabetes.

RESULTS

Among 4.3 million people overall and 144,564 individuals with diabetes seen between 2013 and 2017, 8,351 developed DFU, of which cases 2,252 were complicated by a DFU infection. Sex interactions occurred, as men who experienced a DFU infection more frequently identified as having nonmarried status than their female counterparts. For the population with DFU infection, there were higher rates for other SDOH, including higher neighborhood disadvantaged index score, poverty, nonmarriage, and less access to physician/allied health professionals (all P < 0.01). In multiple logistic regression, those individuals who developed DFU infection came from neighborhoods with greater Hispanic and/or foreign-born concentrations (odds ratio 1.11, P = 0.015).

CONCLUSIONS

We found significant differences in neighborhood characteristics driving a higher risk for DFU infection in comparisons with the grouping of individuals with diabetes overall, including increased risk for individuals with Hispanic and/or foreign-born immigration status. These data strongly support the need to incorporate SDOH, particularly ethnic and immigration status, into triage algorithms for DFU risk stratification to prevent severe diabetic foot complications and move beyond biologic-only determinants of health.

Racial disparities in selected micronutrient deficiencies after bariatric surgery: A systematic review

BACKGROUND

Bariatric surgery has been associated with numerous micronutrient deficiencies. Several observational studies have found that these deficiencies are more common in racially/ethnically minoritized patients.

OBJECTIVES

To conduct a systematic review to investigate whether racially/ethnically minoritized patients experience worse nutritional outcomes after bariatric surgery.

SETTING

University of Wisconsin-Madison.

METHODS

PubMed, CINAHL, PsychINFO, and Cochrane databases were queried. We searched for manuscripts that reported micronutrient levels or conditions related to micronutrient deficiencies according to race/ethnicity (White, African American/Black, and Hispanic) after laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass between 2002 and 2022. Eleven micronutrients (vitamins A, B1 [thiamine], B12, D, E, K, calcium, copper, folate, iron, and zinc), and four conditions (anemia, bone loss, fractures, and hyperparathyroidism) were assessed.

RESULTS

Abstracts from 953 manuscripts were screened; 18 full-text manuscripts were reviewed for eligibility, and ten met the inclusion criteria. Compared to White patients, African Americans had a higher prevalence of thiamine, vitamin D, and vitamin A deficiencies. There were no differences in calcium and vitamin B12 deficiencies. The other six micronutrients were not assessed according to race/ethnicity. Hyperparathyroidism was more prevalent in African Americans than White patients in the three studies that evaluated it. The prevalence of fractures was mixed. Anemia and bone loss were not evaluated according to race/ethnicity.

CONCLUSIONS

Although the literature on micronutrient outcomes following bariatric surgery according to race/ethnicity is limited, African Americans appear to experience a higher prevalence of vitamin deficiencies and associated conditions. Qualitative and quantitative research to explore these disparities is warranted.

Examining health care access disparities in Hispanic populations with peripheral artery disease and diabetes

INTRODUCTION

This study investigated disparities in health care access for Hispanic adults with diabetes and peripheral artery disease (PAD) who are at risk of lower-extremity amputation and other cardiovascular morbidities and mortalities.

METHODS

We utilized the health care access survey data from the All of Us research program to examine adults (⩾ 18 years) with either diabetes and/or PAD. The primary associations evaluated were: could not afford medical care and delayed getting medical care in the past 12 months. Multivariable logistic regression models were used to assess the association of Hispanic ethnicity and survey responses, adjusting for age, sex, income, health insurance, and employment status.

RESULTS

Among 24,104 participants, the mean age was 54.9 years and 67% were women. Of these, 8.2% were Hispanic adults. In multivariable analysis, Hispanic adults were more likely to be unable to afford seeing a health care provider, and receiving emergency care, follow-up care, and prescription medications (p < 0.05) than non-Hispanic adults. Furthermore, Hispanic adults were more likely to report being unable to afford medical care due to cost (odds ratios [OR] 1.72, 95% CI 1.50-1.99), more likely to purchase prescription drugs from another country (OR 2.20, 95% CI 1.69-2.86), and more likely to delay getting medical care due to work (OR 1.46, 95% CI 1.22-1.74) and child care (OR 1.80, 95% CI 1.35-2.39) issues than non-Hispanic White adults.

CONCLUSION

The Hispanic population with diabetes and PAD faces substantial barriers in health care access, including a higher likelihood of delaying medical care and being unable to afford it.