Volume 31, Issue 11 pp. 1410-1417

Research: Epidemiology

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation

L. Amin,

L. Amin

Department of Medicine, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

B. R. Shah,

B. R. Shah

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

A. S. Bierman,

A. S. Bierman

Department of Medicine, University of Toronto, Toronto, ON, Canada

Li KaShing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

L. L. Lipscombe,

L. L. Lipscombe

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

C. F. Wu,

C. F. Wu

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Search for more papers by this author

D. S. Feig,

D. S. Feig

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Division of Endocrinology and Metabolism, Mount Sinai Hospital, Toronto, ON, Canada

Search for more papers by this author

G. L. Booth,

Corresponding Author

G. L. Booth

Department of Medicine, University of Toronto, Toronto, ON, Canada

Li KaShing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Correspondence to: Gillian L. Booth. E-mail: [email protected]Search for more papers by this author

L. Amin,

L. Amin

Department of Medicine, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

B. R. Shah,

B. R. Shah

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Department of Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

A. S. Bierman,

A. S. Bierman

Department of Medicine, University of Toronto, Toronto, ON, Canada

Li KaShing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

L. L. Lipscombe,

L. L. Lipscombe

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Search for more papers by this author

C. F. Wu,

C. F. Wu

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Search for more papers by this author

D. S. Feig,

D. S. Feig

Department of Medicine, University of Toronto, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Division of Endocrinology and Metabolism, Mount Sinai Hospital, Toronto, ON, Canada

Search for more papers by this author

G. L. Booth,

Corresponding Author

G. L. Booth

Department of Medicine, University of Toronto, Toronto, ON, Canada

Li KaShing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

Correspondence to: Gillian L. Booth. E-mail: [email protected]Search for more papers by this author

First published: 23 May 2014

https://doi.org/10.1111/dme.12507

Citations: 49

Share a link

Email
Wechat
Bluesky

Abstract

Aims

To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system.

Methods

We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence.

Results

Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30–1.54; P < 0.0001 for all male gender–socio-economic status interactions) than women (hazard ratio 1.20, 95% CI 1.06–1.36). Overall, the incidence of lower extremity amputation was higher among men than women (hazard ratio for men vs women: 1.87, 95% CI 1.79–1.96), with the greatest disparity between men in the lowest socio-economic status category and women in the highest (hazard ratio 2.39, 95% CI 2.06–2.77 and hazard ratio 2.30, 95% CI 1.97–2.68, for major and minor amputation, respectively).

Conclusions

Despite universal access to hospital and physician care, we found marked socio-economic status and gender disparities in the risk of lower extremity amputation among patients with diabetes. Men living in low-income neighbourhoods were at greatest risk.

