Racial and Ethnic Differences and Disparities in Chronic Wounds ASP Workshop on Wound Repair and Healing in Older Adults Caroline E. Fife, MD Executive Director, U.S. Wound Registry Racial and Ethnic Disparities in Pressure Ulcers A A PU incidence 1.7 Xhigher than Whites in nursing homes (NH) Limited evidence that race is a factor in NH PU development Increased turning among White NH residents Early pressure damage harder to diagnose in dark skin Socioeconomic status is the more predominant factor. A A more likely to reside NH with fewer financial resources (>% with Medicaid White PU incidence increases when they reside in A A nursing homes Harms S, et al. Prevalence of Pressure Ulcers by Race and Ethnicity for Older Adults Admitted to Nursing Homes. J Gerontol Nurs. 2013 Nov 7:1-7.; Li Y,. Association of race and sites of care with pressure ulcers in high-risk nursing home residents. JAMA. 2011;306(2):179-86; Baumgarten M, Margolis D, van Doorn C, et al. Black/White differences in pressure ulcer incidence in nursing home residents. J Am Geriatr Soc. Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer Intellicure development: systematic review. Int J Nurs Stud. 2013;50(7):974-1003. 1
Diabetes Related Lower Extremity Amputation (LEA) by Race/Ethnicity vs. Whites in the USA (All ethnicities more susceptible to diabetes than non Hispanic Whites) African Americans: LEA 2X that of non Hispanic Whites Hispanics: LEA rate varies by origin, culture (~ 2 X) Native Americans: higher LEA than non Hispanic Whites Race and ethnicity not good predictors for LEA but rather: socioeconomic status culture racism and/or biology depending on patient/clinician wound care setting peripheral vascular disease differences, smoking rates Lavery LA, Van Houton WH, Ashry HR, Armstrong DG, Pugh JA. Diabetes-related lower-extremity amputations disproportionately affect Blacks and Mexican Americans. South Med J. 1999;92:593-9; Dillingham TR, Pezzin LE, MacKenzie EJ. Racial differences in the incidence of limb loss secondary to peripheral vascular disease: a population-based study. Arch Phys Med Rehab. 2002;83(9):1252-7; Lanting LC, Joung IM, Mackenbach JP, Lamberts SW, Bootsma AH. Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: Intellicure a review. Diabetes Care. 2005; 28:2280-8. Reasons for Higher Rates of LEA Among African Americans Less aggressive care for limb salvage: White patients receive revascularization prior to amputation A A patients amputated in a shorter time period from wound onset without revascularization. Possible reasons for A A faster amputation: less preventive care patient preference not put off inevitable amputation Racial influence on physicians decision making higher proportion A A smokers Holman KH, Henke PK, Dimick JB, Birkmeyer JD. Racial disparities in the use of revascularization before leg amputation in Medicare patients. J Vasc Surg. 2011;54(2):420-6.e1; Rowe VL, Weaver FA, Lane JS, Etzioni DA. Racial and ethnic differences in patterns of treatment for acute peripheral arterial disease in the United States, 1998-2006. J Vasc Surg. 2010;51(4 Suppl):215-6S; Regenboden SE, Gawande AA, Lipsitz SR, Greenberg CC, Jha AK. Do differences in hospital and surgeon quality explain racial disparities in lower-extremity vascular Intellicure amputations? Ann Surg. 2009;250(3):424-31. 2
Learning about Real World Patterns of Wound Care: The USWR ~100 Hospital Based Outpatient Wound Centers (CDRN) 32 states and Puerto Rico 2 year slice has ~ 100,000 patients (~ 1 million visits) Complete charge data, all products, procedures Can be stratified by patient severity using the Wound Healing Index Agree to share data in exchange for benchmarking Entire EHR is transmitted to host server, data is HIPAA deidentified and moved to separate server (USWR) Data use overseen by independent IRB Also provides physician quality reporting under PQRS VLUs by Race and Use of Advanced Therapeutics in Hospital Based Outpatient Wound Centers Race/Ethnicity % with any % with % VLUs AT* Bioskin Count Caucasian 6290 62.8 80.3 19.9 14.8 African American 1280 12.8 10.1 23.2 18.5 Hispanic 1316 13.1 6.4 26.6 17.7 Asian 93 0.9 0.9 29.1 22.3 Other 379 3.8 2.2 -- 13.5 Total 9358 93.4 100 * Advanced therapeutic = Bioengineered skin, hyperbaric oxygen therapy, negative pressure wound therapy 3
Age >80 VLUs, Use of Advanced Therapeutics and Healing (Overall: 47.5% healed) Race/Ethnicity Count % >80 VLUs >80 years % with any AT Healed % Caucasian 6290 15.2 30.7 23.1 48 African American 1280 10 17.9 29.4 46.6 Hispanic 1316 10.7 20.2 36.0 43.1 Asian 93 14 23.3 35.1 41.2 Other 379 10.6 22.5 34.1 44.9 Total 9358 93.4 100 35.0% of all patients get AT, 24.7% of >80 patients get AT Under 80 years healing rate = 47.8% (same as >80) Outcome non-whites always worse than Whites USWR: Affect of Insurance Type on Likelihood of Bioskin 5 outpatient wound centers in NY state. Protocol based approach to leg ulcer patients: Do The Right Thing (testing USWR quality measures for compression and vascular screening) Physicians employed by hospital system Not motivated to use Bioskin based on revenue Medicare pays 80% of Bioskin charges 20% patient portion ~$348.69 per application May have 5 +applications per ulcer Data from 9/28/2011 to 12/31/2012: 5,487 total patients (851 DFUs, 1,847 VLUs) 36 % of Bioskin pts had Medicare (MC) + secondary 1.8% Bioskin patient applications had MC only Medicare patients without a secondary insurance rarely get any advanced therapeutic treatment in outpatient wound centers 4
Race, Ethnicity, Age and Wounds: Conflicting Data Overwhelming evidence of racial and ethnic disparities in prevention and management of DFUs and PUs (other types) Reasons unclear, multifactorial including: patient, provider, care setting, culture race likely a surrogate for socioeconomic factors. USWR data are surprising: Non whites received advanced therapeutic interventions in higher percentage than Whites data from 100 centers in 32 states Non Whites seem to have worse outcomes in response to advanced therapeutics (? Co morbid diseases) Secondary insurance has powerful effect on use of ATs USWR as a QCDR for PQRS reporting provides a new window PRRS Reporting as a Qualified Clinical Data Registry (QCDR) with USWR wound center Podiatrist Vein expert The EHRs transmit data to the Registry The USWR USWR QCDR reports data to CMS for PQRS National wound care data for analysis 5