Multidisciplinary Care Can Mitigate Socioeconomic Disparities in Patients with Diabetic Foot Ulcers
Caitlin W. Hicks, MD, MS, Joseph K. Canner, MHS, Nestoras Mathioudakis, MD, MHS, Ronald L. Sherman, DPM, MBA, Kathryn Hines, PA-C, Mahmoud B. Malas, MD, MHS, James H. Black, III, MD, Christopher J. Abularrage, MD.
Johns Hopkins Hospital, Baltimore, MD, USA.
OBJECTIVES: Socioeconomic deprivation is associated with poor glycemic control and higher hospital admission rates in patients with diabetes. We sought to assess if using a multidisciplinary approach to DFU was associated with improved wound healing despite socioeconomic disadvantage.
METHODS: All patients presenting to our multidisciplinary DFU clinic from 7/2012-07/2016 were enrolled in a prospective database. Socioeconomic disadvantage was calculated for each patient using the previously validated Area Deprivation Index (ADI) and stratified by quartile (ADI-0: least deprivation through ADI-3: most deprivation). Predictors of wound healing were then assessed using univariable analyses and Cox proportional hazards models accounting for patient demographics, wound characteristics, SVS WIfI stage and ADI quartile.
RESULTS: 264 patients with 556 wounds were enrolled, including 57% ADI-0, 7% ADI-1, 12% ADI-2, and 24% ADI-3. Worse ADI quartile was associated with female gender (ADI-3: 58% vs. ADI-0: 33%), younger age (<65 years, ADI-3: 94% vs. ADI-0: 70%), higher baseline hemoglobin A1c (>8%, ADI-3: 63% vs. ADI-0: 50%), higher prevalence of smoking (ADI-3: 37% vs. ADI-0: 17%), and lower prevalence of peripheral vascular disease (ADI-3: 28% vs. ADI-0: 42%) and dialysis (ADI-3: 4% vs. ADI-0: 13%) (all, P<.01). Patients with worse ADI more commonly had Medicaid insurance (ADI-3: 52% vs. ADI-0: 13%) and were referred via inpatient rather than outpatient consult (ADI-3: 52% vs. ADI-0: 34%) (both, P<.001). Mean wound area and duration were similar between groups (P=NS). On univariable analysis the likelihood of wound healing during the study period was inversely associated with ADI quartile [ADI-3 vs. ADI-0: HR 1.44 (95%CI 1.05-1.98)]. However, after accounting for patient demographics and wound characteristics, the likelihood of wound healing was similar between groups [ADI-3 vs. ADI-0: HR 1.19 (95%CI 0.87-1.63)]. Independent predictors of poor wound healing included female gender (HR 0.69), peripheral vascular disease (HR 0.62), increasing SVS WIfI stage (stage 4: HR 0.59), and larger wound area (HR 0.98 per increase in cm2) (all, P<0.01).
CONCLUSIONS: In our multidisciplinary DFU model, wound healing is largely dependent on wound characteristics and vascular status rather than patient demographics or healthcare disparity. Use of a multidisciplinary approach to the management of DFU may overcome the negative effects of socioeconomic disadvantage frequently described in the diabetic population.
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