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Poverty Linked To Diabetic Amputations In California

People with diabetes in low-income neighborhoods in California are twice as likely to have a leg or foot amputated as those living in wealthier areas, according to a study released Monday.

The study, published in the journal Health Affairs, underscores the stark differences in outcomes for diabetes patients throughout the state.

“We are not particularly surprised, but we are disturbed,” said Carl Stevens, one of the authors and a clinical professor at UCLA David Geffen School of Medicine. “Is it okay that we are losing limbs … in low-income people? Most Americans would find this inequality in outcomes unacceptable, regardless of their political leanings or their opinions.”

About one in seven Californians has diabetes, a metabolic disease that leads to high blood sugar. The vast majority are Type 2 cases, in which the body doesn’t use insulin properly. Amputations are a serious complication of the disease but are generally preventable with proper care. The disease can lead to blindness, kidney disease and death.

The study didn’t determine the cause of the higher rates of amputations, but researchers said less access to ongoing primary care, coordinated teams of providers and trained specialists likely contributes to the problem. In addition, patients in low-income neighborhoods may not be as educated about their health and may have fewer places to buy healthy food or to exercise safely.

As in the state as a whole, the amputation rates in Los Angeles County in 2009 were roughly double in poorer neighborhoods than more affluent ones. In parts of the county, however, the disparities were even greater. For example, there were about 11 amputations per 1,000 diabetics in Compton, compared to 1 per 1,000 patients in Beverly Hills.

The findings are worrisome because nationwide, amputation rates have dropped overall – from 5.8 per 1,000 people in 1990 to 2.8 per 1,000 people in 2010.

American Diabetes Association president-elect Dr. Sam Dagogo-Jack said the California findings support long recognized associations between poverty and increased risk of diseases and their complications.

“This is one prime example of that,” said Dagogo-Jack, a professor at the University of Tennessee Health Science Center. “Poverty becomes a red flag and an important indicator of less than desirable outcomes.”

In the California study, the researchers used U.S. Census data and discharge data from hospitals and surgery centers to map the “hot spots” where high numbers of amputations took place. The data covered about 6,800 patients who had at least one diabetes-related amputation in 2009.

Stevens said he was inspired to do the research after working at a Los Angeles County public hospital and seeing too many patients needing foot amputations to save their lives. He didn’t see the same problem in wealthier areas, and said the health disparity was largely hidden. “Our motivation was to bring this very serious complication out into public view so it could be part of the policy debate,” he said.

Stevens said the study shows doctors and policymakers need to pay more attention to diabetes care for low-income patients. The expansion of health insurance under the Affordable Care Act is helping improve access to care, but primary care doctors are in short supply, the study said. In addition, more effort should go to making neighborhoods healthier and improving health knowledge, Stevens said.