The Effect of Race, Insurance and Location on the Likelihood of Lower Limb Loss:

Understanding the Racial Disparities in Diabetes-Related Amputations

May 24, 2021

Alexis K. Barnes

alexiskbarnes@gwu.edu

In Partial Fulfilment for the Masters of Public Health Degree

Milken Institute School of Public Health

The George Washington University

Abstract

The global, regional and national burden of diabetes mellitus (DM) has a profound impact on

public health. In the United States, an estimated 29.1 million people are affected, with significant

prevalence within ethnic and racial minority groups, and the disease is the 7th leading cause of

death. Notably, underinsured, African American and low-income populations are

disproportionality impacted by diabetes-related lower extremity amputations (LEA). This critical

analysis reviewed the existing literature to understand the associations between race,

socioeconomic status and access to diabetic services. In addition, the analysis examined the

advantages and disadvantages of potential strategies for reducing racial disparities in diabetes-

related limb amputations. The literature review included articles published between 2011-2021

utilizing keyword searches in PubMed, OVID, and Medline. This analysis included published

articles in English and also included gray literature. Results found that although race/ethnicity

and socioeconomic status disparities persist, insurance status plays a critical role in amputation

rate disparities in the United States. Improving access to healthcare through insurance coverage

expansion, as well as instituting substantial policy change to insurance methods, paired with

holistic interventions like proven successful self-care management programs show promise in

reducing disparities in LEA.

Background

More than one-third of the US population is projected to have diabetes, one of the fastest

growing chronic diseases in the United States, by 2050.1 Type 2 diabetes, a condition in which

the body cannot properly utilize insulin causing blood sugar levels to rise, can result from

lifestyle and risk factors such as obesity, family history, high blood pressure, and low physical

activity according to the National Institute of Diabetes and Digestive and Kidney Diseases.

Having diabetes increases the risk of peripheral arterial disease (PAD), a circulatory condition

that reduces blood flow to limbs, causing foot ulcers or sores that can result in a gangrenous

infection and lead to limb amputation.2 Each year, 130,000 diabetes-related lower-extremity

amputations (LEA) are performed, disproportionately impacting lower-income, African-

American, and underinsured communities.3 This disparity is due in part to socioeconomic factors

such as fundamental disinvestment in higher risk communities, historic racial inequities,

geographic variability, as well as reduced access to and the underuse of recommended preventive

care.4

According to Healthy People 2030, a health disparity is defined as “a particular type of

health difference that is closely linked with social, economic, and/or environmental

disadvantage.” 5 These differences adversely affect groups of people who have systematically

experienced greater obstacles to health, discrimination, or exclusion based on their racial and

ethnic group and other characteristics such as socioeconomic status or geographic location.

Social determinants of health (SDOH) contribute to inequities in health, impacting quality of life

and require more public health programming than solely promoting healthy choices. Examples of

these determinants SDOH include, but are not limited to: safe housing and neighborhoods,

access to safe water and nutritious foods, education, income, transportation, and literacy skills.5
The prevailing health behavior paradigm often fails to take into account the importance that

SDOH and their impact on management of chronic diseases like diabetes; these social and

environmental determinants can predict poor health outcomes in vulnerable populations.6

It is well documented that diabetes affects certain groups of people more than others in

the United States due to a myriad of interwoven racial, ethnic, socioeconomic and geographic

health disparities. The table below, adapted from the CDC’s 2020 National Diabetes Statistics

Report, highlights the disproportionate percentage rates of diagnosed and undiagnosed diabetes

between 2013 and 2016. Although people who identify as African-American, non-Hispanic

make up only 13.4 percent on the United States population, according to the U.S. Census Bureau,

the estimated crude prevalence of both diagnosed and undiagnosed diabetes for this minority

group is 16.4 percent.

Table 1: Estimated Crude Prevalence of Diagnosed and Undiagnosed Diabetes among U.S.

