AMPUTATIONS ATTRIBUTED TO DIABETES 1

Amputations Attributed to Diabetes in Miami-Dade County

Kristina Maldonado

University of South Florida

AMPUTATIONS ATTRIBUTED TO DIABETES 2

Amputations attributed to Diabetes in Miami-Dade County

The purpose of this paper is to reveal the current strengths and weaknesses of Miami-

Dade County. This paper will focus and expand upon the increase of amputations in the lower

extremities related to diabetes in the population of Miami-Dade County. This paper will cover

preventative measures regarding amputations related to the complications of diabetes at the

primary, secondary, and tertiary levels of prevention.

Overview of Miami-Dade County

Miami-Dade County is located on the southeast tip of the Florida peninsula and spans

2,000 square miles, making the county geographically larger than the state of Rhode Island and

Delaware. To the east of Miami-Dade County lies Biscayne Bay and the Atlantic Ocean, the

Florida Keys are to the south of the county, and Broward County is found to the north. The

Everglades National Park makes up about one-third of Miami-Dade County (Miami-Dade

County, 2017). Miami-Dade County is the highest populated county in the state of Florida with

a population of 2,702, 890 (Florida Health Charts, 2016). Miami-Dade County has a greater

population than 15 states in the United States. Miami-Dade County is home to the second largest

airport for international passengers in the United States (Miami-Dade County, 2016).

Miami-Dade County is comprised of 34 municipalities and neighborhoods in the

unincorporated area of the county that are very diverse and unique in nature. Urban, suburban,

and rural areas can be found in the county (The Beacon Council, 2017). Homestead, a

municipality within Miami-Dade County, lies 30 miles south of Miami and offers a small-town

atmosphere (The City of Homestead, n.d.). On the other hand, Miami Beach has world-

renowned nightclubs and has an identity strongly rooted in the arts and entertainment industries

(City of Miami Beach, 2017). About half of the county’s residents were born in Latin America,
AMPUTATIONS ATTRIBUTED TO DIABETES 3

the Caribbean, Europe, and Asia. Two-thirds of the population speaks a language other than

English in the household (The Beacon Council, 2017). Out of the 2.7 million residents, 66.6%

are Hispanic (Florida Health Charts, 2015). The population is 77.9% white and 19% black

(Florida Health Charts, 2015). More than half of Miami-Dade County’s population is between

25-64 years of age (Florida Health Charts, 2016). Miami-Dade County Public Schools, Miami-

Dade County, and the federal government are the largest public employers for the county (The

Beacon Council, 2015). Jackson Memorial Hospital, Baptist Hospital of Miami, and the

University of Miami Health System are the major healthcare facilities in the county (The Beacon

Council, 2017). Now the county will be compared to population in the state of Florida.

Comparison of Local vs. State Populations

In 2015, 16.9% of families within Miami-Dade County were living below the poverty

level, compared to the state of Florida at 12% (Florida Health Charts, 2015). In Miami-Dade

County in 2015, 19.9% of individuals above the age of 25 did not have a high school diploma,

while the state of Florida was at 13.1% (Florida Health Charts, 2015). In 2015, it was found that

34.5% of Miami-Dade County’s population above the age of five spoke English less than very

well, while the state of the Florida was at 11.7% (Florida Health Charts, 2015). In 2015, Miami-

Dade County’s total licensed family practice physicians were at rate of 9.7 per 100,000 of the

population, and the state of Florida was at a rate of 14.3 per 100,000 of the population (Florida

Health Charts, 2015). In 2016, the rate of total number of hospital beds per 100,000 persons in

Miami-Dade County was 344.1, and the state of Florida was at 313.7 per 100,000 persons

(Florida Health Charts, 2016).

Analysis and Interpretation of Data

AMPUTATIONS ATTRIBUTED TO DIABETES 4

The strengths and weaknesses of Miami-Dade County will now be examined using the

County Health Status Summary Profile from the online Florida Health Charts from the

Department of Health of the State of Florida.

Identified Strengths

After evaluating Miami-Dade County’s health status summary from 2015 from the

Florida Health Charts of the Department of Health of the State of Florida, three identified

strengths in Miami-Dade County are a diminished cervical cancer rate, diminished chronic lower

respiratory disease hospitalization rate, and a decrease in deaths attributed to lung cancer (Florida

Health Charts, 2015). In 2014, the cervical cancer rate in Miami-Dade County was 9.3 per

100,000 people and the state’s rate was 8.5 per 100,000 (Florida Health Charts, 2014). Although

Miami-Dade County has a higher rate of cervical cancer than the state, the incidence rate within

the county has diminished. In 2015, the rate of lung cancer deaths in Miami-Dade County was

26.4 per 100,000 people and the state’s rate was 41.2 per 100,000 people. Miami-Dade County’s

death rate attributed to lung cancer is significantly lower than the state’s average, and in addition,

the rate in Miami-Dade County has declined. In 2014, the rate of hospitalizations due to chronic

lower respiratory disease was 305.9 per 100,000 people and the state had a rate of 346.9 per

100,000 people (Florida Health Charts, 2014). Miami-Dade County has a lower rate of

hospitalizations due to chronic lower respiratory disease than that of the state of Florida. This

data is significant because it signifies the improvement of health within the county of Miami-

Dade on these three facets.

