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Leg ulceration and ethnicity
Public Health (1997) 111, 327–329 © The Society of Public Health, 1997
Leg ulceration and ethnicity: a study in west London PJ Franks1, N Morton2, A Campbell2 and CJ Moffatt1 1
Centre for Research and Implementation of Clinical Practice, Thames Valley University, Wolfson Institute of Health Sciences, 32–38 Uxbridge Road, London, W5 2BS and 2 West London Healthcare NHS Trust, Uxbridge Road, Southall, Middlesex UB1 3EU, UK Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275000 of whom 53000 have an ethnic background from the Indian subcontinent (South Asian). In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P 0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration. Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community. Keywords: ulceration; lower limb; varicose veins; diabetes; ethnicity; West London
Introduction It is well established that leg ulceration is a major cause of morbidity in elderly western populations, with approximately 100000 suffering from an active leg ulcer in the UK at any time, with three times this many with healed ulceration at risk of recurrence.1–4 However, these studies have been performed in populations which are almost exclusively white, with very little information being gathered from populations from other ethnic groups. There is a clear need to understand whether there are differences in diseases between ethnic groups when allocating resources. This may be particularly important in leg ulceration where it is known that large community based resources are used in their treatment.5 This recent report indicated that total costs of treating 410 patients in a population of 540 000 was £976 000 per annum of which more than 55% was ascribed to community nursing time. The aim of the present study was to examine the ascertainment of patients suffering from leg ulceration through health professionals working in an area of London which has a high proportion with ethnic origin from the Indian sub-continent, and to determine whether this varied with different ethnic background. Methods Prior to the development of a co-ordinated leg ulcer service based on the Riverside model of care,6 health professionals within West London Health Care Trust were contacted to draw up a register of patients suffering from chronic leg
Correspondence: Dr PJ Franks Accepted 17 March 1997
ulceration. General practitioners, district and practice nurses, hospital wards and out-patients departments were contacted and asked to identify patients they were treating, or those patients they knew who were suffering from a current leg sore within the catchment area. Professionals were asked to provide information on the patients name and address together with some details of the treatment that was being provided, and indicate which ethnic group the patient belonged to. Ethnicity was categorised as either white, South Asian (Indian, Pakistani or Bangladeshi),7 Afrocaribbean or other. Following this initial trawl, nursing staff were asked to continue with the register of patients for a one year period.
Results In all, 280 patients were ascertained, of whom 264 had information on sex and age. Crude ascertainment rate was 1.02 per 1000 population, Table 1. However, there was a clear age gradient in both sexes, reaching a maximum in the patients over the age of 85 y, being 15.1/1000 in men and 20.8/1000 in women. There was only a slight sex difference by age, though this difference was consistent over all age categories. Of the 264 patients with age and sex, five patients were classed as South Asian, and one patient as Afro-caribbean. The population of patients with ulceration are also given by race in Table 1. As expected the larger white population had rates similar to that for the total population. However, the number of cases of South Asian patients ascertained with leg ulceration was much lower than expected. From the Mantel Haenzsel test, the odds ratio for white cases was 4.43 that of Asians with a 95% confidence interval between 1.94 and 10.13 (P 0.0004). Also given are the number of South Asian cases expected from the rates calculated in the
Leg ulceration and ethnicity PJ Franks et al
328
Table 1 Prevalence of leg ulceration by age and sex in the catchment population of West London Healthcare NHS Trust Total Number of patients with ulceration
Catchment population
Rate per 1000 population
8 12 20 32 14
106474 12306 8847 4890 927
0.08 0.98 2.26 6.54 15.10
13 14 32 63 56
