Impact Of Rurality On Outcomes Of Diabetic Foot Infections
Sarah A. Fermawi, BS, Andrew H. Rice, DPM, Allison M. Rottman, DPM, Jennifer Pappalardo, MD, Wei Zhou, MD, Shannon Knapp, PhD, Tze-Woei Tan.
University of Arizona, Tucson, AZ, USA.
Objective:
Rural disparities in diabetic foot problems and lower extremity amputations are not well studied. This study aimed to examine the impact of the urban-rural residency on major amputation and mortality following diabetic foot infections (DFIs).
Methods:
This retrospective study included patients presented to Southern Arizona Limb Salvage Alliance (SALSA) with between December 2018 through June 2019 for DFIs. Sociodemographic, clinical factors, and non-clinical variables associated with major amputation and mortality were compared based on rural and urban residencies. Rurality was determined based on Rural-Urban Commuting Area Codes. Multivariable logistic regression was used to assess the association of rural-urban residency major amputation/death, adjusting for sociodemographic factors and presentation using the Wound, Ischemia, Foot Infection (WIfI) classification.
Results:
Among 183 patients with DFIs, 56 (30%) were minorities, 110 (60%) had Medicare/Medicaid, and 37 (20%) resided in rural areas. Overall, 27 (14.8%) underwent major amputation or died during hospitalization. Compared to patients residing in urban areas, those living in rural areas were more likely to be minorities (51.4% vs. 25.3%) and higher mortality (13.5% vs. 0%). There was no significant difference in the presentation based on WIfI classification, insurance status, medical comorbidities, and the rate of major amputation among rural and urban cohorts. In multivariable analysis, rural-urban residency was not an independent predictor of major amputation or death (adjusted Odd Ratio (aOR)=0.36, p=0.54). The factor associated with major amputation or death was peripheral arterial disease (aOR=1.38, p=0.012).
Conclusion:
Although rural patients with DFIs were more likely to be minorities and had higher mortality than their urban counterparts, rural residency was not an independent predictor of lower extremity amputation and death. Further studies are warranted to advance understanding of patient-level factors contributing to rural disparities of lower extremity amputation.
| Urban (n=146) | Rural (n=37) | P Value | |
| Female | 44 (30.1%) | 17 (45.9%) | 0.1 |
| White | 109 (74.7%) | 18 )48.6%) | 0.004 |
| Age, SD | 57.6 (12.5) | 59.6 (10.6) | 0.39 |
| CKD | 53 (36.3%) | 17 (45.9%) | 0.37 |
| CAD | 40 (27.4%) | 15 (40.5%) | 0.18 |
| PAD | 65 (44.5%) | 15 (40.5%) | 0.80 |
| Osteomyelitis | 88 (71,0%) | 29 (85.3%) | 0.14 |
| major amputation | 19 (13%) | 3 (8.1%) | 0.58 |
| Mortality | 0 (0%) | 5 (13.5%) | <0.001 |
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