Outpatient clinic attendance and lower extremity amputation risk among patients hospitalized with diabetic foot ulcers in a large, public hospital in Atlanta, Georgia Restricted; Files Only

Abstract

Background: Diabetes-related amputations are typically precipitated by a diabetic foot ulcer (DFU). Progression from ulceration to amputation can be halted by appropriate medical and surgical care.

 

Objective: Our study aims to identify which populations would benefit from interventions to increase access to outpatient limb salvage care.

 

Methods: We conducted a retrospective cohort study of patients hospitalized with a DFU from 2016-2019 at Grady Memorial Hospital in Atlanta, Georgia. Among patients hospitalized with a DFU, we measured 30-day post-discharge outpatient clinic attendance with limb salvage providers and identified predictors of attendance with these providers. We also investigated the association between 30-day post-discharge clinic attendance and 12-month amputation incidence. Log-binomial regression was used to estimate risk ratios and 95% confidence intervals (CI).

 

Results: Among 911 patients included in the study, the mean age was 57 years, 69% were male, 80% were Black, and 68% were insured by Medicaid or Medicare. More than half (54%) of eligible patients attended ≥ 1 appointment with limb salvage providers within 30 days post-discharge. Predictors of 30-day post-discharge clinic attendance included age < 56 years (RR 0.88, 95% CI 0.80 – 0.96), being uninsured (RR 1.16, 95% CI 1.05 – 1.28), no history of homelessness (RR 0.85, 95% CI 0.74 – 0.97), and attending ≥ 1 appointment with limb salvage providers 30 days prior to initial hospitalization with DFU (RR 1.17, 95% CI 1.06 – 1.29). Among 375 patients included in the 12-month outcome analyses, the risk of any amputation or all-cause mortality was 22% (n=84). The 12-month adjusted risk of major amputation among patients who attended both medical and surgical post-discharge clinics was 0.49 times (95% CI 0.20 – 1.19) the risk of patients with no attendance.

 

Conclusion: More than one in five patients experienced amputation or mortality within 12 months of discharge. We observed a non-significant trend between 30-day post-discharge clinic attendance and 12-month incidence of amputation. Interventions to increase access to outpatient care and prevent diabetes-related amputations could prevent amputations.

Table of Contents

INTRODUCTION 1

METHODS 2

     Study setting and design 2

     Participant eligibility criteria 2

     Study definitions 3

     Outpatient clinic attendance definition 5

     12-month outcomes definitions 5

     Statistical analyses 5

RESULTS 6

     Study population and baseline characteristics 6

     Predictors of 30-day post-discharge attendance 7

     12-month outcomes 8

     Adjusted association between30-day post-discharge attendance and 12-month outcomes 9

DISCUSSION 9

CONCLUSIONS 12

REFERENCES 13

FIGURE AND TABLES 16

SUPPLEMENTAL MATERIAL 23

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	M.P.H.
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Keyword	Lower extremity amputation Outpatient clinic attendance Diabetes
Committee Chair / Thesis Advisor	Matthew Magee, Emory University
Committee Members	Marcos Coutinho Schechter, Emory University

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