107716 12510 10761 8109 2688
0.12 1.12 2.97 7.77 20.83
Men, age (y) < 55 55–64 65–74 75–84 85 Women, age (y) < 55 55–64 65–74 75–84 85
White Number of patients with ulceration
Catchment population
Rate per 1000 population
8 11 16 31 14
67205 8964 7551 4529 856
0.12 1.23 2.12 6.84 16.36
13 14 32 63 56
67781 9613 9583 7706 2604
0.19 1.46 3.34 8.18 21.51
Men age (y) < 55 55–64 65–74 75–84 85 Women age (y) < 55 55–64 65–74 75–84 85
South Asians Number of patients with ulceration
Catchment population
Rate per 1000 population
Expected patients
Men age (y) < 55 55–64 65–74 75–84 85
0 1 3 1 0
23011 2047 910 268 61
0 0.49 3.30 3.73 0
2.8 2.5 1.9 1.8 1.0 10.0
Women age (y) < 55 55–64 65–74 75–84 85
0 0 0 0 0
23999 1867 787 249 54
0 0 0 0 0
4.6 2.7 2.6 2.0 1.2 13.1
Number of South Asian cases seen 5 Expected number of South Asian cases 23 Mantel Haenzsel Chi Square 12.48, P 0.0004 Odds ratio 4.43 95%CI 1.94 to 10.13
white group. This shows that whilst five patients were ascertained from South Asian background, 23 would be expected assuming a similar rate to the white population. Discussion There is little evidence of racial differences in leg ulcer prevalence, though some on differences in the recognised diseases which cause ulceration. It is known that approximately 70% of ulcers of the leg are caused by venous disease, with nearly 30% of ulcers having an arterial component.8,9 Diabetes may be present in about 10% of all patients with leg ulceration.9
There is good evidence of differences in varicose vein prevalence in different ethnic groups. Lowest prevalence has been reported in lowland native New Guinea.10 In a sample of 1457 adults over the age of 20 y, only 0.1% women and 5.1% men appeared to be suffering from varicose veins. However, migrant studies have indicated that prevalence varies according to the degree of westernisation.11,12 In polynesian groups, prevalence was highest in Maoris and lowest in the Cook and Tokelau Islanders. Varicose vein prevalence has been examined in railway workers from different regions of India. The results suggest a higher prevalence in south (25%) compared with north (6.8%) Indians, which appears to relate largely to diet.13
Leg ulceration and ethnicity PJ Franks et al
This may be important since the population of South Asians who live in West London are largely from the Punjab, which is in the north of India. Whilst the prevalence of venous disease may be lower in South Asians living in the UK, this has yet to be proven. It is acknowledged that diabetes may play a role in leg ulceration, but its overall contribution is likely to be relatively small. In Sweden, higher prevalence of ulceration was found in diabetics compared with non diabetics, the prevalence being significantly higher in insulin dependent diabetics (4.9%) compared with those on other treatment (2.6%).14 However, it has been found that diabetes is approximately twice as common in patients from South Asia, so this is unlikely to be the reason for low ascertainment in this group.15 The results from the present study suggest a very low ascertainment in South Asians, with expected numbers in the population of 23 patients, but only five cases found. Clearly this may be due to a racial difference in leg ulceration caused by different disease profiles or through low ascertainment due to patient reluctance to present to the health services. However, the latter does not appear to be supported by examination of general practice consultation rates in north-west London. Consultation rates were similar between South Asians and other ethnic groups, and when South Asians consulted, they did so more frequently.16 In the Asian population there were no women reported with leg ulceration and only half the expected number of men. Evidence from other studies suggest that women have a similar (or higher) risk of developing leg ulceration.1,3 For these results to reflect true cases there would have to be both a sex and race difference in the prevalence of ulceration. Although there may be a real difference between the races, it is likely that there may be an underreporting in South Asian women. With these results in mind, West London Health Care is attempting to increase awareness of leg ulcer treatment to all patients in the target area, to try and examine whether the effects observed are real or due to under-reporting with a consequent unmet need in the community. Acknowledgement We thank all community nursing staff of West London Health Care Trust for their contributions to this study.
