Results of a Qualitative Study to Understand Risk Factors for Amputation in Patients With Diabetes and/or Peripheral Arterial Disease in a Highly Rural State

Abstract

Amputation is a devastating but preventable complication of diabetes and peripheral arterial disease (PAD). It serves as a marker for severe disease as well as for disparities in quality of care. The majority of studies on this issue use quantitative methods, which are useful for identifying prevalence rates and patterns of disease, but have difficulty providing deeper explanations about why certain groups have higher risks for amputation than others. Qualitative methods are ideal for providing rich, meaningful answers for such questions. The purpose of this study was to use a qualitative approach to understand barriers to limb preservation in patients with diabetes and/or PAD in the highly rural state of West Virginia. Participant recruitment was directed by preliminary research identifying high-risk areas for amputation across the state. Focus groups and interviews were conducted by a moderator using a semistructured interview guide focused on barriers to limb preservation. Four groups were interviewed: diabetic and/or PAD patients who have undergone amputation (and their caretakers), vascular providers and surgeons, wound care providers, and primary care providers. Audio recordings of each session were transcribed verbatim and data were analyzed by two coders using NVivo software. Conventional content analysis was carried out to develop a codebook and analyze data for themes related to patient and provider barriers. Eight focus groups, three phone interviews, and three in-person interviews (n = 64) were conducted. Lack of education was the most frequently cited barrier by both patients and providers across all sessions. Geographic isolation, lack of transportation, and cultural norms also emerged as barriers to limb preservation. There was also consensus that health care costs, access to care, and care coordination were major obstacles patients faced when attempting to manage their conditions. Providers emphasized that patient adherence to care plans was a significant barrier to limb preservation. In addition to these barriers, three main risk factors related to patient care emerged: depression, diabetes, and tobacco use. This qualitative study identified important themes contributing to the risk of amputation in West Virginia from the perspective of patients and providers. These include (1) lack of education, (2) geographic and cultural barriers, (3) difficulty with care coordination, (4) poor patient adherence and (5) depression, diabetes and tobacco use. Based on these themes, amputation prevention efforts in West Virginia should be directed toward improving patient education, improving access to care, improving social and mental health support systems, and providing culturally sensitive approaches to patient care.