Adults Aged 18 years or Older by Racial and Ethnic Group, 2013-2016

Characteristic Diagnosed diabetes Undiagnosed diabetes Total diabetes

Percentage Percentage Percentage
(95% CI) (95% CI) (95% CI)
Total 10.2 (9.3-11.2) 2.8 (2.4-3.3) 13.0 (12.0-14.1)
Age in years
18-44 3.0 (2.6-3.6) 1.1 (0.7-1.8) 4.2 (3.4-5.0)
45-64 13.8 (12.2–15.6) 3.6 (2.8–4.8) 17.5 (15.7–19.4)
≥65 21.4 (18.7–24.2) 5.4 (4.1–7.1) 26.8 (23.7–30.1)
Sex
Men 11.0 (9.7–12.4) 3.1 (2.3–4.2) 14.0 (12.3–15.5)
Women 9.5 (8.5–10.6) 2.5 (2.0–3.2) 12.0 (11.0–13.2)
Race/ethnicity
White, non-Hispanic 9.4 (8.4–10.5) 2.5 (1.9–3.3) 11.9 (10.9–13.0)
Hispanic 10.3 (8.1–13.1) 3.5 (2.5–4.8) 14.7 (12.5–17.3)
Asian, non-Hispanic 11.2 (9.5–13.3) 4.6 (2.8–7.2) 14.9 (12.0–18.2)
Black, non-Hispanic 13.3 (11.9–14.9) 3.0 (2.0–4.5) 16.4 (14.7–18.2)
Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2020. Atlanta, GA: Centers for Disease Control
and Prevention, U.S. Dept of Health and Human Services; 2020.
 Risk factors for diabetes-related complications like amputation are complex. According

to national data from the Centers for Medicare and Medicaid (CMS) from 2007 to 2016, African

American patients with PAD and diabetes were two to three times more likely than Caucasian

patients with the same diagnosis to have a limb amputation.7 The use of routine preventative

measures, such as foot exams and bypass surgery to avoid or mitigate amputation, also varied by

region and race. Although improvements in vascular treatment strategies have been associated

with declining diabetes-related amputation rates, a study between 2002 and 2010 of 17,463 fee-

for-service Medicare patients found that only one-third of patients were seen by a vascular

specialist in the year before amputation.8 Socioeconomic factors and Medicaid/Medicare

participation are significant contributors to increased risk of amputation among minorities,9

however no data within the last decade have determined the correlation between insurance status,

low income, and race on amputation rate disparities. This is significant because much of the at-

risk target diabetic population exist in economically disadvantaged regions with limited

physician referral and multidisciplinary care management.10

Limb salvage care, defined as limb-related admissions and procedures that occur during

the 2 years prior to amputation, provide promise for at-risk diabetic patients. However, black

patients are significantly less likely to have undergone arterial testing, revascularization

procedures, limb-related hospital admissions, toe amputation, or wound debridement prior to

amputation.11 Diabetic patients with severe blockages in leg arteries can sometimes be treated

with minimally invasive revascularization procedures to restore blood flow, yet angiograms-

which act like an X-ray for blood vessels- are used less on black patients to access

revascularization potential. Angiograms catch the buildup of fats and cholesterol before they

narrow blood vessels and starve limbs and organs of oxygen-rich blood or assess how badly a
blockage threatens a limb. Unchecked, this buildup can progress to non-healing sores, gangrene,

that require amputation.12 While racial bias may factor into diabetic amputation disparities, gaps

exist in recent data on the role of insurance status, specialized care referrals and environmental

factors, such as adequate health workforce and geographic proximity to hospital referral

regions.13

Disparities persist not only in the rate of amputations, but also in the severity of the

surgeries, most often a consequence of delay in diagnosis and care.13 The adverse effects of race,

insurance coverage, geographic location, lack of medical provider trust and compliance, and

comorbidities increase the risk for lower extremity ischemia and amputation.14 Other countries

have been successful in reducing disparities in diabetes-related complications through increased

access to care. For example, in Taiwan, despite some disparities between genders, age groups,

and levels of urbanization, a population-based study did find an overall downward trend in the

annual prevalence of LEA in people with type 2 diabetes from 2009 to 2013 after the

implementation of universal health insurance coverage.15 These findings show promise that the

removal of financial and insurance barriers could improve access to care, increase utilization of

preventative care seeking, and reduce unnecessary amputations.

