Impact of Regional Differences and Neighborhood Socioeconomic Deprivation on the Outcomes of Patients with Lower Extremity Wounds Evaluated by a Limb-Preservation Service

Introduction Management of lower extremity (LE) wounds has evolved with the establishment of specialized limb preservation services. While clinical factors contribute to limb outcomes, socioeconomic status and community factors also influence the risk for limb loss. The Distressed Community Index (DCI) score is a validated index of social deprivation created to provide an objective measure of economic well-being in U.S communities. Few studies have examined the influence of geographic deprivation on outcomes in patients with LE wounds. We examined relationships between socioeconomic deprivation and outcomes of inpatients evaluated by a dedicated limb preservation service (FLEX). Methods Inpatients referred to FLEX over a 5-year period were included. Wound, Ischemia, foot Infection (WIfI) staging was collected. DCI scores were determined using 7 indices based on ZIP Code. Outcomes included any minor or major amputations, any endovascular or open LE revascularization, or wound care procedures. Disease etiology, demographic, and anthropometric data were collected. Associations between neighborhood deprivation and limb-specific outcomes were evaluated in models for the DCI and each of its components separately. Results 677 patients were included. Thirty-eight percent were female, with a mean age of 64 years. Sixty percent had WIfI stage 3 or 4 risk of amputation, and 43% had WIfI stage 3 or 4 risk of revascularization. Mean (SD) ABI and toe pressure were 0.96 (0.43) and 80 (57) mmhg. Thirty-five percent were non-white. Amputation was performed in 31% of patients while 17% underwent revascularization. The mean (SD) distress score was 64 (24). Mean DCI scores did not differ across WIfI scores. Likewise, overall DCI distress score was not related to any of the outcomes in univariable or multivariable LR models. In univariable LR models for amputation, higher poverty rate (odds ratio (OR) for SD increase 1.20, 95% confidence limits (CL) 1.02-1.42, P=0.025) was significantly associated with the outcome. In multivariable models, neither DCI distress score nor any of its components remained significantly associated with the outcome. Conclusions Despite known racial disparities in limb-specific outcomes, an aggregate measure of community level distress was not found to be related to outcomes. While poverty rate demonstrated a significant relationship with amputation in univariable analysis, this association was not found in multivariable models. Notably, non-white race emerged as a predictor of amputation, underscoring the importance of addressing racial disparities in LE outcomes. Further investigation of potential determinants of LE outcomes is needed, particularly the interaction of such factors with race.