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Patients with diabetes and peripheral artery disease (PAD) face a very real risk — limb amputation. But Black patients also face a grim reality. Non-traumatic amputation rates for Black patients are up to eight times higher than the U.S. average, depending on location, according to data from a Dartmouth Atlas of Health Care Series, and regardless of location, they are up three times more likely than any other race to receive an amputation.
Amputations can be devastating. Half of patients with a diabetic foot ulcer who undergo amputation will die within five years. Patients with PAD who undergo a lower extremity amputation have even worse outcomes: half will die within one year of amputation and 70% will die within three years.
Geographical and Racial Differences
Amputation rates in the U.S. vary significantly by region. Cities such as San Diego and Las Vegas have low overall amputation rates (2.1 and 2.2 per 1,000), while the highest rates are in the southeastern states among Black patients who have diabetes and live in rural areas. For example, Lynchburg, Virginia has an amputation rate of 14 per 1,000; Meridian, Mississippi is 14.2 per 1,000 and Tupelo, Mississippi is 16.1 per 1,000.
The average U.S. amputation rate for Black patients is significantly higher than the average amputation of all races (5.6 vs. 2-3 per 1,000). When comparing Black and non-Black patients, Black patients with the lowest geographical risk of amputation still face a higher risk of amputation than nearly all non-Black patients, regardless of geography.
Even within the same geography, amputation rates differ by race. For example, in Monroe, Louisiana, amputation rates among Black patients were more than ﬁve times higher than among non-Black patients (7.9 vs. 1.5 per 1,000). Tupelo, Mississippi had the highest amputation rates for both Black and non-Black patients, but the rate among Black patients was more than three times higher (16.1 versus 4.7 per 1,000).
Why the Disparity?
In an article for Wound Source, Alton Johnson, Jr., clinical assistant professor and attending physician at the University of Michigan School of Medicine, compares amputation prevention in the Black community to a war zone, citing poverty, food deserts, and smoking as the enemies.
Johnson also attributes the high rate of amputation in Black patients to the fact that there may be no other option by the time the patient goes to the doctor. “From an economic and socioeconomic standpoint, there’s a lack of access to appropriate healthcare, being able to afford preventative medicine, not having transportation to get to appointments and not wanting to be a burden to family members,” he says. “Sometimes by the time we do see patients, amputation — transmetatarsal, below knee or above knee — is the only option we have — all of their arteries are clogged.”
When patients do come for preventive healthcare appointments, there’s an additional barrier because many of the medications to treat PAD and diabetes are expensive or have expensive copays, Johnson says. Putting in an angiostent is a minimally invasive procedure for PAD or ischemia, but usually requires prior insurance approval and mandates a certain number of medical visits — all of which requires money, transportation and social support.
“We’re doctors so we’re always thinking about lower limb preservation, but we also have to consider the patient’s social and economic situation,” Johnson says. The cost of limb amputation is about half that of limb preservation, he says, which likely includes regular home nursing visits and dressing supplies. Even when doctors attempt limb preservation, it may be ultimately unsuccessful and lead to eventual amputation for the patient.
The Way Forward
The solution, says Johnson, is that the medical community must take a holistic approach to patient care rather than focusing solely on acute care. This could be done by someone in the doctor’s office, hospital or even a third party, he says. Education should focus disease prevention by eating fresh fruits and vegetables and minimizing chips and canned goods.
Patients may need assistance finding the best grocery stores for their dietary needs and figuring out transportation. Once a patient is ill, it might be about logistics like helping to schedule a nurse for home visits or finding transportation for medical appointments. “We need a synergistic approach and a team system to patient care,” Johnson says. “In terms of getting patients to appointments, sometimes a surgeon is so busy that if the patient is 10 minutes late, they cancel the appointment and that can set the patient back a month.”
Some medical facilities have already begun these types of initiatives, Johnson says. Patients with diabetes may be offered free courses on topics including diabetic foot ulcers and the effect of nutrition on healing as well as access to a free patient advocate. “I think that’s the only way we’re going to solve this whole situation of amputations in Black communities,” he says.