Race trumps region when it comes to which people with diabetes might be more at risk of having a leg amputated, according to the latest installment of the Dartmouth Atlas of Health Care Series. The raison d’être of the series is to measure practice variation variation across the country.
However, this report ‘also takes a more patient-centered view,’ writes Michael J. Barry, MD, of Harvard Medical School in the foreward to ‘Variation in the Care of Surgical Conditions: Diabetes and Peripheral Arterial Disease.’
The national average rate for leg amputation among Medicare patients from 2007 to 2011 was 2.4 per 1,000; for blacks, it was 5.6 per 1,000, nearly three times the rate it was for other beneficiaries.
‘Across the United States, the risk of amputation averages between 2 and 3 per 1,000 patients with diabetes and peripheral arterial disease,’ the study states. ‘However, the rate can be up to eight times higher in some places, especially among black patients. In fact, when comparing black and nonblack patients, the lowest-risk black patients have a higher risk of amputation than nearly all nonblack patients.’
About 100,000 leg amputations occur among Medicare patients each year — more than half because of diabetes, according to the study, which divides the country into 306 hospital regions.
Treatment approach varies as well. There are prevention and more invasive techniques to stave off amputation.
Prevention might not work if the disease is advanced, and invasive procedures used on low-risk patients could do more harm than good, while also wasting a lot of money. Unfortunately, the educational level needed to make these choices seems to vary as well.
‘In some regions of the United States,’ the study states, ‘invasive vascular care was rarely provided, while in other regions, vascular interventions, including interventional procedures and surgical bypass operations, were common. The use of these procedures also varied markedly by patient race. Further, while the rates of revascularization were higher among black patients in many regions, the extent of variation for both endovascular procedures and open bypass surgery was much more dramatic among black patients, indicative of a poorer understanding of what works best to limit amputation risk for these high-risk patients.’