329
References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 29: 1855–1856. 2 Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986; 73: 693–696. 3 Nelzen O, Bergqvist D, Lindhagen A, Hallbrook T. Chronic leg ulcers: an underestimated problem in primary health care among elderly patients. J Epid Comm Health 1991; 45: 184– 187. 4 Baker SP et al. Epidemiology of chronic venous ulcers. Br J Surg 1991; 78: 864–867. 5 Simon DA et al. Community leg ulcer clinics: a comparative study in two health authorities. Br Med J 1996; 312: 1648– 1651. 6 Moffatt CJ et al. Community clinics for leg ulcers and impact on healing. Br Med J 1992; 305: 1389–1392. 7 Chaturvedi N, McKeigue PM. Methods for epidemiological surveys of ethnic minority groups. J Epid Comm Health 1994; 48 107–111. 8 Nelzen O, Bergqvist D, Linghagen A. Leg ulcer etiology—a cross sectional population study. J Vasc Surg 1991; 14: 557– 564. 9 Baker SR et al. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992; 6: 245–251. 10 Stanhope JM. Varicose veins in a population of lowland New Guinea. Int J Epidemiol 1975; 4: 221–225. 11 Beaglehole R, Prior IAM, Salmond CE, Davidson F. Varicose veins in the South Pacific. Int J Epidemiol 1975; 4: 295–299. 12 Beaglehole R, Salmond CE, Prior IAM. Varicose veins in New Zealand: prevalence and severity. NZ Med J 1976; 84: 396– 399. 13 Malhotra SL. An epidemiological study of varicose veins in Indian railroad workers from the south and north of India, with special reference to the causation and prevention of varicose veins. Int J Epidemiol 1972; 1: 177–183. 14 Nelzen O, Bergqvist D, Lindhagen A. High prevalence of diabetes in chronic leg ulcer patients: a cross sectional population study. Diabetic Med 1993; 10: 345–350. 15 Marmot MG, Adelstein AM, Busulu L. Lessons from the study of immigrant mortality. Lancet 1984; i: 1455–1457. 16 Gillam SJ, Jarman B, White P, Law R. Ethnic differences in consultation rates in urban general practice. Br Med J 1989; 299: 953–957.
Leg ulceration and ethnicity: a study in west London PJ Franks1, N Morton2, A Campbell2 and CJ Moffatt1 1
Centre for Research and Implementation of Clinical Practice, Thames Valley University, Wolfson Institute of Health Sciences, 32–38 Uxbridge Road, London, W5 2BS and 2 West London Healthcare NHS Trust, Uxbridge Road, Southall, Middlesex UB1 3EU, UK Little is known of the influence race has on the development of leg ulceration, with most studies being performed in almost exclusively white populations. As part of a wider audit of leg ulcer services, health care professionals were contacted to give details of age, sex and ethnic background of all patients who attended for treatment of leg ulceration over a one year period in an area of west London. West London Health Care Trust provides services to a population of 275000 of whom 53000 have an ethnic background from the Indian subcontinent (South Asian). In all, 280 patients were identified, of whom 264 (94%) had details of age and sex. This gave a crude ascertainment rate of 1.02 per 1000 population. Of the 264 patients, five were classified as South Asians, with one patient classified as Afro-caribbean. The Mantel Haenzsel test demonstrated a significantly higher proportion of whites suffering from leg ulceration than South Asians, giving an odds ratio of 4.43, with 95% confidence intervals between 1.94 and 10.13 (P 0.0004). The expected frequency of South Asian patients should be 23, based on rates from the white population, of which 13 would be women and 10 men. Only five South Asian men were identified, and no Asian women with leg ulceration. Reasons for this low ascertainment are two-fold. Either there is a real difference between the white and South Asian populations, or South Asian patients are not presenting for treatment. Further work must be performed to determine whether this is an effect of low prevalence, or unmet need in the community. Keywords: ulceration; lower limb; varicose veins; diabetes; ethnicity; West London
Introduction It is well established that leg ulceration is a major cause of morbidity in elderly western populations, with approximately 100000 suffering from an active leg ulcer in the UK at any time, with three times this many with healed ulceration at risk of recurrence.1–4 However, these studies have been performed in populations which are almost exclusively white, with very little information being gathered from populations from other ethnic groups. There is a clear need to understand whether there are differences in diseases between ethnic groups when allocating resources. This may be particularly important in leg ulceration where it is known that large community based resources are used in their treatment.5 This recent report indicated that total costs of treating 410 patients in a population of 540 000 was £976 000 per annum of which more than 55% was ascribed to community nursing time. The aim of the present study was to examine the ascertainment of patients suffering from leg ulceration through health professionals working in an area of London which has a high proportion with ethnic origin from the Indian sub-continent, and to determine whether this varied with different ethnic background. Methods Prior to the development of a co-ordinated leg ulcer service based on the Riverside model of care,6 health professionals within West London Health Care Trust were contacted to draw up a register of patients suffering from chronic leg
Correspondence: Dr PJ Franks Accepted 17 March 1997
ulceration. General practitioners, district and practice nurses, hospital wards and out-patients departments were contacted and asked to identify patients they were treating, or those patients they knew who were suffering from a current leg sore within the catchment area. Professionals were asked to provide information on the patients name and address together with some details of the treatment that was being provided, and indicate which ethnic group the patient belonged to. Ethnicity was categorised as either white, South Asian (Indian, Pakistani or Bangladeshi),7 Afrocaribbean or other. Following this initial trawl, nursing staff were asked to continue with the register of patients for a one year period.