Identified Weaknesses

According to the Florida Health Charts from the Department of Health of the State of

Florida, three weaknesses in Miami-Dade County include the rise of infectious syphilis, an
AMPUTATIONS ATTRIBUTED TO DIABETES 5

increase in chlamydia, and an increase in amputations due to diabetes (Florida Health Charts,

2015). In 2015, Miami-Dade County had a rate of infectious syphilis cases of 18.6 per 100,100

people, and the state had a rate of 10.5 infectious syphilis cases per 100,000 people (Florida

Health Charts, 2015). Miami-Dade County has a worse rate of infectious syphilis than the state’s

average and has only increased in incidences since 2011 (Florida Health Charts, 2015). In 2015,

Miami-Dade County had at a rate of chlamydia cases of 447.5 per 100,000 people and the state’s

average rate was 456.4 per 100,000 (Florida Health Charts, 2015). The rate of chlamydia cases

in Miami-Dade is slightly lower than the state, but has risen in the county (Florida Health Charts,

2015). In 2014, Miami-Dade County had a rate of 35.22 per 100,000 people hospitalizations

from amputations of a lower extremity attributed to diabetes (Florida Health Charts, 2014). In

2014, the state of Florida had an average rate of 30.1 per 100,000 people that were hospitalized

from an amputation of a lower extremity attributed to diabetes (Florida Health Charts, 2014).

Miami-Dade County has a higher rate of hospitalizations from amputations attributed to diabetes

than the state, and the count of hospitalizations from amputations related to diabetes in Miami-

Dade County has only risen since 2008 (Florida Health Charts, 2014). The data reveals that

these three health issues are evidently weaknesses that are afflicting the population of Miami-

Dade County tremendously.

Identification of a Priority Health Issue

This paper will focus on the increased rate and incidence of amputations attributed to

diabetes in Miami-Dade County. This is a priority health issue because amputations have

physical and psychological adverse effects on the patient and are preventable complications.

More than 50% of Latinos are expected to develop type 2 diabetes over their lifetime (Centers

for Disease Control and Prevention, 2016). Latinos are also 50% more likely to die from
AMPUTATIONS ATTRIBUTED TO DIABETES 6

diabetes than their white counterparts (Centers for Disease Control and Prevention, 2016). Poor

glycemic control poses the greatest threat to complications in the lower extremities (Pemayun,

Naibaho, Novitasari, Amin, & Minuljo, 2015). In 2013, 30.7% of adults in Miami-Dade County

with diabetes fell into the 65 and older age range (Health Council of South Florida, 2013). More

than half of Miami-Dade’s population of 2.6 million is Latino and given this large proportion of

potentially affected persons at higher risk of diabetes, the proper management of diabetes to

prevent complications, such as amputations, is of critical importance.

Discussion and Application of Community Health Models

Community health models assist in creating effective plans and interventions for different

communities within a population that is in need. These health models can create an appropriate

plan of care tailored for a specific target population taking into account a variety of relevant

factors that influence the community’s health. The Determinants of Health Model proposes that

a person’s health, or lack thereof, is a result of the physical environment, a person’s lifestyle,

biological factors, and accessibility to healthcare (World Health Organization, 2017). Many of

the factors that determine health are out of an individual’s control and the Determinants of

Health Model takes into account those factors. Income and socioeconomic status, education,

gender, and social support networks are but a few determinants of health (World Health

Organization, 2017). The interrelationships between the determinants of health dictate the health

of a person and of the population. A successful result is likely if interventions that target

multiple determinants of health are implemented (Healthy People 2020, 2017).

