Abstract
BackgroundRural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts. We sought to identify health system barriers contributing to this disparity.MethodsWe interviewed 44 participants involved in the care of rural patients with DFUs: 6 rural primary care providers (PCPs), 12 rural specialists, 12 urban specialists, 9 support staff, and 5 patients/caregivers. Directed content analysis was performed guided by a conceptual model describing how PCPs and specialists collaborate to care for shared patients.ResultsRural PCPs reported lack of training in wound care and quickly referred patients with DFUs to local podiatrists or wound care providers. Timely referrals to, and subsequent collaborations with, rural specialists were facilitated by professional connections. However, these connections often were lacking between rural providers and urban specialists, whose skills were needed to optimally treat patients with high acuity ulcers. Urban referrals, particularly to vascular surgery or infectious disease, were stymied by 1) time-consuming processes, 2) negative provider interactions, and 3) multiple, disconnected electronic health record systems. Such barriers ultimately detracted from rural PCPs’ ability to focus on medical management, as well as urban specialists’ ability to appropriately triage referrals due to lacking information. Subsequent collaboration between providers also suffered as a result.ConclusionsPoor connections across rural and urban healthcare systems was described as the primary health system barrier driving the rural disparity in major amputations. Future interventions focusing on mitigating this barrier could reduce the rural disparity in major amputations.
Highlights
Rural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts
We chose to focus on health system factors because 1) they are modifiable, 2) they may be generalized to other rural disparities, and 3) recent advances in urban health systems have reduced the risk of major amputations by ~ 40% [14]
All six Primary care provider (PCP) practiced in a rural setting spanning five unique health systems (Group 1)
Summary
Rural Americans with diabetic foot ulcers (DFUs) face a 50% increased risk of major amputation compared to their urban counterparts. Specific to DFUs, rural patients face 50% higher odds of major (above-ankle) amputation and 40% higher odds of death compared to their urban counterparts [9, 10]. Many urban health systems have initiated teams to provide multidisciplinary care that addresses four physiologic factors in a timely and coordinated manner: glycemic control, local wound management, vascular disease, and infection. These teams are composed of specialists working side-by-side within a single health system. Rural providers are unlikely to benefit from this model of multidisciplinary care due to the rarity of specialists and need to collaborate across multiple health systems
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