The effect of risk and race on lower extremity amputations among Medicare diabetic patients

J Vasc Surg. 2012 Dec;56(6):1663-8. doi: 10.1016/j.jvs.2012.05.100. Epub 2012 Sep 8.


Objective: The effect of national quality initiatives aiming at limiting lower extremity amputations in diabetic patients remains uncertain. We therefore explored trends in amputation among Medicare diabetic patients with a focus on those at highest risk.

Methods: The Diabetes Analytical File, an enhanced sample of all diabetic patients from the Medicare 5% sample, was used to study the national incidence of amputation in diabetic patients. Within a cohort of ∼5 million diabetic patients between 1999 and 2006, we compared the incidence of amputation in high-risk (end-stage renal disease or more than three comorbidities) and low-risk groups and by race.

Results: Between 1999 and 2006, 23,976 amputations were performed, comprising 11,558 in high-risk and 12,418 in low-risk patients. The amputation rate declined over time from 4.8/1000 in 1999 to 4.4/1000 in 2006 (P<.001). High-risk patients represented a growing proportion of all amputations (33% in 1999, 50% in 2006; P<.001) despite representing 4% of diabetic patients in 1999 and 10% in 2006 (P<.001). The incidence of amputation was 29.6/1000 in the high-risk group vs 2.7/1000 in low-risk patients (P<.001). African Americans had higher rates of amputation in high-risk and low-risk groups.

Conclusions: High-risk patients represent a minority of Medicare diabetic patients but account for 50% of all amputations, and this effect is magnified in African Americans. Future quality improvement efforts should focus on high-risk patients and African Americans.

MeSH terms

  • African Americans / statistics & numerical data*
  • Aged
  • Aged, 80 and over
  • Amputation / statistics & numerical data*
  • Diabetes Complications / ethnology*
  • Diabetes Complications / surgery*
  • European Continental Ancestry Group / statistics & numerical data*
  • Female
  • Humans
  • Incidence
  • Kidney Failure, Chronic / epidemiology
  • Lower Extremity
  • Male
  • Medicare / statistics & numerical data*
  • Middle Aged
  • Risk Factors
  • United States / epidemiology