Southern Association for Vascular Surgery
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Assessing the Influence of Rural Residence and Economic Distress on Lower Extremity Risk Stratification among Diabetic Foot Ulcer Patients: Utilization of the Wound, Ischemia, Infection (WIfI) Classification System.
Jordan Tasman1, Devin J Clegg2, Colten Carver1, Saahit Adabala1, Ryan M. Buckley2, Mitchell H. Goldman2, Patricia N.E. Roberson1
1University of Tennessee College of Nursing, Knoxville, TN;2University of Tennessee Graduate School of Medicine, Knoxville, TN

Background: Diabetic foot ulcers (DFU) are major sequelae of uncontrolled diabetes that have a high risk of adverse outcomes, including hospital admission, infection, lower extremity amputation, and mortality. The burden of DFU disproportionately impacts rural and economically distressed patients due to a lack of access to, and affordability of diabetic guideline-directed care and specialized multidisciplinary wound care facilities for proper wound management. Lack of access to standardized care may result in a more advanced stage of a wound at presentation, leading to poorer health outcomes. Thus, the purpose of this study is to assess how geographic and economic disparities influence presenting lower extremity disease burden among DFU patients using the Society of Vascular Surgeons (SVS) Wound, Ischemia, and foot Infection (WIfI) classification system.
Methods: A retrospective review of 513 patients diagnosed with a diabetic foot ulcer (DFU) from January 2011 to December 2020 at a single institutionís inpatient and outpatient wound care service was performed. Patients >18 years old, with type II diabetes mellitus, and foot ulcer not determined to be from other causes were included. Disease burden of DFU was determined using the SVS WIfI Classification system with WIfI composite scores and individual WIfI components (Wound, Ischemia, and Foot Infection). Rural status and county economic distress were determined by Rural-Urban Continuum Codes (RUCA) and the Appalachia Regional Commission (ARC), respectively. T-tests were conducted to test effects between rural status and WIfI scores, and ANOVA was performed to test effect between economic distress and WIfI scores.
Results: Rural patients had significantly higher WIfI composite scores (t(490) = 3.538, p = .007) than their urban counterparts. Specifically, rural patients demonstrate a significantly higher grade of both wound (t(476) =10.84, p = .006) and ischemia (t(416) = 44.45, p = .010) than urban. DFU patients living in distressed economic counties had significantly higher grades of ischemia (F(2,415) = 4.043, p = .018) than patients in transitional economic counties (Table 1).
Conclusion: Our findings are the first to provide evidence of the impact of geographic and economic disparities, including rural status and county economic distress, on the disease burden of DFU at presentation utilizing the SVS WIfI classification system. This may demonstrate the disproportionate lack of access to care, availability for healthy living (i.e., food security), and multidisciplinary primary care prevention strategies in rural and economically underserved populations and communities. Future research is needed to determine risk factors for worsened DFU disease burden on an individual, interpersonal, and community level to aid in the development of effective multilevel and multidisciplinary interventions.


Table 1. One Way Analysis of Variance (ANOVA) and T-test Results for the Association between DFU Patientís County Economic Distress and Rural Status with Patientís Composite WIfI Score and Individual Component Scores (Wound, Ischemia, Foot Infection; N= 513).
County Economic Distress (ANOVA Results)
M(SD)F-statisticp-valueDf, errorEffect sizea
Composite WIfI
Distressed3.82(1.91)1.9360.152, 489.008
At-Risk4.16(1.44)
Transitional3.63(1.62)
Wound
Distressed1.48(.70)1.466.232, 475.006
At-Risk1.59(.64)
Transitional1.41(.64)
Ischemia
Distressed.52(1.02)4.04.02*2, 415.019
At-Risk.31(.80)
Transitional.24(.63)
Foot infection
Distressed2.03(.86)1.29.282, 480.005
At-Risk2.32(.88)
Transitional.24(.63)
Rural Status (T-test Results)
M(SD)T-statisticp-valueDfCohens D
Composite WIfI
Urban2.60(1.53)-2.51.013*157.061.62
Rural3.09(1.88)
Wound
Urban1.38(.61)-2.85.005*159.10.64
Rural1.60(.72)
Ischemia
Urban.22(.59)-2.65.009*113.4.71
Rural.51(1.01)
Foot Infection
Urban1.10(.93)-.12.903489.93
Rural1.11(.93)
*p < .05 for ANOVA. aEffect size is assessed with η2: small effect η2 = .01; medium effect η2 = .06; large effect η2 = .14.

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