Socioeconomic Distressed Communities Index Associated with Higher Burden of Amputation in Diabetic Peripheral Arterial Disease

Category: Diabetes; Other Introduction/Purpose: The prevalence of diabetes and one of its complications, peripheral arterial disease (PAD), is increasing. Diabetic PAD is known to lead to high rates of lower extremity amputations. Diabetes disproportionately affects people of low socioeconomic status. The Distressed Community Index (DCI) is a proxy social risk factor, calculated at the zip code level as a function of seven metrics of community economic well-being: no high school diploma, housing vacancy rate, unemployment rate, poverty rate, median income ratio, change in employment, and change in establishments. Higher DCI has been linked to longer operative times, longer hospital length of stay, and increased incidence of postoperative complications. This analysis sought to analyze the impact of a socioeconomic risk factor, DCI, on amputation rate in patients with diabetic PAD. Methods: Data from a regional hospital abstract reporting system was obtained from the State Department of Health. It was sorted to include patient records with a diagnosis of peripheral arterial disease (ICD-10-CM diagnostic codes). Data was further stratified by diagnosis of diabetic PAD and DCI score. DCI scores were obtained from the Economic Innovation Group. Procedure codes were used to identify amputations starting with ‘detachment at [R/L] foot, complete, open approach’ and including all progressively distal amputations (ICD-10-PCS codes). Statistical analysis was performed using XLSTAT, significance was assigned at alpha of 0.05. Results: From 2016 to 2018, there were 33664 patients requiring inpatient treatment with a diagnosis of PAD. 13261 patients (39.4%) had diabetic PAD, 3078 patients (9.1%) originated from a zip code with a DCI score greater than or equal to 75 (top quartile) and 1394 patients (4.1%) had diabetic PAD and DCI greater than 75. While patients with diabetic PAD and a DCI less than 75 had approximately the same rate of amputations as all patients with diabetic PAD (15.3% and 15.7%, respectively), patients with diabetic PAD and a DCI greater than 75 were 1.30 times more likely (p=0.0003) to require amputation than all patients with diabetic PAD (19.1% and 15.7% overall amputation rates, respectively). The relationship with DCI was not significant in non- diabetic PAD patients. Conclusion: Approximately one in five patients presenting for inpatient treatment with a diagnosis of diabetic PAD originating from a zip code with a DCI score greater than or equal to 75 required a lower extremity amputation. Though diabetes by itself was a stronger risk factor for amputation (OR 8.24, p<0.0001) than DCI in the comprehensive PAD patient population, a patient with a high DCI score in the diabetic PAD population was significantly more likely to require amputation. DCI is a proxy social risk factor providers can use to preemptively identify patients at increased risk of lower extremity amputation secondary to PAD. [Table: see text]

Abstract P552: The Role of Traditional Risk Factors in Mediating the Influence of Cumulative Social Risk Exposure on Cardiovascular Death

Introduction: Cumulative social risk exposure, defined as experiencing more than one social risk factor and captured through an index of cumulative social risk, is associated with a significant increase in cardiovascular disease (CVD) mortality. However, the role of CVD risk factors in explaining this association is unclear. Methods: This analysis included 15,906 participants (45.6±19.5 years, 53.4% women, 57.7% minority race) from the Third National Health and Nutrition Examination Survey (NHANES-III) who were CVD-free at enrollment. Baseline social risk factors (minority race, poverty-income ratio<1, education<12 grade, and living single) were used to create a cumulative social risk score (0 to ≥3). The mediation by each CVD risk factor was assessed by estimating the magnitude of attenuation in the hazard ratio for the association between social risk score and CVD death adjusted by demographics and risk factors. Results: During a median follow up of 14 years, 1,309 CVD deaths occurred. Participants with more than one social risk factor were at increased risk of CVD death (Table) . The risk of CVD death in demographic adjusted models was attenuated by 31%, 21% and 36% in people with social risk score 1, 2, and ≥3 versus 0, respectively, after further adjustment for traditional CVD risk factors. Among all CVD risk factors included in the analysis, current smoking was the most powerful mediating effect, accounting for approximately one half of the combined risk factor effect, followed by obesity and diabetes ( Table ). Conclusions: Traditional CVD risk factors explain about one third of the association between cumulative social risk exposure and CVD death. While these findings underscore the importance of management of traditional CVD risk factors, particularly smoking, in socially disadvantaged population, they call for further studies to identify other pathways that explain the link between social risk exposure and CVD.

Twenty years and counting: epidemiology of an outbreak of isoniazid-resistant tuberculosis in England and Wales, 1995 to 2014

An outbreak of isoniazid-resistant tuberculosis first identified in London has now been ongoing for 20 years, making it the largest drug-resistant outbreak of tuberculosis documented to date worldwide. We identified culture-confirmed cases with indistinguishable molecular strain types and extracted demographic, clinical, microbiological and social risk factor data from surveillance systems. We summarised changes over time and used kernel-density estimation and k-function analysis to assess geographic clustering. From 1995 to 2014, 508 cases were reported, with a declining trend in recent years. Overall, 70% were male (n = 360), 60% born in the United Kingdom (n = 306), 39% white (n = 199), and 26% black Caribbean (n = 134). Median age increased from 25 years in the first 5 years to 42 in the last 5. Approximately two thirds of cases reported social risk factors: 45% drug use (n = 227), 37% prison link (n = 189), 25% homelessness (n = 125) and 13% alcohol dependence (n = 64). Treatment was completed at 12 months by 52% of cases (n = 206), and was significantly lower for those with social risk factors (p < 0.05), but increased over time for all patients (p < 0.05). The outbreak remained focused in north London throughout. Control of this outbreak requires continued efforts to prevent and treat further active cases through targeted screening and enhanced case management.