Transcript Slide 1

PREDICTORS OF DIABETIC WOUND HEALING BY RACIAL/ETHNIC CATEGORIES
Ranjita Misra1, Lynn Lambert2, David Vera3, Ashley Mangaraj3, Suchin R Khanna3, Chandan K Sen3
1Department
of Health & Kinesiology, Texas A&M University; 2National Healing Corporation (NHC), Boca Raton, Florida;
3The 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 HbA1c ≥ 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.
Data 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.
Introduction
Wound healing rates are not homogenous in the population.
There is paucity of information on healing outcomes by racial/ethnic
subgroups.
Chronic wounds, produced by trauma or pathologic insult do not heal with
conventional treatment and often require aggressive wound care.
Chronic lower extremity wounds are common among individuals with
diabetes and lead to amputations.
Blacks and Hispanics are disproportionately burdened by treatment
failures of diabetes and its complications such as diabetic foot ulcers.
Non-healing wounds and amputations represent a major health burden
contributing to increased disability, mortality, and reduced quality of life.
Multiple factors contribute to impaired wound healing such as infections,
advanced age, malnutrition, diabetes, ill fitting shoes, poor management and
other disease complications.
Methods: Data collection and entry
Six 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.
Completed data collection forms were de-identified and data coded and entered
into an SPSS database (SPSS Inc., Chicago, IL).
Measures
Patient 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.
Diabetes - This was defined by self reported diabetes status among patients.
Wound Healing- This was evaluated with actual healing rates at 4,8, 12 and 16
weeks of wound management at the chronic wound center.
Expected 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.
Ulcer related amputations – This was measured as patients who underwent
amputations during their treatment periods.
Clinical measures – These included wound age, debridement level, size of the
wound, etiology, stage/grade, medications, blood glucose values, and HA1c levels.
 Mean age = 55.2 ± 17 years; mean number of wounds = 1.9± 1.4.
37% of the patients had diabetes and 30% had infected wounds (defined by
history of antibiotic use).
More than half of the population were females ( 53%) and 69% were obese/
overweight.
61% of the patients’ wounds healed during the treatment period.
Individuals 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
 This retrospective study examined differences in healing outcomes
among patients treated at a Chronic Wound Center.
Methods: sample
The 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
Patient factors such as lifestyle behaviors and compliance can delay
successful wound healing.
 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
 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.
 Laboratory results (not shown in the results) indicated higher blood glucose
and A1c 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.
 Infection and C-reactive protein was higher among Whites than African
Americans indicating higher inflammation and need for patient education.
Individuals 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 HbA1c ≥ 7.0.
 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).
 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).
 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