PREDICTORS OF DIABETIC WOUND HEALING BY RACIALETHNIC CATEGORIES

PREDICTORS OF DIABETIC WOUND HEALING BY RACIAL/ETHNIC CATEGORIES Ranjita Misra 1, Lynn Lambert 2, David Vera 3, Ashley Mangaraj 3, Suchin R Khanna 3, Chandan K Sen 3 1 Department of Health & Kinesiology, Texas A&M University; 2 National Healing Corporation (NHC), Boca Raton, Florida; 3 The Ohio State University Comprehensive Wound Center, Columbus OH Abstract Methods: study site Purpose: Wound healing rates are not homogenous in the population and there is a paucity of information on healing outcomes by racial/ethnic subgroups. Hence, this retrospective study examined differences in healing outcomes among 1003 patients (53% females, 37% diabetics) from three major racial/ethnic groups i. e. , Non Hispanic White (NHW; 72%), African American (14%) and other (14%; Asian/Hispanic/Am Indian, Biracial). 1003 patients were treated for acute, acute traumatic or chronic wounds at a hospital-affiliated Comprehensive Wound Center that provide advanced outpatient care for 16 weeks. Wound healing was evaluated for the treatment period. All wound patients were evaluated for healing at 4, 8, 12, and 16 weeks with expected rate of healing set by the care team at a rate of 25%, 50%, 75%, and 100% at the end of 4, 8, 12, and 16 week treatment period. Every four weeks, a complete progress report is filled out on the patient and the wound care physician along with his/her case manager review the progress of the patient and assess the cause of why they have not reached the targeted progress rate. Results: The mean age and number of wounds was 55. 2± 17 years and 1. 9± 1. 4 wounds respectively. Individuals with diabetes were more likely to be overweight/obese, used tobacco, and have ulcer related amputations as compared to their non-diabetic peers; 53% had Hb. A 1 c ≥ 7. 0. 61% of patients’ wounds healed during the treatment period (56% Males, 66% females, 59% White, 61% African Americans, 55% other race, 55% diabetics, 60% non-diabetics). Ulcer-related amputation was as follows: 10% diabetics, 3% non-diabetics, 7% males, 4% females, 5. 6% White, 5. 7% African American, 5. 3% Other Race category). A differential healing pattern was noted by racial/ethnic category, gender, and diabetes status. African Americans and White females, and male African American diabetics had delayed healing as compared to others. Conclusion: Results provide important information for evidence based wound care interventions and developing culturally appropriate education strategies among high risk groups. ØData were abstracted from patient charts for the period of 2006 and 2009 from one hospital-affiliated and research-based care at Ohio State University’s Comprehensive Wound Center (CWC) in Columbus Ohio. The CWC provides advanced care to approximately 1200 patients every month with chronic, nonhealing wounds. Methods: Data collection and entry Introduction ØWound healing rates are not homogenous in the population. ØThere is paucity of information on healing outcomes by racial/ethnic subgroups. ØChronic wounds, produced by trauma or pathologic insult do not heal with conventional treatment and often require aggressive wound care. ØChronic lower extremity wounds are common among individuals with diabetes and lead to amputations. ØBlacks and Hispanics are disproportionately burdened by treatment failures of diabetes and its complications such as diabetic foot ulcers. ØNon-healing wounds and amputations represent a major health burden contributing to increased disability, mortality, and reduced quality of life. ØMultiple factors contribute to impaired wound healing such as infections, advanced age, malnutrition, diabetes, ill fitting shoes, poor management and other disease complications. ØSix trained research assistants abstracted the data using standardized forms developed for the project. The data collected included patient demographics, patient education, functional status, clinical history, co-morbid disease states, laboratory test results, wound factors, and drug therapy pertinent to wound care. ØCompleted data collection forms were de-identified and data coded and entered into an SPSS database (SPSS Inc. , Chicago, IL). Measures ØPatient Demographics – These included patient’s age, gender, race/ethnicity, type of insurance, educational level, medical history, health risk behaviors, and perception of current health status. ØDiabetes - This was defined by self reported diabetes status among patients. ØWound Healing- This was evaluated with actual healing rates at 4, 8, 12 and 16 weeks of wound management at the chronic wound center. ØExpected rates of healing by the care team is 25%, 50%, 75% and 100% at the end of 4, 8, 12 and 16 weeks respectively. Every four weeks the wound care physician along with his/her case manager reviews the progress of the patient and assess the cause of why they have not reached the targeted progress rate. ØUlcer related amputations – This was measured as patients who underwent amputations during their treatment periods. ØClinical measures – These included wound age, debridement level, size of the wound, etiology, stage/grade, medications, blood glucose values, and HA 1 c levels. Ø Mean age = 55. 2 ± 17 years; mean number of wounds = 1. 9± 1. 4. Ø 37% of the patients had diabetes and 30% had infected wounds (defined by history of antibiotic use). ØMore than half of the population were females ( 53%) and 69% were obese/ overweight. Ø 61% of the patients’ wounds healed during the treatment period. ØIndividuals with diabetes were more likely to be overweight/obese, use tobacco and have ulcers related amputations as compared to their non-diabetic peers. Figure 1: Differences in healing rates during the treatment period (%) Purpose Ø This retrospective study examined differences in healing outcomes among patients treated at a Chronic Wound Center. Methods: sample ØThe sample comprised of 1003 patients (72 % whites, 53% females) treated for acute, acute traumatic or chronic wounds at a hospital-affiliated Comprehensive Wound Center. Variable Number Percent Gender Male Female 468 535 46. 7 53. 3 57 426 407 6. 4 47. 9 45. 7 385 438 136 14 27 38. 5 43. 8 13. 6 1. 4 2. 7 603 357 62. 8 37. 2 730 270 73. 0 27. 0 Educational Background Grade school High school College Health Insurance Private Medicare Medicaid Supplemental Self pay Diabetes Yes No Age ≤ 65 years >65 years Figure 3: Pattern of Wound Healing by Race/Ethnicity, Gender and Diabetes Status Results ØPatient factors such as lifestyle behaviors and compliance can delay successful wound healing. Ø We examined clinical (wound characteristics and treatment) and nonclinical determinants (lifestyle, psychosocial, barriers to care, knowledge of the disease and compliance) to explain disparities in healing outcomes by racial/ethnic categories. Table 1: Demographics Characteristics of Patients Figure 2: Ulcer- related amputations (%) Discussion and Conclusion Ø Results of this study showed African Americans had higher rate of diabetes, lower healing and higher amputation rates as compared to Whites and other racial/ethnic groups. Ø Laboratory results (not shown in the results) indicated higher blood glucose and A 1 c levels among African Americans (especially males). Hence patient education for this group should focus on assessing perceptions and barriers, and better management of their diabetes for successful wound healing. Ø Infection and C-reactive protein was higher among Whites than African Americans indicating higher inflammation and need for patient education. ØIndividuals with diabetes were more likely to be overweight/obese, used tobacco, and had ulcer related amputations as compared to their non-diabetic peers; 53% had Hb. A 1 c ≥ 7. 0. Ø 61% of patients’ wounds healed during the treatment period (56% Males, 66% females, 59% White, 51% African Americans, 55% other race, 55% diabetics, 60% non-diabetics). Ø Ulcer-related amputation was significantly higher among diabetics (10%) and males (7%). No significant differences by racial/ethnic category (5. 6% White, 5. 7% African American, 5. 3% Other Race category). Ø Differential healing pattern was noted by racial/ethnic category, gender, and diabetes status. Conclusion: Results provide important information for evidence based wound care interventions and developing culturally appropriate education strategies among high risk groups. Funded by the Ohio State University and National Healing Corporation