Supporting Information

References

1Lipscombe LL, Austin PC, Manuel DG, Shah BR, Hux JE, Booth GL. Income-related differences in mortality among people with diabetes mellitus. CMAJ 2010; 182: E1–E17.
10.1503/cmaj.090495
PubMed Web of Science® Google Scholar
2Booth GL, Bishara P, Lipscombe LL, Shah BR, Feig DS, Bhattacharyya O et al. Universal drug coverage and socioeconomic disparities in major diabetes outcomes. Diabetes Care 2012; 35: 2257–2264.
10.2337/dc12-0364
PubMed Web of Science® Google Scholar
3Mackenbach JP, Stirbu I, Roskam AJ, Schaap MM, Menvielle G, Leinsalu M et al. European Union Working Group on Socioeconomic Inequalities in Health in 22 countries. N Engl J Med 2008; 358: 2468–2481.
10.1056/NEJMsa0707519
CAS PubMed Web of Science® Google Scholar
4Stringhini S, Dugravot A, Shipley M, Goldberg M, Zins M, Kivimäki M et al. Health behaviours, socioeconomic status, and mortality: further analyses of the British Whitehall II and the French GAZEL prospective cohorts. PLoS Med 2011; 8: e1000419.
10.1371/journal.pmed.1000419
PubMed Web of Science® Google Scholar
5Wilkins R, Berthelot JM, Ng E. Trends in mortality by neighbourhood income in urban Canada from 1971 to 1996. Health Rep (Statistics Canada Cat no. 82–003) 2002; 13(Suppl): 1–27.
Google Scholar
6Booth GL, Hux J. Relationship between avoidable hospitalizations for diabetes mellitus and income level. Arch Intern Med 2003; 163: 101–106.
10.1001/archinte.163.1.101
PubMed Web of Science® Google Scholar
7Johnson PJ, Ghildayal N, Ward AC, Westgard BC, Boland LL, Hokanson JS. Disparities in potentially avoidable emergency department (ED) care: ED visits for ambulatory care sensitive conditions. Med Care 2012; 50: 1020–1028.
10.1097/MLR.0b013e318270bad4
PubMed Web of Science® Google Scholar
8Jaakkimainen L, Upshur R, Klein-Geltink JE, Leong A, Maaten S, Schultz S et al. Primary Care in Ontario.Toronto: Institute for Clinical Evaluative Sciences, 2006. Available at: http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=3655&type=atlas. Last accessed 7 July 2013.
Google Scholar
9Oladele CR, Barnett E. Racial/Ethnic and social class differences in preventive care practices among persons with diabetes. BMC Public Health 2006; 6: 1–8.
10.1186/1471-2458-6-259
PubMed Web of Science® Google Scholar
10Altenburg N, Joraschky P, Barthel A, Bittner A, Pöhlmann K, Rietzsch H et al. Alcohol consumption and other psycho-social conditions as important factors in the development of diabetic foot ulcers. Diabet Med 2011; 28: 168–174.
10.1111/j.1464-5491.2010.03151.x
CAS PubMed Web of Science® Google Scholar
11Baker DW, Wolf MS, Feinglass J, Thompson JA, Gazmararian JA, Huang J. Health literacy and mortality among elderly persons. Arch Intern Med 2007; 167: 1503–1509.
10.1001/archinte.167.14.1503
PubMed Web of Science® Google Scholar
12Pinkhasov RM, Wong J, Kashanian J, Lee M, Samadi DB, Pinkhasov MM et al. Are men shortchanged on health? Perspective on health care utilization and health risk behavior in men and women in the United States. Int J Clin Pract 2010; 64: 475–487.
10.1111/j.1742-1241.2009.02290.x
CAS PubMed Web of Science® Google Scholar
13Bierman AS (ed). Toronto: St. Michael's Hospital and the Institute for Clinical Evaluative Sciences, 2010. Available at: http://www.powerstudy.ca/the-power-report/the-powerreport-volume-2/diabetes. Last accessed 5 May 2013.
Google Scholar
14 Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the prevention and management of diabetes in Canada. Can J Diab 2013; 37(Suppl. 1): S1–S12.
10.1016/j.jcjd.2013.01.009
PubMed Web of Science® Google Scholar
15Eslami MH, Zayaruzny M, Fitzgerald GA. The adverse effects of race, insurance status, and low income on the rate of amputation in patients presenting with lower extremity ischemia. J Vasc Surg 2007; 45: 55–59.
10.1016/j.jvs.2006.09.044
PubMed Web of Science® Google Scholar
16Giacovelli JK, Egorova N, Nowygrod R, Gelijns A, Kent KC, Morrissey NJ. Insurance status predicts access to care and outcomes of vascular disease. J Vasc Surg 2008; 48: 905–911.
10.1016/j.jvs.2008.05.010
PubMed Web of Science® Google Scholar
17Feinglass J, Abadin S, Thompson J, Pearce WH. A census-based analysis of racial disparities in lower extremity amputation rates in northern Illinois, 1987–2004. J Vasc Surg 2008; 47: 1001–1007.
10.1016/j.jvs.2007.11.072
PubMed Web of Science® Google Scholar
18Rucker-Whitaker C, Feinglass J, Pearce WH. Explaining racial variation in lower extremity amputation: A 5-year retrospective claims data and medical record review at an urban teaching hospital. Arch Surg 2003; 138: 1347–1351.
