4/28/2009. Are Uninsured Border Minorities Most at Risk for Life-threatening Complications Associated with Type 2 Diabetes?

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1 Presented by: Jane Nelson Bolin, RN, JD PhD; Marcia Ory, PhD, MPH; Nelda Mier, PhD; and Janet Helduser, MA, This research was supported by a pilot grant from the Mexican American Latino Research Center (MALRC) Grant # This research was also supported in part by the NIH Program for the Study of Rural and Minority Health Disparities and the Southwest Rural Health Research Center. School of Rural Public Health, TAMHSC College Station, TX Are Uninsured Border Minorities Most at Risk for Life-threatening Complications Associated with Type 2 Diabetes? Diabetes related peripheral vascular disease (PVD) and peripheral poly-neuropathy secondary to diabetes is the leading cause of non-traumatic amputation of the lower extremities in the U.S. In fact, more than 50% of all non-traumatic lower limb amputations are performed on persons with diabetes. Most lower extremity amputations are preceded by foot and leg ulcers, infection and tissue necrosis, all indicators of peripheral vascular disease. Peripheral Vascular Disease Diabetic foot ulcers Previous literature has reported that Latinos, especially those living along the U.S.-Mexico border, have higher rates of lower extremity amputations (LEA) than do whites (MMWR, 2006). The CDC reports that the risk of LEA is times higher for diabetics than nondiabetics (2006). 1

2 Diabetes alone accounts for more than 30,000 non-traumatic amputations per year amounting to over $800 million in disability and other costs. Many factors may contribute to the observed severity of diabetes, including insurance status, race/ethnicity, poverty, and region of residence. Foot ulcers and compromised circulation substantially reduce mobility and diminish HR- QoL. Ability to work regularly is reduced especially for manual laborers. Foot ulcers and peripheral vascular disease substantially limit community and social interaction. Foot and leg ulcers precede 84% of lower extremity amputations in the U.S. (Goodridge et al, 2005). The long term costs of treating and managing foot ulcers for diabetic patients range from $16,100 (non-severe ischemia) - $26,700 (severe ischemia) (1995 U.S. dollars). The costs of an amputation range from $43,100 (minor) - $63,100 (major). Adequate health care for prevention and treatment are essential if foot ulcers and amputation are to be prevented. Accessing preventive healthcare for foot ulcers and peripheral vascular disease may be a significant challenge in rural areas Apelqvist, et al, (1995) We know that rates of LEA have been shown to be higher along the Texas-Mexico border. What is not known if whether there are rural vs. urban differences in rates of LEA in Texas. It is also not clear whether there are racial, ethnic or rural differences in level of severity of disease status of diabetics admitted to the hospital in Texas. Finally, it is not known whether there are border vs. non-border differences in hospital treatment received for diabetes related peripheral vascular disease an important pre-curser to LEA 2

3 1. Compare rates of LEA across categories of race, ethnicity, urban v. rural status and disease severity. 2. Compare rural vs. urban differences in rates of diabetes-related disease severity in Texas. 3. Examine differences in hospital treatment for diabetes-related peripheral vascular disease and lower extremity amputation (LEA) among adults age 18 and older who were admitted to hospitals in Texas in The data used in this study is the 2005 Texas Hospital Inpatient Discharge data for all regions of Texas for all quarters of We select all adults age 18 and older with diagnosis of type 2 diabetes (T2DM) using the ICD-9 codes for (1) admission diagnosis, (2) principal diagnosis and (3) next 4 ICD-9 codes. We also use the same ICD-9 codes to identify related co-morbidities. After selecting for type 2 diabetes we then code according to border and non-border, using the 32 counties identified as the federal definition of border region under the La Paz agreement. Analytical Model Our analytical approach begins with statistical comparisons of rates of diabetes and LEA along the Texas-Mexico border vs. nonborder regions. We compare these rates in Hispanic and non- Hispanic population, U.S. vs. Non-U.S. citizens and across rural and non-rural areas using RUCC/FIPS codes. We also identify HPSA (Health Professional Shortage Areas) counties. 3

4 Reference Categories = Females, white, employer insurance, Age nonrural,, mild illness 1. This study confirms prior literature that Hispanics and African Americans have an increased risk of LEA than do whites, independent of insurance status. 2. Hispanic males are significantly more likely to undergo LEA than all others. 3. Persons with type 2 diabetes living in rural areas along the Texas-Mexico Border are more likely to undergo LEA than urban border dwellers with type 2 diabetes. 4

5 However, persons living along the border are more likely to be admitted to the hospital in extremely ill condition. Level of severity upon admission is the most highly predictive factor for undergoing LEA. The next most significant predictive factor is presence of peripheral vascular disease. Leg amputations are not only a personal tragedy, they are also financially expensive (Ulbrecht, Cavanagh, Caputo (2004); Not only are hospital and medical care costs dramatically increased leg amputations are highly predictive of work disability. Prevention of peripheral vascular disease and peripheral nerve damage are key to preventing lower limb amputations. Prevention! Prevent diabetes, ulcers and compromised circulation. Prevent diabetes first and foremost. If currently a diabetic overall goal should be patient education directed towards effective management, and prevention of complications. Focus more on the needs of rural HC providers in managing complicated cases. 5