It is well known that the prevalence of diabetes is higher in the Latino population. There

seems to be a genetic predisposition in Latinos that puts them at a higher risk of acquiring

diabetes. In 2013, the Slim Initiative in Genomic Medicine for the Americas identified a genetic
AMPUTATIONS ATTRIBUTED TO DIABETES 7

carrier, SLC16A11, as a novel candidate gene for type 2 diabetes that may play a role in

triacylglycerol metabolism in Mexicans and Latin Americans (The Slim Initiative in Genomic

Medicine for the Americas Type 2 Diabetes Consortium, 2013). One in four Latino households

are considered food insecure, meaning that there is access to food, but there is lack of financial

resources or other resources that permit obtaining the food (The State of Obesity, 2014). About

23% of Latinos in the United States live below the poverty line, while 11% of whites live below

the poverty line (The State of Obesity, 2014). There is a relationship between income and food

choice, and because food that is cheaper is lower in nutritional quality, the lower income Latino

community purchases high calorie foods that are high in fat, sodium and carbohydrates (The

State of Obesity, 2014). Latino neighborhoods have one-third of the number of supermarkets as

non-Latino neighborhoods do (The State of Obesity, 2014). In addition, only one-third of

Latinos live walking distance to a park and have less access to safe places to be physically active

(The State of Obesity, 2014). The typical Latino cuisine varies amongst Latin American

countries yet rice, beans, and other carbohydrate dense foods are staples amongst all (American

Diabetes Association, 2017). Many Latino dishes are prepared with unhealthy amounts of fat

and salt as well (American Diabetes Association, 2017). In 2013, 55.8% of adults in Miami-

Dade County were inactive or insufficiently active (Florida Health Charts, 2013).

In 2013, 39.8% of adults were overweight in Miami-Dade County (Florida Health Charts,

2013). In 2013, it was found that 68% of adults had any type of insurance in Miami-Dade

County, and that the state’s average of adults with insurance was at 77.1% (Florida Health

Charts, 2013). Miami-Dade County’s percentage of insured adults is less than the state of

Florida’s insured adults. Consequently, 32% of the adults in Miami-Dade are uninsured. In

study conducted in 2015, it was found that amongst 300 Latinos with poorly controlled diabetes
AMPUTATIONS ATTRIBUTED TO DIABETES 8

in Miami-Dade County, 83% were not adherent to their medications and not managing their

diabetes (Kenya, Lebron, Chang, Ll, Alonzo, & Carrasquillo, 2015).

Population Diagnosis

Latino older adults with diabetes in Miami-Dade County are at risk for lower extremity

amputations due to poorly managed diabetes.

Community/Population-based Interventions

Health teaching, surveillance, consultation, referral and follow-up from the Intervention

Wheel Model, will be a part of diabetic amputation prevention. According to the Intervention

Wheel Model, at home glucometer monitoring and diabetic foot checks qualify as community-

focused interventions due to the newly desired practices and behaviors that are being introduced

and established in patients with diabetes (Savage, Kub, & Groves, 2016).

Primary Level of Prevention

Tight glycemic control can slow the progression of many type 2 diabetes complications

(American Diabetes Association, 2015). Peripheral neuropathy and peripheral arterial disease

are complications from diabetes that put an individual at risk for ulceration and amputation.

(American Diabetes Association, 2016). Latino older adults in Miami-Dade County should be

educated on the importance of keeping their blood sugar within the normal range and how to do

so. Latino older adults in Miami-Dade County should be taught how to measure their blood

glucose levels at home with a glucometer. This intervention is considered primary prevention, as

the goal of this intervention is to prevent the complication of amputations from occurring. This

intervention would be considered risk factor modification, because by keeping blood glucose

levels within normal range, overall risks for complications are reduced. Stakeholders include the

community and healthcare professionals. Nurses and physicians need to properly educate the
AMPUTATIONS ATTRIBUTED TO DIABETES 9

Latino older adult diabetic population through patient-centered care. Teaching and learning

materials should be available in Spanish. In order for a patient to be able to monitor their

glucose at home they will need, glucose test strips, a glucometer, lancet devices, and a glucose

control solution (U.S. Food and Drug Administration, 2016). The community health nurse

would need to assess whether the patient is insured and if their insurance covers these diabetes

supplies. Medicare Part B covers some diabetic supplies (U.S. Centers for Medicare and

Medicaid Services, n.d.). The role of the community health nurse would be to instruct the patient

on the importance of maintaining blood glucose levels in the normal range, to instruct the patient

on how to use a glucometer, and aiding the patient in obtaining the necessary supplies to measure

glucose levels at home.

Secondary Level of Prevention

In order to prevent diabetic foot ulcers and amputations in Latino older adults with

diabetes in Miami-Dade County, patients should be taught how to conduct daily at home self-

foot examinations. The purpose of daily foot examinations is to catch early signs of skin

breakdown and if ulceration has developed. If ulceration has occurred, the patient needs to seek

urgent medical attention from a podiatrist. The goal of treatment is to heal the ulcer and prevent

infection and amputation. The podiatrist will determine if infection is present, and if so,

antibiotic therapy and dressing changes must be implemented (American Podiatric Medical

Association, 2017). This secondary prevention intervention falls into screening, possible

diagnosis, and possible treatment. This intervention is geared at the Latino older adult

community of Miami-Dade County and the physicians and nurses of Miami-Dade County.