Results In all, 280 patients were ascertained, of whom 264 had information on sex and age. Crude ascertainment rate was 1.02 per 1000 population, Table 1. However, there was a clear age gradient in both sexes, reaching a maximum in the patients over the age of 85 y, being 15.1/1000 in men and 20.8/1000 in women. There was only a slight sex difference by age, though this difference was consistent over all age categories. Of the 264 patients with age and sex, five patients were classed as South Asian, and one patient as Afro-caribbean. The population of patients with ulceration are also given by race in Table 1. As expected the larger white population had rates similar to that for the total population. However, the number of cases of South Asian patients ascertained with leg ulceration was much lower than expected. From the Mantel Haenzsel test, the odds ratio for white cases was 4.43 that of Asians with a 95% confidence interval between 1.94 and 10.13 (P 0.0004). Also given are the number of South Asian cases expected from the rates calculated in the
Leg ulceration and ethnicity PJ Franks et al
328
Table 1 Prevalence of leg ulceration by age and sex in the catchment population of West London Healthcare NHS Trust Total Number of patients with ulceration
Catchment population
Rate per 1000 population
8 12 20 32 14
106474 12306 8847 4890 927
0.08 0.98 2.26 6.54 15.10
13 14 32 63 56
107716 12510 10761 8109 2688
0.12 1.12 2.97 7.77 20.83
Men, age (y) < 55 55–64 65–74 75–84 85 Women, age (y) < 55 55–64 65–74 75–84 85
White Number of patients with ulceration
Catchment population
Rate per 1000 population
8 11 16 31 14
67205 8964 7551 4529 856
0.12 1.23 2.12 6.84 16.36
13 14 32 63 56
67781 9613 9583 7706 2604
0.19 1.46 3.34 8.18 21.51
Men age (y) < 55 55–64 65–74 75–84 85 Women age (y) < 55 55–64 65–74 75–84 85
South Asians Number of patients with ulceration
Catchment population
Rate per 1000 population
Expected patients
Men age (y) < 55 55–64 65–74 75–84 85
0 1 3 1 0
23011 2047 910 268 61
0 0.49 3.30 3.73 0
2.8 2.5 1.9 1.8 1.0 10.0
Women age (y) < 55 55–64 65–74 75–84 85
0 0 0 0 0
23999 1867 787 249 54
0 0 0 0 0
4.6 2.7 2.6 2.0 1.2 13.1
Number of South Asian cases seen 5 Expected number of South Asian cases 23 Mantel Haenzsel Chi Square 12.48, P 0.0004 Odds ratio 4.43 95%CI 1.94 to 10.13
white group. This shows that whilst five patients were ascertained from South Asian background, 23 would be expected assuming a similar rate to the white population. Discussion There is little evidence of racial differences in leg ulcer prevalence, though some on differences in the recognised diseases which cause ulceration. It is known that approximately 70% of ulcers of the leg are caused by venous disease, with nearly 30% of ulcers having an arterial component.8,9 Diabetes may be present in about 10% of all patients with leg ulceration.9
There is good evidence of differences in varicose vein prevalence in different ethnic groups. Lowest prevalence has been reported in lowland native New Guinea.10 In a sample of 1457 adults over the age of 20 y, only 0.1% women and 5.1% men appeared to be suffering from varicose veins. However, migrant studies have indicated that prevalence varies according to the degree of westernisation.11,12 In polynesian groups, prevalence was highest in Maoris and lowest in the Cook and Tokelau Islanders. Varicose vein prevalence has been examined in railway workers from different regions of India. The results suggest a higher prevalence in south (25%) compared with north (6.8%) Indians, which appears to relate largely to diet.13
Leg ulceration and ethnicity PJ Franks et al
