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Cited by 111Diabetic Foot Ulcer Assessment and ManagementPeripheral Artery Disease ManagementStreptococcal Infections and Treatments

Disparities in outcomes of patients admitted with diabetic foot infections.

Open access
Tan, Tze-Woei, Shih, Chia-Ding, Concha-Moore, Kirsten C., Diri, Muhanad M., Hu, Bo, Marrero, David, Zhou, Wei, Armstrong, David G.·2019·PLoS ONE
DOI 10.1371/journal.pone.0211481PMC PMC6361439
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Abstract

OBJECTIVE: The purpose of this study was to evaluate the disparities in the outcomes of White, African American (AA) and non-AA minority (Hispanics and Native Americans (NA)), patients admitted in the hospitals with diabetic foot infections (DFIs). RESEARCH DESIGN AND METHODS: The HCUP-Nationwide Inpatient Sample (2002 to 2015) was queried to identify patients who were admitted to the hospital for management of DFI using ICD-9 codes. Outcomes evaluated included minor and major amputations, open or endovascular revascularization, and hospital length of stay (LOS). Incidence for amputation and open or endovascular revascularization were evaluated over the study period. Multivariable regression analyses were performed to assess the association between race/ethnicity and outcomes. RESULTS: There were 150,701 admissions for DFI, including 98,361 Whites, 24,583 AAs, 24,472 Hispanics, and 1,654 Native Americans (NAs) in the study cohort. Overall, 45,278 (30%) underwent a minor amputation, 9,039 (6%) underwent a major amputation, 3,151 underwent an open bypass, and 8,689 had an endovascular procedure. There was a decreasing incidence in major amputations and an increasing incidence of minor amputations over the study period (P < .05). The risks for major amputation were significantly higher (all p<0.05) for AA (OR 1.4, 95%CI 1.4,1.5), Hispanic (OR 1.3, 95%CI 1.3,1.4), and NA (OR 1.5, 95%CI 1.2,1.8) patients with DFIs compared to White patients. Hispanics (OR 1.3, 95%CI 1.2,1.5) and AAs (OR 1.2, 95%CI 1.1,1.4) were more likely to receive endovascular intervention or open bypass than Whites (all p<0.05). NA patients with DFI were less likely to receive a revascularization procedure (OR 0.6, 95%CI 0.3, 0.9, p = 0.03) than Whites. The mean hospital length of stay (LOS) was significantly longer for AAs (9.2 days) and Hispanics (8.6 days) with DFIs compared to Whites (8.1 days, p<0.001). CONCLUSION: Despite a consistent incidence reduction of amputation over the past decade, racial and ethnic minorities including African American, Hispanic, and Native American patients admitted to hospitals with DFIs have a consistently significantly higher risk of major amputation and longer hospital length of stay than their White counterparts. Native Americans were less likely to receive revascularization procedures compared to other minorities despite exhibiting an elevated risk of an amputation. Further study is required to address and limit racial and ethnic disparities and to further promote equity in the treatment and outcomes of these at-risk patients.

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  • The diagnosis of diabetic foot infection is primarily based on clinical assessment and is suggested by presence of more than 2 signs of inflammation, such as erythema, swelling and possibly purulence, fluctuance, or lymphangiitis.

    “The diagnosis of diabetic foot infection is primarily based on clinical assessment and is suggested by presence of more than 2 signs of inflammation, such as erythema, swelling and possibly purulence, fluctuance, or lymphangiitis.7,13”

    From Diabetic Foot Ulcers (2023) · cites this paper as [13]

    The Study cohort section (page unavailable) identifies patients using ICD-9 codes, but does not describe clinical diagnostic criteria. The Introduction and additional passages found by searching for the listed inflammatory signs and clinical assessment do not address a threshold of more than two signs or the listed findings. (LLM, conf=0.76)

    Experimental — accuracy not yet measured

  • Randomized clinical trial data are not available to support obtaining wound cultures from all patients with diabetic foot ulcers.

    “Randomized clinical trial data are not available to support obtaining wound cultures from all patients with diabetic foot ulcers.7,13”

    From Diabetic Foot Ulcers (2023) · cites this paper as [13]

    The Study cohort and Outcomes and variables sections describe a retrospective analysis of hospital admissions and outcomes, not whether wound cultures should be obtained. Searches for randomized trials and wound cultures found no passage addressing the availability of trial evidence for culturing all diabetic foot ulcers. Page numbers were not available in our copy. (LLM, conf=0.75)

    Experimental — accuracy not yet measured

  • For diagnosing osteomyelitis, bone biopsy and culture remain the gold standard.

    “For diagnosing osteomyelitis, bone biopsy and culture remain the gold standard.7,13”

    From Diabetic Foot Ulcers (2023) · cites this paper as [13]

    The Study cohort section identifies patients with osteomyelitis using ICD-9 codes, but does not discuss how osteomyelitis is diagnosed. Searches for bone biopsy, culture, and a diagnostic gold standard found no supporting passage in our copy. (LLM, conf=0.75)

    Experimental — accuracy not yet measured

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Research works printed but not linked: 1

  1. [20]Healthcare Cost and Utilization Project (HCUP): Agency for Healthcare Research and Quality, Rockville, MD.; February 2018 [Available from: https://www.hcup-us.ahrq.gov/nisoverview.jsp. 21413206

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Authors
Tan, T.-W., Shih, C.-D., Concha-Moore, K. C., Diri, M. M., Hu, B., Marrero, D., Zhou, W., & Armstrong, D. G.
Affiliations
  • University of Arizona (US)
  • University of Southern California (US)
  • Cleveland Clinic (US)
Corresponding author
Tan, Tze-Woei
ORCID
Venue
PLoS ONE
Publisher
Public Library of Science (PLoS)
Published
2019-02-04
Volume
14
Issue
2
Pages
e0211481
ISSN
1932-6203 (ISSN-L)
DOI
10.1371/journal.pone.0211481
PMC
PMC6361439
OpenAlex
W2913555931
Cited by
111
References
37
Citations by year
2026: 3 · 2025: 13 · 2024: 27 · 2023: 22 · 2022: 14 · 2021: 11 · 2020: 18 · 2019: 2
FWCI
9.13
Type
journal article
Language
en
Update notices
correction (2019-04-11)
Open access
Licence
Locations
  • PLoS ONE (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • UA Campus Repository (The University of Arizona) (acceptedVersion, cc-by)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • Figshare (submittedVersion, cc-by)
Funders
National Institute of Diabetes and Digestive and Kidney Diseases (P30DK111022)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetic Foot Ulcer Assessment and Management
  • Health Sciences › Medicine › Surgery › Peripheral Artery Disease Management
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Streptococcal Infections and Treatments
Keywords
diabetic foot infection, racial disparities, ethnic disparities, amputation, major amputation, minor amputation, revascularization, endovascular intervention, length of hospital stay, African American patients, Hispanic patients, Native American patients, hospital admission outcomes, health care access disparities, health care quality disparities
MeSH terms
Amputation, Surgical, Ethnicity, Female, Hospitalization, Humans, Male, Middle Aged, Prognosis, Cohort Studies, Treatment Outcome, Diabetic Foot, Racial Groups, Healthcare Disparities, Endovascular Procedures

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