10.1001/archsurg.138.12.1347
PubMed Web of Science® Google Scholar
19Young BA, Maynard C, Reiber G, Boyko EJ. Effects of ethnicity and nephropathy on lower-extremity amputation risk amongdiabetic veterans. Diabetes Care 2003; 26: 495–501.
10.2337/diacare.26.2.495
PubMed Web of Science® Google Scholar
20Holman N, Young RJ, Jeffcoate WJ. Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 2012; 55: 1919–1925.
10.1007/s00125-012-2468-6
CAS PubMed Web of Science® Google Scholar
21Leese GP, Feng Z, Leese RM, Dibben C, Emslie-Smith A. Impact of health-care accessibility and social deprivation on diabetes related foot disease. Diabet Med 2013; 30: 484–490.
10.1111/dme.12108
CAS PubMed Web of Science® Google Scholar
22Bergin SM, Brand CA, Colman PG, Campbell DA. The impact of socio-economic disadvantage on rates of hospital separations for diabetes-related foot disease in Victoria. Australia. J Foot Ankle Res 2011; 4: 17.
10.1186/1757-1146-4-17
PubMed Web of Science® Google Scholar
23Ferguson HJM, Nightingale P, Pathak R, Jayatunga AP. The Influence of Socio-economic Deprivation on Rates of Major Lower Limb Amputation Secondary to Peripheral Arterial Disease. Eur J Vasc Endovasc Surg 2010; 40: 76e80.
10.1016/j.ejvs.2010.03.008
CAS PubMed Web of Science® Google Scholar
24Hux HE, Ivis FF, Flintoft VF, Bica A. Diabetes in Ontario: Determination of prevalence and incidence using a validated administrative data algorithm. Diabetes Care 2002; 25: 512–516.
10.2337/diacare.25.3.512
PubMed Web of Science® Google Scholar
25Shah BR, Victor JC, Chiu M, Tu JV, Anand SS, Austin PC et al. Cardiovascular complications and mortality after diabetes diagnosis for South Asian and Chinese patients: a population-based cohort study. Diabetes Care 2013; 36: 2670–2676.
10.2337/dc12-2105
PubMed Web of Science® Google Scholar
26Glazier RH, Bajcar J, Kennie NR, Willson K. A systematic review of interventions to improve diabetes care in socially disadvantaged populations. Diabetes Care 2006; 29: 1675–1688.
10.2337/dc05-1942
PubMed Web of Science® Google Scholar
27Margolis DJ, Hoffstad O, Nafash J, Leonard CE, Freeman CP, Hennessy S et al. Location, location, location: Geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes. Diabetes Care 2011; 34: 2363–2367.
10.2337/dc11-0807
PubMed Web of Science® Google Scholar
28Booth GL, Polsky JY, Gozdyra P, Kiran T, Shah BR, Lipscombe LL et al. (eds). Regional Measures of Diabetes Burden. An ICES Mapbook. Toronto: Institute for Clinical Evaluative Sciences, 2012. Available at: http://www.ices.on.ca/webpage.cfm?site_id=1&org_id=68&morg_id=0&gsec_id=0&item_id=7448&type=report. Last accessed 16 September 2013.
Google Scholar
29Tunceli K. Bradley CJ, Nerenz D, Williams LK, Pladevall M, Elston Lafata J. The impact of diabetes on employment and work productivity. Diabetes Care 2005; 11: 2662–2667.
10.2337/diacare.28.11.2662
Web of Science® Google Scholar
30van Battum P, Schaper N, Prompers L, Apelqvist J, Jude E, Piaggesi A et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med 2011; 28: 199–205.
10.1111/j.1464-5491.2010.03192.x
PubMed Web of Science® Google Scholar
31Krieger N. Overcoming the absence of socioeconomic data in medical records: validation and application of a census-based methodology. Am J Public Health 1992; 82: 703–710.
10.2105/AJPH.82.5.703
CAS PubMed Web of Science® Google Scholar
32Glazier RH, Creatore MI, Agha MM, Steele LS. Inner City Toronto Time Trends Working Group. Socioeconomic misclassification in Ontario's Health Care Registry. Can J Public Health 2003; 94: 140–143.
10.1007/BF03404588
PubMed Web of Science® Google Scholar
33Shah SR, Booth GL, Lipscombe LL, Feig DS, Bhattacharyya O, Bierman AS. Inequities in medication utilization for seniors with diabetes receiving universal medication insurance in Ontario, Canada. J Eval Clin Pract 2013; 20: 176–193.
10.1111/jep.12104
PubMed Web of Science® Google Scholar

Citing Literature

Volume31, Issue11

November 2014

Pages 1410-1417

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation

Abstract

Aims

Methods

Results

Conclusions

Supporting Information

References

Citing Literature

References

Information

About Wiley Online Library

Help & Support

Opportunities

Connect with Wiley

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation

Abstract

Aims

Methods

Results

Conclusions

Supporting Information

References

Citing Literature

References

Related

Information