Black diabetics have leg amputations more often than non-blacks do in every part of the U.S., according to a new report that analyzed variations in care. Black patients are nearly three times as likely to lose limbs overall, though the disparity is greater in some areas, particularly the South, according to the report from the Dartmouth Institute for Health Policy and Clinical Practice.
Diabetes, combined with artery blockages that can reduce circulation to limbs, can turn otherwise minor wounds in the feet into dangerous infections; more than half of the almost 100,000 leg amputations Medicare pays for annually are linked to diabetes.
But those amputations aren’t evenly distributed. Diabetics are far more likely to keep their legs in Royal Oak, Mich., where the amputation rate is 1.2 per 1,000 patients with diabetes and peripheral artery disease, than in Tupelo, Miss., where it’s 6.2, according to the analysis of Medicare data from 2007 to 2011. Some areas had smaller gaps in the amputation rate between blacks and non-blacks, but amputations were more common for blacks in all of the 306 markets studied.
All the patients in the study were on Medicare, so the disparities aren’t explained by lack of access to insurance. Patients’ environments account for some of the difference, says Marshall Chin, a University of Chicago doctor and director of the Finding Answers: Disparities Research for Change program. His patients on the South Side of Chicago may not have access to healthy food to help manage blood sugar, and may not live in neighborhoods where it’s safe to walk for exercise. “We currently as a system don’t do a great job of addressing the social determinants of health,” he said on a conference call unveiling the report.
The disparity in amputation rates is also related to how well patients are cared for before they arrive in front of doctors who have to decide whether to remove a leg. Regular medical care can help people who lose sensation in their feet because of diabetes recognize problematic wounds or ulcers, says Robert Gabbay, chief medical officer at the Joslin Diabetes Center in Boston, who was not involved in the research. The loss of sensation from diabetes comes from uncontrolled high blood sugar, so patients need regular care and medication to keep their blood sugar levels in check and lower the risk for amputation. Otherwise, everyday activity such as trimming toenails can become hazardous, leading to wounds vulnerable to infection.