From the Guidelines
Black and Hispanic patients with diabetes are more likely to undergo amputation compared to white patients with similar degrees of illness, with Black patients having a 2- to 4-fold higher risk of amputation, as reported in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline for the management of lower extremity peripheral artery disease 1. This disparity persists even when controlling for disease severity, socioeconomic factors, and access to healthcare. Studies have shown that these disparities reflect systemic inequities in healthcare delivery, including differences in preventive care, early intervention, and referral patterns. Contributing factors include delayed diagnosis, less frequent specialist referrals, reduced access to advanced wound care, and fewer vascular interventions aimed at limb salvage. Healthcare providers should be aware of these disparities and work to ensure equitable care through comprehensive foot examinations, early referrals to specialists for at-risk patients, culturally appropriate diabetes education, and addressing social determinants of health that may impact diabetes management, as highlighted in the 2021 Diabetologia study 1. Key factors to consider include:
- Racial and ethnic disparities in the outcome and care among patients with peripheral artery disease (PAD) and diabetes
- Higher rates of risk-amplifying comorbidities, such as systemic hypertension, diabetes, and chronic kidney disease (CKD), among Black patients
- Later stage disease detection and lower rates of prescription of guideline-directed medical therapy (GDMT) among Black patients
- Significant disparities in amputation risk, with Black patients having a 2- to 4-fold higher risk of amputation compared to White patients, as reported in the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS guideline 1. Recognizing and addressing these disparities is essential for improving outcomes for all patients with diabetes.
From the Research
Racial Disparities in Diabetes-Related Amputations
- Black and Hispanic patients with diabetes are more likely to undergo amputation compared to white patients with similar degrees of illness 2, 3, 4, 5, 6.
- Studies have consistently shown that the rate of diabetes-related lower-extremity amputations is higher among black and Hispanic patients compared to white patients 2, 4, 6.
- The average major lower-extremity amputation rate in diabetic Medicare patients was 1.78 per 1,000 per year for black patients, 1.15 per 1,000 per year for Hispanic patients, and 0.56 per 1,000 per year for white patients 2.
Factors Contributing to Racial Disparities
- Poor footwear, elevated hemoglobin A1c levels, peripheral neuropathy, and peripheral vascular disease are independent risk factors for diabetes-related lower-extremity amputations in black and Hispanic patients 5.
- Inadequate access to quality healthcare, health information technology, and diabetes education may also contribute to the higher rates of amputations among minority populations 3, 4.
- Regional and racial/ethnic variation in the incidence of concomitant diabetes and peripheral artery disease may also play a role in the disparities in amputation rates 4.
Trends and Declines in Amputation Rates
- Despite the higher rates of amputations among black and Hispanic patients, studies have shown that the incidence of major amputation in Medicare patients with diabetes has declined over the past decade, with similar declines across racial groups 2, 4.
- The use of quality improvement initiatives, health information technology, and consistent hemoglobin A1c testing may be effective in reducing amputation rates and improving diabetes outcomes in all racial groups 2, 3.