Disparities in initial presentation and treatment outcomes of diabetic foot ulcers in a public, private, and Veterans Administration hospital

J Diabetes. 2014 Jan;6(1):68-75. doi: 10.1111/1753-0407.12050. Epub 2013 May 29.


Background: Disparities in diabetic foot ulcer (DFU) treatment outcomes are well described, although few studies identify risk factors contributing to disparate healing and amputation rates. In a unique academic center serving urban public, private, and veteran patients, we investigated amputation and healing rates and specific risk factors for disparate treatment outcomes.

Methods: A retrospective chart review of diabetic patients with a new diagnosis of a foot ulcer at geographically adjacent, but independent public, private, and Veterans Administration (VA) hospitals was conducted. Healing and lower extremity amputation outcomes were assessed.

Results: Across the three hospitals, 234 patients met the inclusion criteria. Patients at the VA hospital were older (mean 72.5 years; P < 0.001) and had gangrenous ulcers (mean 14.1%; P < 0.001) compared with patients in the private and public hospitals. Public hospital patients were mostly Hispanic (mean 54%; P < 0.001) with a shorter duration of diabetes (mean 12.8 years; P = 0.02), but were more poorly controlled than VA and private hospital patients (P ≤ 0.001). Prior amputation (odds ratio [OR] 1.97; P = 0.016) and non-Caucasian race (OR 2.42; P = 0.004) increased the risk of amputation on multivariate analysis. Osteomyelitis (P = 0.0371) and gangrene (P < 0.001) are independent risk factors for amputation. Across all three hospitals, 42.3% of patients were treated by amputation (6.8% private, 12% public and 23.5% VA; P < 0.001).

Conclusion: In a single triumvirate health care system where the patient population is stratified primarily by insurance, VA patients have significantly higher amputation rates compared with patients at adjacent private and public hospitals. The VA patients are largely racial minorities with advanced DFU progression to gangrenous ulcers.

Keywords: diabetic foot ulcer; health care disparities; lower extremity amputation; wound healing; 糖尿病足溃疡,卫生保健差距,下肢截肢,伤口愈合.

Publication types

  • Comparative Study
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Aged
  • Amputation / statistics & numerical data*
  • Delayed Diagnosis
  • Diabetes Complications / diagnosis*
  • Diabetes Complications / etiology
  • Diabetes Complications / therapy
  • Diabetes Mellitus, Type 2 / complications*
  • Diabetic Foot / diagnosis*
  • Diabetic Foot / etiology
  • Diabetic Foot / therapy
  • Female
  • Follow-Up Studies
  • Healthcare Disparities / statistics & numerical data*
  • Hospitals, Private
  • Hospitals, Public
  • Hospitals, Veterans
  • Humans
  • Male
  • Middle Aged
  • Prognosis
  • Retrospective Studies
  • Ulcer / diagnosis*
  • Ulcer / etiology
  • Ulcer / therapy
  • Wound Healing*