Association of Race With Referral Disparities for Patients With Diabetic Foot Ulcers at an Institution Serving Rural and Urban Populations

Abstract

Background: Racial minorities are more likely to develop type 2 diabetes and experience associated microvascular complications. Non-Hispanic Blacks and Hispanics initially present with more severe diabetic foot ulcers (DFUs) and peripheral artery disease (PAD), with an associated 10-fold increase in risk for lower extremity amputation within the first year after diagnosis. This study was designed to determine if race is associated with a failure to refer to specialists for DFU treatment, and the severity of DFU at the time of initial presentation. Methods: Patients were identified from the medical record based on a diagnosis related to diabetic foot complications between January 1, 2018, and June 1, 2023, in the family medicine, endocrinology, orthopaedic, or emergency clinics at a Midwest Academic Hospital serving rural and urban populations. Patients self-reported race, demographics, severity of ulcer based on Wagner ulcer scale at time of referral, eventual amputation status, and measures of social determinants of health including the national Area Deprivation Index (ADI) and Rural-Urban Commuting Area (RUCA) codes were manually extracted and analyzed for correlations with referral status. Results: A total of 597 patients were eligible for inclusion. Race was not associated with lower referral rates ( P > .99) or source of referral ( P = .58) to specialty clinic and ulcer severity at initial examination ( P = .34). Patients who initially presented to the emergency department had more severe ulcers ( P = .016), and higher severity was significantly associated with lower limb amputation vs mild ulcers (odds ratio = 38.8, P = .02). No significant differences in referral source or severity of ulcer at presentation were seen for sex, age, marital status, insurance type, rural status, ADI, time from referral to appointment, or eventual amputation. Conclusion: In this study, we found that patient race was not associated with severity of DFU at presentation or subsequent referral to a Midwest academic specialty orthopaedic clinic for care. Level of Evidence: Level III, retrospective review.