Utilization of large-scale electronic health record database to understand social determinants of health disparities in the diabetic patient population with major lower extremity amputation.

Abstract

Poorly controlled diabetes is associated with higher risks of lower extremity amputations (LEAs). Social determinants of health, alternatively termed social drivers of health (SDoH), have been shown to play an important role in health outcomes. However, specific SDoH domains that impact poorly controlled diabetics (PC-diabetics) are undefined. This study aimed to use Epic Cosmos, a cross-institutional electronic health record (EHR) database, to identify these specific social risk factors to better inform and tailor support services. Epic Cosmos is a Health Insurance Portability and Accountability Act-compliant data platform with longitudinal EHR records of >300 million patients. PC-diabetics were queried based on having at least one hemoglobin A1c test of ≥7.0%, and nondiabetic or controlled diabetic (N/C-diabetic) patients were identified as having an A1c test of <7.0% and none >7.0% from 2014 to 2018. LEAs within 5 years of the A1c test were identified through selected CPT codes (27590, 27591, 27592, 27594, 27880, 27881, 27882, and 27884). SDoH diagnoses specific to this patient cohort were extracted using International Classification of Diseases, 10th edition, Clinical Modification, Z-codes (Z55-Z75). All statistical significance was calculated using χ² tests in Microsoft Excel and R Studio, with the significant level set at a P value of .05. Our study included 4,512,612 PC-diabetic and 13,659,422 N/C-diabetic patients. The PC-diabetic cohort had 20,944 individuals with LEA and the N/C-diabetic group had 7981 patients with LEA. In PC-diabetics with LEA, 28.41% had at least one SDoH diagnosis, in contrast with 12.20% of PC-diabetics without LEA or 11.80% of N/C-diabetics (P < .05). Patients with PC-diabetes and LEA are 3.02 times more likely to have problems related to housing/economic circumstances (Z59) and 2.54 times more likely to have problems related to lifestyle (Z72), compared with PC-diabetics without LEA. Our study also found high rates of smoking (Z72.0, 20.85% of total) in PC-diabetics with LEA. Moreover, African American PC-diabetics without LEA have higher baseline rates of SDoH diagnoses (14.90%) than their White counterparts (11.92%, P < .05). Our analysis on PC-diabetics with LEA showed higher SDoH diagnosis rates in housing/economic and lifestyle challenges compared with PC-diabetics without LEA. Tobacco use was found to be a particularly notable risk factor among this patient cohort. This study demonstrates the feasibility of using large-scale EHR databases to generate hypotheses and guide future strategies to address SDoH risk factors.