title: Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population.
abstract: OBJECTIVE
  To describe geographic variation in rates of lower-limb major amputation in Medicare patients with and without diabetes.
  
  
  METHODS
  This cross-sectional population-based study used national fee-for-service Medicare claims from 1996 through 1997. The unit of analysis was 306 hospital referral regions (HRRs) representing health care markets for their respective tertiary medical centers. Numerators were calculated using nontraumatic major amputations and the diabetes code (250.x) for individuals with diabetes. Denominators for individuals with diabetes were created by multiplying the regional prevalence of diabetes (as determined using a 5% sample of Medicare Part B data identifying at least two visits with a diabetes code for 1995-1996) by the regional Medicare population. Denominators for individuals without diabetes were the remaining Medicare beneficiaries. Rates of major amputations were adjusted for age, sex, and race.
  
  
  RESULTS
  Rates of major amputations per year were 3.83 per 1,000 (95% CI 3.60-4.06) individuals with diabetes compared with 0.38 per 1,000 (95% C1 0.35-0.41) individuals without diabetes. Marked geographic variation was observed for individuals with and without diabetes; however, patterns were distinct between the two populations. Rates were high in the Southern and Atlantic states for individuals without diabetes. In contrast, rates for individuals with diabetes were widely varied. Variation across HRRs for individuals with diabetes was 8.6-fold compared with 6.7-fold in individuals without diabetes for major amputations.
  
  
  CONCLUSIONS
  Diabetes-related amputation rates exhibit high regional variation, even after age, sex, and race adjustment. Future work should be directed to exploring sources of this variation.
authors.affiliation: Veterans Affairs Medical and Regional Office Center, White River Junction, Vermont 05009, USA. james.s.wrobel@dartmouth.edu
authors.forename: J S
authors.initials: JS
authors.lastname: Wrobel
authors.forename: J A
authors.initials: JA
authors.lastname: Mayfield
authors.forename: G E
authors.initials: GE
authors.lastname: Reiber
mesh_terms: D017677:Age Distribution; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D017719:Diabetic Foot / Q000453:epidemiology* / Q000601:surgery*; D005260:Female; D005843:Geography; D006801:Humans; D007866:Leg; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D015995:Prevalence; D014481:United States / Q000453:epidemiology