Understanding Diabetes and Peripheral Artery Disease-Related Amputation Disparities in North Carolina

Amputation is a devastating but preventable complication of diabetes (DM) and peripheral artery disease (PAD); it serves as a marker for severe cardiovascular disease and for gaps in quality of care. Although amputation risk is highest in communities with higher levels of traditional risk factors, such as DM, PAD, cardiovascular disease, and tobacco use, it is also disproportionately higher in communities impacted by high economic hardship and chronic external stressors. Disparities in amputation rates, thus, serve as a marker for issues related to health care access, quality of health care, and nonmedical factors, such as food security, transportation, and housing stability. There is a critical gap in research on effective amputation prevention interventions in communities experiencing amputation disparities. Through my K23 project we found that a community-engaged, implementation science-driven intervention to decrease DM/PAD limb complications in rural West Virginia (WV) was both feasible and acceptable. The preliminary work for the K23 required high granularity geographic analysis of the state of WV to identify amputation “hot spots” to focus our study. This was coupled with focus groups in a sequential explanatory mixed methods approach to gain a better understanding of the risk factors specific to people with amputation in the state. This preliminary data was essential to gaining community support and partnerships for the K23. The objective of this R03 project is to take the first steps to expand the WV project to a larger scale in North Carolina (NC), a state with a much larger population that is also impacted by high rates of amputation and rural and urban health disparities. To achieve this objective, we will perform a mixed methods study in NC to identify geographic “hot spots” for amputation across the state and determine pertinent risk factors for people with amputations. The Aims of this project are to: 1) Determine contemporary rates and risk factors for DM/PAD-related amputations in NC and identify geographic areas with disproportionately higher rates of amputation. This will be performed using the state inpatient HCUP dataset through descriptive and inferential statistics and advanced Bayesian spatial analyses; 2) Identify the barriers faced by patients and their providers that lead to amputation. Informed by geospatial findings, we will use focus groups to gain an understanding of the contextual, cultural, systemic and environmental factors that increase or mitigate risk factors for amputations; 3) Translate and disseminate findings to communities disproportionately impacted by amputation. We will develop and implement a comprehensive translation and dissemination plan using community engagement best practices. Upon completion of the Aims of this R03, I will have the data to scale my K23 findings to a large quasi-experimental intervention effectiveness study and transition to independent funding, which will help me to achieve my long-term goal, which is to reduce amputation disparities through the implementation of feasible, acceptable and effective community-engaged interventions.