Diabetic people in low-income neighborhoods in California were up to 10 times more likely to lose a leg or a foot than diabetic patients in wealthier ZIP Codes, UCLA researchers have reported.
Their analysis, published online Monday by the journal Health Affairs, pinpointed amputation "hot spots" where as many as 10.7 out of 1,000 diabetic adults ages 45 and older wound up losing a lower limb because of complications of diabetes.
San Fernando, Compton and broad swaths of South and East L.A. had some of the highest amputation rates. In ZIP Codes with the lowest amputation rates -- including many affluent areas such as Malibu, Beverly Hills and Santa Clarita -- no more than 1.5 diabetics per 1,000 lost a limb to the disease.
On the Palos Verdes Peninsula, adjacent ZIP Codes landed on opposite ends of the scale, with South Bay cities having among the lowest levels of amputations among diabetics and San Pedro having among the highest.
"This represents an intolerable health disparity," said study lead author Carl Stevens, a professor of medicine at UCLA‘s David Geffen School of Medicine. "Where the poor people are is where the amputations are."
Stevens said that the higher incidence of amputations among diabetics in lower-income ZIP Codes was almost certainly related to two factors: difficulties patients in those neighborhoods had in getting access to primary care, and hurdles they faced in understanding how to manage their condition.
Amputations due to diabetes are preventable, he said, through careful control of blood sugar and lipid levels and other health risks. But when diabetes goes unchecked over the course of many years, it can set off a cascade of complications. Blood vessels suffer damage, impairing circulation to the feet. Damaged nerves can make it hard for diabetic patients to realize when they‘ve suffered an injury or a cut and treat it properly. Reduced immunity can then lead to limb-threatening infections.
To conduct their analysis, the team examined patient discharge records compiled by the California Office of Statewide Health Planning and Development, identifying the number of "non traumatic" amputations in diabetic patients for each ZIP Code. The researchers then used census data to identify income levels and UCLA‘s California Health Interview Survey to estimate diabetes incidence for each ZIP Code.
In all, the researchers identified nearly 8,000 diabetes-related amputations in 6,828 people. In Los Angeles, they reported, the amputation rate for people with diabetes in neighborhoods where more than 40% of households have incomes below 200% of poverty, or $31,460 for a household of two, was about twice that of neighborhoods in which fewer than 10% of households fell below that line.
"We have a safety net with big holes in it," Stevens said.
The outlook isn‘t entirely grim, he noted. Monday‘s study used patient data from 2009, before the rollout of the Affordable Care Act, which greatly increased the number of Californians covered through Medi-Cal, the state‘s healthcare program for the poor. Provided there are enough primary care doctors in the system, Stevens said, and with improvements in patient education, many low-income patients should have better access to primary care services than they have in the past.
"We‘re already making big strides in California," he said. "I suspect if we repeated this two years from now, we‘d see fewer disparities."
最近，加州大学洛杉矶分校的研究员们报告称，加州低收入地区的糖尿病患者所面临的截肢风险要高于高收入地区的10倍。
这份研究于周一发布于健康事务网站。研究表明，在“热点地区”，在45岁以上的糖尿病患者中，1000人中就有10.7人因糖尿病并发症而导致下肢截肢。
圣费尔南多，康普顿，南洛杉矶和东洛杉矶有着最高的截肢比率。而截肢率较低的地区多是富人小区，包括马里布，比弗利山庄和圣克拉里塔。在这些地区，1000糖尿病患者中截肢的不到1.5人。
而在帕洛斯弗德斯半岛上，相邻的两个区域有着截然不同的截肢比率。南湾城是截肢率最低的地区之一，而圣佩德罗则有着全加州最高的截肢率。
该研究第一作者，UCLA大卫格芬医学院医学教授Carl Stevens说，“这份结果显示了严重的贫富差距。越是贫穷的地区，截肢率越高。”
Stevens说，导致低收入地区拥有高截肢率的因素主要有两点：一是这些社区的患者难以获得基本的医疗护理，二来这里的人们并不是太明白要如何治疗。
他还说，糖尿病引起的截肢可以通过控制血糖和血脂水平来预防。如果常年不进行检查，那它可能会引发一系列并发症。血管破损，破坏脚部的血液循环。而神经受损会让患者感受不到病痛，延误治疗。免疫力退化则更容易感染，增加截肢风险。
为了进行研究分析，团队检查了加州全州卫生规划和发展办公室提供的病人病历记录，甄别出各个地区因糖尿病导致截肢的患者。然后通过人口普查数据查找各地区的平均收入水平，和健康采访调查估算各区糖尿病的发病率。
最终，研究团队鉴别出了6828名患者，近8000例糖尿病截肢病例(这是有人不止一次截肢啊)。报告称，在洛杉矶，40%居民处于200%贫困线以下，或是家庭收入低于$31460的 贫困社区的糖尿病患者截肢率 是 仅有10%居民处于贫困线以下的 社区的两倍。
“这是我们国家的安全网上的一个巨大空洞”，Stevens说。
不过他补充说，也许并没有这么糟糕。这份研究所使用的病患数据来自于2009年，那时还没有推行平价医保法案。该法案极大增大了加州医疗补助计划的受众范围。他还说，鉴于现在医疗系统中有足够多的护理医师，和患者的教育程度提升，许多低收入患者有着比以往更多的机会得到相应的医疗护理。
"我们在加利福尼亚大步前进"，他说，"如果我们继续这样努力两年，我估计情况会好很多"。