This may be important since the population of South Asians who live in West London are largely from the Punjab, which is in the north of India. Whilst the prevalence of venous disease may be lower in South Asians living in the UK, this has yet to be proven. It is acknowledged that diabetes may play a role in leg ulceration, but its overall contribution is likely to be relatively small. In Sweden, higher prevalence of ulceration was found in diabetics compared with non diabetics, the prevalence being significantly higher in insulin dependent diabetics (4.9%) compared with those on other treatment (2.6%).14 However, it has been found that diabetes is approximately twice as common in patients from South Asia, so this is unlikely to be the reason for low ascertainment in this group.15 The results from the present study suggest a very low ascertainment in South Asians, with expected numbers in the population of 23 patients, but only five cases found. Clearly this may be due to a racial difference in leg ulceration caused by different disease profiles or through low ascertainment due to patient reluctance to present to the health services. However, the latter does not appear to be supported by examination of general practice consultation rates in north-west London. Consultation rates were similar between South Asians and other ethnic groups, and when South Asians consulted, they did so more frequently.16 In the Asian population there were no women reported with leg ulceration and only half the expected number of men. Evidence from other studies suggest that women have a similar (or higher) risk of developing leg ulceration.1,3 For these results to reflect true cases there would have to be both a sex and race difference in the prevalence of ulceration. Although there may be a real difference between the races, it is likely that there may be an underreporting in South Asian women. With these results in mind, West London Health Care is attempting to increase awareness of leg ulcer treatment to all patients in the target area, to try and examine whether the effects observed are real or due to under-reporting with a consequent unmet need in the community. Acknowledgement We thank all community nursing staff of West London Health Care Trust for their contributions to this study.
329
References 1 Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 29: 1855–1856. 2 Cornwall JV, Dore CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986; 73: 693–696. 3 Nelzen O, Bergqvist D, Lindhagen A, Hallbrook T. Chronic leg ulcers: an underestimated problem in primary health care among elderly patients. J Epid Comm Health 1991; 45: 184– 187. 4 Baker SP et al. Epidemiology of chronic venous ulcers. Br J Surg 1991; 78: 864–867. 5 Simon DA et al. Community leg ulcer clinics: a comparative study in two health authorities. Br Med J 1996; 312: 1648– 1651. 6 Moffatt CJ et al. Community clinics for leg ulcers and impact on healing. Br Med J 1992; 305: 1389–1392. 7 Chaturvedi N, McKeigue PM. Methods for epidemiological surveys of ethnic minority groups. J Epid Comm Health 1994; 48 107–111. 8 Nelzen O, Bergqvist D, Linghagen A. Leg ulcer etiology—a cross sectional population study. J Vasc Surg 1991; 14: 557– 564. 9 Baker SR et al. Aetiology of chronic leg ulcers. Eur J Vasc Surg 1992; 6: 245–251. 10 Stanhope JM. Varicose veins in a population of lowland New Guinea. Int J Epidemiol 1975; 4: 221–225. 11 Beaglehole R, Prior IAM, Salmond CE, Davidson F. Varicose veins in the South Pacific. Int J Epidemiol 1975; 4: 295–299. 12 Beaglehole R, Salmond CE, Prior IAM. Varicose veins in New Zealand: prevalence and severity. NZ Med J 1976; 84: 396– 399. 13 Malhotra SL. An epidemiological study of varicose veins in Indian railroad workers from the south and north of India, with special reference to the causation and prevention of varicose veins. Int J Epidemiol 1972; 1: 177–183. 14 Nelzen O, Bergqvist D, Lindhagen A. High prevalence of diabetes in chronic leg ulcer patients: a cross sectional population study. Diabetic Med 1993; 10: 345–350. 15 Marmot MG, Adelstein AM, Busulu L. Lessons from the study of immigrant mortality. Lancet 1984; i: 1455–1457. 16 Gillam SJ, Jarman B, White P, Law R. Ethnic differences in consultation rates in urban general practice. Br Med J 1989; 299: 953–957.