title: Lower-extremity amputation risk is associated with variation in behavioral risk factor surveillance system responses.
abstract: OBJECTIVE
  To determine whether regional variation in the rate of lower-extremity amputation (LEA) is associated with health behaviors.
  
  
  METHODS
  This was a cross-sectional prevalence study of merged data from the U.S. Census, Medicare parts A and B, and the Behavioral Risk Factor Surveillance System. We used regression models to determine whether previously described regional variation in LEA incidence was associated with responses to the Behavioral Risk Factor Surveillance System. Regions were created using Dartmouth Atlas Health Referral Regions.
  
  
  RESULTS
  The mean and median incidence of LEA was 4.5 per 1,000 persons with diabetes; the rate varied from 2.4 to 7.9 LEA per 1,000 persons by health referral region. Statistically significant inverse associations were found between LEA and the rate of patients reporting colorectal screening (P < 0.0001) or the participation in diabetes management classes (P = 0.018). Most other factors, including daily foot evaluations, were not associated with a decreased risk of LEA. These findings were also found to be associated with geographically clustered regions known for increased risk of LEA.
  
  
  CONCLUSIONS
  LEA is known to vary by region in the U.S., and regions with higher rates of LEA tend to be clustered together. Some of this variation may be explained by health behaviors in those regions, such as attending diabetes education classes or better health prevention habits (e.g., colon cancer screening). It should be possible to prevent unwanted LEAs by educating individuals with diabetes and foot ulcers about the need for participation in foot ulcer treatment.
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PADepartment of Dermatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA margo@mail.med.upenn.edu.
authors.forename: David J
authors.initials: DJ
authors.lastname: Margolis
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Ole
authors.initials: O
authors.lastname: Hoffstad
authors.affiliation: Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
authors.forename: Douglas J
authors.initials: DJ
authors.lastname: Weibe
mesh_terms: D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D040343:Behavioral Risk Factor Surveillance System; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000453:epidemiology / Q000601:surgery; D017719:Diabetic Foot / Q000453:epidemiology / Q000601:surgery; D005260:Female; D016523:Foot Ulcer / Q000453:epidemiology / Q000601:surgery; D015438:Health Behavior; D006801:Humans; D015994:Incidence; D035002:Lower Extremity / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012309:Risk-Taking; D014481:United States / Q000453:epidemiology