Residential Address Amplifies Health Disparities and Risk of Infection in Individuals with Diabetic Foot Ulcers

Objective: To determine the association between social determinants of health (SDOH) and a diagnosis of diabetic foot ulcer (DFU) infection. Research Design and Methods: Targeted interrogation of electronic health record data using novel search engines to analyze individuals with a DFU infection during a five-year period (2013-2017). We extracted geolocated neighborhood data and SDOH characteristics from the National Neighborhood Data Archive and used univariate and multiple logistic regression to evaluate associations with outcomes in the diabetes population. Results: Among 4.3 million individuals overall and 144,564 persons with diabetes seen between 2013-2017, 8351 developed DFU, of which 2252 were complicated by a DFU infection. Sex interactions occurred as men who experienced a DFU infection more frequently identified as having non-married status than their female counterparts. Other SDOH occurred at higher rates in the DFU infection population and included greater neighborhood disadvantaged index score, increased poverty, increased rates of non-marriage, decreased access to physician/allied health professionals (all p<0.01). In multiple logistic regression, those persons who developed DFU infection came from neighborhoods with greater Hispanic and/or foreign-born concentrations (OR 1.11, p=0.015). Conclusion: We found significant differences in neighborhood characteristics driving a higher risk for DFU infection compared with persons with diabetes overall, including increased risk for individuals with Hispanic and/or foreign-born immigration status. These data strongly support the need to incorporate SDOH, particularly ethnic and immigration status into triage algorithms for DFU risk stratification to prevent severe diabetic foot complications and move beyond biologic-only determinants of health.