Abstract: Background: Diabetic foot disease (DFD) is one of the leading reasons why a person with diabetes is hospitalised. These complications are the result of significant patho-physiological changes from diabetes that includes peripheral neuropathy (foot numbness), peripheral arterial disease (poor circulation), and foot ulceration (foot sores) which are collectively known as diabetic foot disease. In some instances, DFD leads to diabetes-related lower extremity amputations (DRLEA) and death. Whilst clinical risk factors for DFD and DRLEA have been well researched, there is limited knowledge about non-clinical risk factors. Non-clinical risk factors in the form of wider social determinants of health and their effects on the distribution of DFD and DRLEA have not been extensively researched. From the perspective of Social Determinants of Health (SDoH), determinants such as socio-economic status, racial disparities and geographical remoteness are key factors in the disease process and mortality. Aim: The objective of this research was to investigate inequalities in DFD and DRLEA within a representative population of people hospitalised with DFD. The primary aim was to investigate the likelihood of acquiring a DRLEA based on socio-economic status, Aboriginal and Torres Strait Islander status and geographical remoteness. The secondary aim is to investigate the pattern of DFD hospitalisation and DRLEA by age, sex, socio-economic status, Aboriginal and Torres Strait Islander status and geographical remoteness. Method: This observational study obtained hospitalisation data for individuals who presented to a tertiary hospital and were diagnosed with a DFD-related complication in Queensland between 2005 and 2011. This study also captured individuals who were hospitalised and subsequently had a DRLEA procedure. The participant’s socio-demographic data included age, sex, Index of Relative Socio-economic Disadvantage score to assess area-level socio-economic status (SES), Access/Remoteness Index of Australia to measure geographical of remoteness (GR), and Aboriginal and Torres Strait Isl ander status. Univariate and bivariate statistics and logistic regression were undertaken to assess associations between DFD, DRLEA by age, sex, SES, GR and Aboriginal and Torres Strait Islander status. Results Between 2005 and 2011, 19,790 people in Queensland (65.9% male) were hospitalised for DFD. Compared with patients from socio-economically advantaged areas, those from more disadvantaged areas tended to be younger when admitted, were more likely to live in outer regional, remote, and very remote areas, and be of Aboriginal and Torres Strait Islander origin. Of those admitted for DFD, 22.4% (n=4,442) subsequently underwent a DRLEA. After simultaneously adjusting for all of the social variables, the odds of amputation were significantly higher for persons of Aboriginal and Torres Strait Islander status (OR 1.63, 95%CI 1.23-2.16) and significantly lower for those living in very remote areas (OR 0.70, 95%CI 0.53-0.94). There was no significant association between area-level socio-economic disadvantage and the odds of experiencing an amputation. Discussion: This study is unique as it examines the association between SES, GR and Aboriginal and Torres Strait Islander status independently and simultaneously in regards to DFD and DRLEA. Furthermore, it is the first time a study has investigated the pattern of DFD hospitalisation and subsequent DRLEA by age, sex, and SES, GR and Aboriginal and Torres Strait Islander status. This level of analysis has demonstrated gradients that have been reported in large population studies investigating other clinical outcomes and mortality. This study design has redressed certain selection biases found in other studies by acquiring a hospitalisation data set over a large population for seven years. The findings of this study demonstrate that, within the wider population, DFD and DRLEA are distributed unevenly across the SES spectrum, GR and Aboriginal and Torres Strait Islander status. Further research is required to understand what individual factors contributed to these findings. However, this study has demonstrated the need to plan and deliver targeted services to reduce hospitalisation for DFD and subsequent incidence of DRLEA.
Singh, Adrian, 2018, Socio-economic, geographic, and Aboriginal and Torres Strait Islander inequalities in diabetic foot disease and diabetes-related lower extremity amputations, Volume:Master of Applied Science, Thesis, viewed 19 May 2019, https://www.nintione.com.au/?p=13491.