I had the pleasure of working with an amazing group of podiatrists, biostatisticians and public health experts on a paper that was just published in Clinics in Podiatric Medicine and Surgery, entitled “Walking the Line: How Social Forces Shape Diabetic Foot Outcomes in the Texas Rio Grande Valley”, first author Amanda L. Killeen DPM. All I contributed to this initiative were ignorant questions, but isn’t that is how all learning begins?
My ignorant question was “What can we learn from the ZIP codes of wound care patients that might help us care for them better?” I had found many links to information from the Centers for Disease Control and other research entities that were analyzing “social determinants of health.” I was frustrated because I think everyone knows that social factors – including where you live – matters to health outcomes, but no one would help me figure out what to DO about it. At the very least, ZIP codes could account for higher than usual failure rates and maybe if we could create some sort of “ZIP Code Rosetta Stone,” we could incorporate the information into health care and wound care registries. We didn’t get all the way to my goals, but this paper is a great start. I should hasten to mention that experts told me the “ZIP code idea” would not work because ZIP codes are too large an area. My own ZIP code includes very affluent areas and low income areas. It is possible to use “geocodes” to get “address level” information about healthcare risk factors, but I wanted to start with something easier like ZIP codes (mostly because I could not figure out how to use the geocode data that I found)—because I thought, “Surely there must be SOMETHING useful in the ZIP code. It can’t be worthless, even if it is not ideal.” The great team from the Schools of Medicine and Podiatric Medicine at the University of Texas Rio Grande Valley (including the Division of Population Health and Biostatistics and the Department of Information Systems), as well as Cy Dove, now in the Department of Endocrinology at Oregon Health Sciences University, found a way to glean information from Texas Rio Grande Valley ZIP codes.
The analysis suggests that diabetic foot amputations in the Texas Rio Grande Valley are driven less by biology than social forces. Nearly 1 in 3 adults in the region has diabetes, and amputation rates far exceed state and national averages—but not because patients are sicker. Poverty, geography, education gaps, and limited access to specialty care systematically delay treatment and push patients toward limb loss rather than limb salvage. A scoping review of the literature found factors that are not new when it comes to diabetic foot ulcer amputation rates: being Hispanic, poor, and unemployed are separate risk factors for amputation, lower educational attainment correlates with worse vascular disease, living over 50 miles from high-volume vascular centers which makes limb salvage less likely, and living conditions in colonias—often lacking clean water or reliable electricity—make diabetes and wound care especially difficult. Even though these findings are not surprising, the figures in the paper are innovative and educational.
Using the analysis of these zip codes, we propose that using ZIP-code–level social risk data embedded with an EHR could identify some high-risk patients earlier and target interventions such as mobile clinics, community health workers, and early PAD screening. That is what I’ve been trying to figure out for several years. Now it is time for someone to use the ZIP code information already available across the USA to provide a ZIP Code Rosetta Stone that we can use to alert healthcare practitioners of community risk factors. Eventually we will figure out a way to use address, but for now, let’s start with ZIP codes. Then we can start talking about interventions that would make a difference, and how the data can be incorporated into real-world diabetic foot ulcer registries like the US Wound Registry, which is doing real-world outcomes research and which is able to link wound care data with payer claims.
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