Primary care physicians and ARNP’s should instruct their patients on how to conduct an at home

self-foot examination. If ulceration has occurred, a home health nurse may be needed for
AMPUTATIONS ATTRIBUTED TO DIABETES 10

dressing changes. Patients who need home health nursing care for their wound dressing would

need to be assessed whether they can afford this, or if their insurance covers this. Patients can

also go to a wound care clinic. If antibiotics were necessary, insurance coverage would need to

be verified for the patient as well.

Tertiary Level of Prevention

The tertiary level of prevention for Latino older adults with diabetes in Miami-Dade

County would be chronic management of their diabetes and the management of the amputation

per se. It would require assisting the patient with their activities of daily living, medication

adherence, glucose control and helping the patient adjust to living without a lower extremity.

Rehabilitation to foster healing of the surgical site would be necessary. The patient will need to

be monitored physically and psychiatrically in order to prevent further negative impact on health.

Physical therapy, wound care nurses, podiatry, home health, family and friends, are stakeholders

in this intervention. Funding is of concern since there are various health teams involved and

multiple interventions concurrently taking place. The patient’s insurance coverage will be

variable. Some services can be covered while others may not. The role of the community health

nurse is imperative to the recovery and management of the chronic disease for the patient. The

community health nurse can help monitor the patient and report alterations in health.

Development of Health Policy

The general impact of health policy on healthcare determines the health outcomes for the

nation. The health policy proposed is to lower the incidence of lower extremity amputations in

the older Latino population with diabetes in Miami-Dade County by 50% by implementing at-

home foot examinations. The foot examination should be in accordance with the current

guidelines of the American Diabetes Association covering bathing water temperature, oil and
AMPUTATIONS ATTRIBUTED TO DIABETES 11

cream usage, callus maintenance, foot wear, and ulcer detection (American Diabetes

Association, 2016). Stakeholders include the targeted community, primary care physicians, and

community health nurses. Primary care physicians will be educating and providing foot exam

demonstrations and examination procedure pamphlets to patients in both English and Spanish.

Diabetes support groups should highlight speaking about foot care and proper foot hygiene. Due

to the high incidence of amputations and minority target population, a grant can be requested

from the American Diabetes Association. Medicare should cover foot examinations for patients

with diabetes. Miami-Dade County should consider investing in foot examination pamphlets due

to the high incidence of amputations. Supporters of the health policy include, community

members, healthcare providers, and public officials. Patient advocacy warrants large support for

this health policy. Opposing forces could include legislators who would want to limit the

Medicare budget and invest financial resources elsewhere. The opposition can impede this

health policy from being implemented. The plan of action commences by conducting an

outreach to all primary care physicians and ARNP’s in Miami-Dade County to request a standard

foot examination for each patient with diabetes. Primary care physicians and ARNP’s should be

asked to teach patients how to conduct at home self-foot examinations. Funding would be

requested from the American Diabetes Association for self-foot examination pamphlets in

Spanish and English to be distributed to each patient. This health proposal will bring awareness

to the increase of amputations, and the severity of diabetes and how it is profoundly impacting

and disabling the older Latino population in Miami-Dade County. Given the high incidence of

amputations, one can presume that the population with diabetes is not being managed

adequately. There could be provider-patient miscommunication, lack of proper education, and

lack of disease management materials. This health policy will enhance the overall health of
AMPUTATIONS ATTRIBUTED TO DIABETES 12

Miami-Dade County by facilitating the proper management of patients with diabetes.

Additionally, families and friends will become aware of the dangerous consequences of diabetes.

Conclusion

A priority health issue in Miami-Dade County is the high rate of lower extremity

amputations attributed to diabetes. Miami-Dade County has a higher rate of lower extremity

amputations attributed to diabetes than that of the state of Florida. Diabetes is an overwhelming

urgent issue for Latinos and the health consequences can be as debilitating. Diabetic

amputations can be prevented at the primary, secondary, and tertiary levels of prevention. This

health policy aims to reduce the number of amputations by 50% in the older adult Latino

population of Miami-Dade County by implementing at home self-foot examinations. At home

foot examinations can catch early signs of any foot skin breakdown, and thus, prevent ulceration

and a future amputation.

This paper has allowed me to explore a serious health issue in the county that I grew up

in that I was not aware of. I better understand that health is far beyond a patient’s control and

that there are many factors that determine a person’s health. I learned that disease prevention,

health promotion, diagnosing an illness, implementing interventions, and recovery, involve

aspects outside of the health care team, including the community, legislators, and public

officials. Researching this health problem made me realize the severity of diabetes and its

consequences. Diabetes is often looked at as a mild disease by society at large, but it is complex

and serious. As a nurse, I want to assist my patients with their management of diabetes to

prevent the preventable complication of amputation.

AMPUTATIONS ATTRIBUTED TO DIABETES 13

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