News

UCLA Researchers Say Low Income Diabetics More Likely to Lose a Limb

Susan Abram

08/14/2014

Aug. 14--Paul Vinci's feet were deteriorating, and he didn't know why.

Small sores turned into large wounds. Ulcers had eaten away the skin on the top of his toes and on the soles of his feet. The skin around his toenails began to darken with gangrene. Diabetes-related nerve damage had made him feel as if his feet were burning.

Homeless and without health insurance, Vinci almost lost his right foot. "I was living on the street, wrapping my feet up every day," Vinci, 51, said recently. "My feet were on fire, and I didn't know why."

After several months in a hospital in Las Vegas, then some treatment at a Los Angeles County hospital, Vinci was referred to the Amputation Prevention Center at Valley Presbyterian Medical Center in Van Nuys.

The amputation center operates near communities in the San Fernando Valley where residents with diabetes are 10 times more likely to lose a toe, a foot, or a leg to diabetes because they are too poor, too preoccupied with surviving and live in areas where the right treatment is unavailable, according to a recent study by UCLA.

Using surveys, statistics from the U.S. Census Bureau, and California hospital discharge data, UCLA researchers created maps that show diabetic amputation rates by neighborhood. What they discovered were clusters of high amputation rates in areas where household incomes fell below the federal poverty level. South Los Angeles and the east San Fernando Valley were among the most affected areas.

Interactive: The rate of amputations for diabetics by zip code

"Amputation rates in California were 10 times higher in the poorest neighborhoods, like Compton and East Los Angeles, than in the richest neighborhoods, such as Malibu and Beverly Hills," said co-author Dylan Roby, director of health economics at the UCLA Center for Health Policy Research and an assistant professor at the UCLA Fielding School of Public Health.

The data was based on information from 2009, a time when doctors removed about 8,000 legs, feet and toes from 6,800 Californians with diabetes.

The findings don't surprise Dr. George Andros, a vascular surgeon who launched the Amputation Prevention Center at Valley Presbyterian. While poverty is a great risk factor that can lead to an amputation, there's more to it, he said. Andros said he helped open the center in 2010 because his goal was to use a team-based approach to treat the ulcerated wounds associated with diabetes and prevent amputations.

But that kind of prevention is expensive, unappealing to many young doctors and few hospitals want to invest in long-term care that involves everything from vascular surgery to specialized podiatry and nursing.

"These people need a lot of care, a lot of attention," he said of the diabetic patients he sees. "They come to us, and they're already pretty desperate."

Andros said the five-year survival rate of a diabetic who has lost a leg is worse than someone with rectal cancer.

In their study, UCLA researchers found African-Americans and non-English speaking residents are more likely to undergo an amputation.

While less than 6 percent of diabetic Californians are African-American, they accounted for nearly 13 percent of those who underwent one or more amputations in 2009, according to the study.

Asians made up 12 percent of the diabetic population but had less than 5 percent of diabetes-related amputations that year, researchers said.

The high amputation rate among the poor is a result of a lack of organization within the health care system, said Dr. David Schriger, a professor of emergency medicine at the Geffen School of Medicine. For all the money the U.S. spends on health care, helping patients manage their sugar levels can be as easy as sending daily text messages. But there are no economic incentives for that kind of care, Schriger said, which is why the disease festers in some communities.

"To me it's an embarrassment and a tragedy," Schriger said of the results of the study. "Should we tolerate a tenfold disparity for the loss of a limb and a patient's ability to walk when we can prevent amputations with proper care? What we're talking about here is one human being taking care of one another."

Those with diabetes may develop foot problems because of nerve damage, or neuropathy. Feet can feel like they are burning, or else can go numb, which is why a diabetic may not feel small sores that can then grow, and become infected.

Vinci said he once owned a restaurant in San Luis Obispo but had to sell it because he felt sick all the time. He was about 100 pounds overweight, and his feet always felt like they were burning.

But he didn't feel the sores and didn't know he was diabetic. As a result, he lost a tip of one of his toes.

The rate of leg and foot amputations among American adults 40 and older with diagnosed diabetes declined by 65 percent between 1996 and 2008, according to the federal Centers for Disease Control and Prevention.

But Andros and others said they believe it's starting to rise again and that could have economic impacts.

In general, the total estimated cost of diagnosed diabetes in 2012 was $245 billion, including $176 billion in direct medical costs and $69 billion in reduced productivity, according to the American Diabetes Association.

Researchers who wrote the UCLA study said their next goal is to continue to analyze the data to develop ways to lower the risk for diabetic people living in impoverished neighborhoods. They also hope their findings, published in the August issue of Health Affairs, will motivate public health officials and medical providers to reach out more to patients who are at risk.

"We hope our findings spur policymakers nationwide to improve access to treatment by expanding Medicaid and other programs targeting low-income residents, as we did in California in 2014," said lead author Dr. Carl Stevens, a clinical professor of medicine at the David Geffen School of Medicine at UCLA.