Impact of Missed Initial Wound Clinic Visit on 6-Month Wound Healing Among Patients with Chronic Limb Threatening Ischemia by Race/Ethnicity
Sydney E Browder, Avital Yohann, Teresa R Filipowicz, Nikki LB Freman, William A Marston, Stephen Heisler, Mark A Farber, Shrunjay R Patel, Jacob C Wood, Katharine L McGinigle
University of North Carolina at Chapel Hill, Chapel Hill, NC
Background: Chronic limb-threatening ischemia (CLTI) is associated with significant morbidity, including major limb amputation, and mortality. Healing ischemic wounds is necessary to optimize outcomes and can be facilitated by dedicated appointments at a wound clinic. This study aimed to estimate the association of non-compliance to wound-related healthcare appointments with the proportion of wound healing, with specific attention to the effect of race/ethnicity on this association. Methods: This retrospective study included 398 patients with CLTI and at least one ischemic wound who scheduled an appointment at our wound clinic between January 2015 and July 2020. The exposure was the status of patients’ first scheduled wound care appointment (complete/not complete) and the primary outcome was 6-month wound healing (healed/not healed). The analysis focused on how this association was modified by race/ethnicity. Interaction between first visit completion and race/ethnicity and modification by race/ethnicity were respectively examined using a likelihood ratio test and producing stratum specific estimates. We used the Aalen-Johansen estimator to assess the association between the exposure and outcome, accounting for major amputation and all-cause mortality as competing events. Risk ratios within strata of race/ethnicity were calculated (Table I). Cumulative incidence curves of healing stratified by race/ethnicity were created (Figure I) and compared using Gray’s tests. We used bootstrapping to produce 95% confidence intervals (CIs) for all risks and risk ratios. The final adjustment set included age, revascularization, and initial wound size. Clustering was addressed for patients with more than one wound. Individuals who did not complete their first visit were used as the reference group. Results: Patients had a mean age of 67±14 years, were 41% female, 46% non-White and had 517 total wounds. In the overall cohort, 70% of patients completed their first visit, 34% of wounds healed within 6-months, and 10% of patients underwent major limb amputation. We calculated a likelihood ratio test statistic of 5.37 and p-value=0.021, indicating interaction between race/ethnicity and first visit completion. Stratum specific estimates displayed modification of the outcome by race/ethnicity (Table I). There was no significant difference in 6-month healing based on first visit completion status for White/non-Hispanic individuals [RR (95% CI)=1.19 (0.87, 1.63), p=0.138], while non-White individuals were 3 times more likely to heal their wounds if they completed their first scheduled wound care appointment [RR (95% CI)=3.04 (1.94, 4.75), p<0.001] (Table I). Conclusions: Non-White patients were approximately 3 times more likely to heal their wound in 6-months if they completed their first scheduled wound care appointment while White/non-Hispanic individuals’ risk of healing was similar regardless of first visit completion status. Future efforts should focus on providing additional resources to ensure minority groups have the support they need to access care and successfully schedule and complete their first wound care appointment.
| Race/ethnicity | First visit completion status | Risk Ratio (95% CI) | p-value | |||
| Crude # (%) of Wounds that Healed | Adjusted 6-Month Risks (95% CI) | |||||
| Completed | Not Completed | Completed | Not Completed | |||
| White/Non-Hispanic | 76 (39.2%) | 30 (32.3%) | 0.33 (0.27, 0.40) | 0.28 (0.21, 0.36) | 1.19 (0.87, 1.63) | 0.138 |
| Non-White | 60 (38.2%) | 9 (12.3%) | 0.32 (0.25, 0.42) | 0.11 (0.05, 0.21) | 3.04 (1.94, 4.75) | <0.001 |
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