title: The effect of risk and race on lower extremity amputations among Medicare diabetic patients.
abstract: 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.
authors.affiliation: Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03765, USA. joshua.b.goldberg@hitchcock.org
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Goldberg
authors.forename: Philip P
authors.initials: PP
authors.lastname: Goodney
authors.forename: Jack L
authors.initials: JL
authors.lastname: Cronenwett
authors.forename: Frank
authors.initials: F
authors.lastname: Baker
mesh_terms: D001741:Black or African American / Q000706:statistics & numerical data*; D000368:Aged; D000369:Aged, 80 and over; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D048909:Diabetes Complications / Q000208:ethnology* / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D007676:Kidney Failure, Chronic / Q000453:epidemiology; D035002:Lower Extremity; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data*; D008875:Middle Aged; D012307:Risk Factors; D014481:United States / Q000453:epidemiology; D044465:White People / Q000706:statistics & numerical data*