American Diabetes Association
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Racial, Rural, and Regional Disparities in Diabetes-Related Lower-Extremity Amputation Rates, 2009–2017

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posted on 2021-07-22, 14:39 authored by Marvellous A. Akinlotan, Kristin Primm, Jane N. Bolin, Abdelle L. Ferdinand Cheres, JuSung Lee, Timothy Callaghan, Alva O. Ferdinand

To examine the racial/ethnic, rural-urban, and regional variations in the trends of diabetes-related lower extremity amputations (LEA) among hospitalized U.S. adults from 2009-2017.

Research Design and Methods

We used the National Inpatient Sample (NIS) (2009-2017) to identify trends in LEA rates among those primarily hospitalized with diabetes in the United States. We conducted multivariable logistic regressions to identify individuals at risk of LEA based on their race/ethnicity, census region location (North, Midwest, South and West) and rurality of residence.


From 2009 to 2017, the rates of minor LEAs increased across all racial/ethnic, rural/urban, and census region categories. The increase in minor LEAs was driven by Native Americans (Annual Percent Change (APC)=7.1%, p < 0.001) and Asian/Pacific Islanders (APC=7.8%, p < 0.001). Residents of Non-Core (APC=5.4%, p < 0.001) and Large Central Metropolitan areas (APC=5.5%, p < 0.001), experienced the highest increases over time in minor LEA rates. Whites, residents of the Midwest, Non-Core and Small Metropolitan areas experienced a significant increase in major LEAs. Regression findings showed that Native Americans and Hispanics were more likely to have a minor or major LEA, compared to Whites. The odds of a major LEA increased with rurality and was also higher among residents of the South, compared to those of the Northeast. A steep decline in major to minor amputation ratios was observed, especially among Native Americans.


Despite increased risk of diabetes-related lower limb amputations in underserved groups, our findings are promising when the major to minor amputation ratio is considered.


This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS) under cooperative agreement #U1CRH30040. The information, conclusions, and opinions expressed in this brief are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred.


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