title: Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation.
abstract: OBJECTIVE
  To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system.
  
  
  METHODS
  We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence.
  
  
  RESULTS
  Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30-1.54; P < 0.0001 for all male gender-socio-economic status interactions) than women (hazard ratio 1.20, 95% CI 1.06-1.36). Overall, the incidence of lower extremity amputation was higher among men than women (hazard ratio for men vs women: 1.87, 95% CI 1.79-1.96), with the greatest disparity between men in the lowest socio-economic status category and women in the highest (hazard ratio 2.39, 95% CI 2.06-2.77 and hazard ratio 2.30, 95% CI 1.97-2.68, for major and minor amputation, respectively).
  
  
  CONCLUSIONS
  Despite universal access to hospital and physician care, we found marked socio-economic status and gender disparities in the risk of lower extremity amputation among patients with diabetes. Men living in low-income neighbourhoods were at greatest risk.
authors.affiliation: Department of Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: L
authors.initials: L
authors.lastname: Amin
authors.forename: B R
authors.initials: BR
authors.lastname: Shah
authors.forename: A S
authors.initials: AS
authors.lastname: Bierman
authors.forename: L L
authors.initials: LL
authors.lastname: Lipscombe
authors.forename: C F
authors.initials: CF
authors.lastname: Wu
authors.forename: D S
authors.initials: DS
authors.lastname: Feig
authors.forename: G L
authors.initials: GL
authors.lastname: Booth
mesh_terms: D000328:Adult; D000671:Amputation, Surgical / Q000191:economics; D015331:Cohort Studies; D017719:Diabetic Foot / Q000191:economics / Q000453:epidemiology / Q000503:physiopathology / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D054624:Health Status Disparities; D006801:Humans; D015994:Incidence; D019458:Insurance Coverage; D007349:Insurance, Health, Reimbursement; D008297:Male; D009864:Ontario / Q000453:epidemiology; D011204:Poverty Areas; D016016:Proportional Hazards Models; D012042:Registries; D012307:Risk Factors; D012720:Severity of Illness Index; D012737:Sex Factors; D013222:State Medicine