Disparities by race, hospital type exist in diabetes-related lower-extremity amputations

The authors of a recent study called for public awareness, screening, and accessible and early multidisciplinary care, as well as neighborhood-level public health interventions, to reduce the disproportionate burden of lower-extremity amputation in underserved communities.

There are significant disparities in rates of lower-extremity amputation by patient race, ethnicity, sex, and age and across hospital referral regions, residential area characteristics, and income levels, as well as by payer type and hospital characteristics, a review found.

Researchers conducted a systematic review of literature from 2000 to 2020, finding 19 studies of U.S. adults with type 2 diabetes that investigated differences in rates or levels of diabetic neuropathy or rates of diabetes-related lower-extremity amputation by demographic characteristics, social determinants of health, or barriers to care. Results were published by Health Affairs on July 5.

Fourteen of the 16 studies that included race as a variable found substantial disparities in the rates of lower-extremity amputation based on race, as did six of nine that looked at ethnicity. However, the study authors noted that adjustment for factors related to diabetes and other comorbidities “appeared to attenuate the association between race and the risk for lower extremity amputation, underscoring the role of health inequities in lower extremity amputation.”

In addition, 11 of 16 studies that included sex found differences in amputation rates based on this characteristic, as did nine of 15 that included age. A link between payer type and lower-extremity amputation rates was found in five of eight studies that included it as a variable, with lower risk for lower-extremity amputation in privately insured patients. One included study involved a retrospective chart review of 234 patients with diabetes and a new diagnosis of a foot ulcer treated at geographically adjacent but independent public, private, and Veterans Affairs (VA) hospitals in New York. The highest rate of lower-extremity amputation was recorded at the VA hospital (23.5%), followed by the public hospital (12%), with the lowest rate at the private hospital (6.8%).

Another included study found that being treated at an urban hospital rather than a rural hospital was associated with a reduction in likelihood of lower-extremity amputation, by 9.2% if the urban hospital was a teaching hospital and 5.7% if it was a nonteaching hospital (P<0.01 for both comparisons). However, another study reported that teaching facilities were significantly more likely to perform major and minor amputations compared with nonteaching facilities.

There was a reduction in major lower-extremity amputation rates among Black, Hispanic, and White patients with diabetes over time, which narrowed disparities and may be due to earlier and more aggressive treatment of type 2 diabetes, the study authors said. Native Americans were the lone racial group that did not have a significantly decreasing incidence of major lower-extremity amputations, the authors added.

They pointed out that about 75% of patients who undergo lower-extremity amputation in the U.S. do not receive diagnostic angiography beforehand and that 54% do not undergo revascularization. Two centers that began routine angiograms saw a significant decline in amputation rates. A routine practice of not performing lower-extremity amputation without arterial testing could help mitigate the effects of implicit bias, according to the authors.

“There is a need for a national strategy that integrates public awareness, screening, early initiated multidisciplinary care, and quality measures for peripheral artery disease management, as well as neighborhood-level public health interventions, to reduce the disproportionate burden of lower extremity amputation in underserved communities,” the authors wrote.

The July issue of Health Affairs included several other articles about diabetes.