Despite an increase in targeted public health initiatives to reduce ethnic and racial

disparities in diabetes care, geographic variability also exists within the United States and

presents additional and unique challenges in decreasing diabetes-related complications. The

“Diabetes Belt”, a geographically distinct cluster of 15 states spanning from Texas to West

Virginia, has a diabetes prevalence of 11% or greater among the adult population. This

Appalachian and Delta region is populated by 23.8% non-Hispanic African-Americans compared

to 12.1% representation in the rest of the country and has a higher prevalence of obesity and
sedentary lifestyle, and shorter life expectancy at birth.16,17 Amputation rates in rural Southeast

United States were seven times higher than any other part of the country.18 This population is

also largely uninsured and underinsured.

Diabetic amputation places a physical, mental and financial burden on patients and

society. Every year, each Medicare amputee beneficiary costs approximately $52,000.19 The

disability can also cause loss of productivity at work, reduced income and quality of life,

increased drug and healthcare cost expenditures and reduction in physical activity, an

exacerbating risk factor of diabetes.12,20 Understanding the feasibility and limitations of

procedures for reducing these disparities, such as mandatory preventative screenings for at-risk

individuals and expansion of insurance coverage, is critical to determining what challenges to

care exacerbate disparities in diabetes health outcomes.

Health inequities have been well documented decades, however the majority of previous

studies evaluating disparities examined racial/ethnic disparities and socioeconomic factors

independently. I seek to examine the intersection of race/ethnicity, socioeconomic status,

insurance status and geographic location to evaluate the feasibility of comprehensive multi-

layered policy recommendations. Evidence suggests that improving and standardizing access to

healthcare with sustainable federal funding, instituting substantial policy change to insurance

methods, bolstering primary care workforce in underserved US regions paired with proven

successful self-care management programs combined will have greatest impact in high-risk

communities.

Specific Aims

The first aim of this critical analysis is to understand the intersections and pathways

between race, insurance status, geography and healthcare access on diabetes-related amputations.
The second specific aim is to examine the advantages and disadvantages of potential strategies

for reducing racial disparities in diabetes-related limb amputations, such as public health

programming targeting at-risk communities, and the influence of insurance coverage or status.

The third aim of this critical analysis and unique contribution to the literature will be policy

recommendations to address this target population’s unique socio-economic and environmental

factors that make positive diabetic healthcare outcomes harder to achieve. The overall goal of

this analysis is to identify comprehensive solutions necessary for addressing this systemic and

preventable health outcome.

To address these aims, the following research questions will be asked in this critical analysis:

1. What is the intersection of race, socioeconomic factors, geographic variability and

healthcare access on diabetes care management and what impact does this intersection

have on diabetes-related limb amputations?

2. Does expanding insurance coverage impact access to vascular services that could

mitigate lower-extremity amputations?

3. What are current US policies impacting diabetes-related disparities and what policy

recommendations will address these disparities in lower-extremity amputations?

Methods

To address these aims, a systematic literature review was conducted using the following

databases: PubMed, OVID, and Medline. In each database, a search of title/abstracts was

performed for the following search terms: “disparities and amputation,” “race and amputation,”

“diabetes and socioeconomic factors”, “African-American and amputation and disparities”, and

“Medicaid expansion and diabetes.” A complete list of search terms is located in Appendix 1. In

addition, resources from federal organizations and professional societies, such as the Society for
Vascular Surgery, Centers for Disease Control and Prevention (CDC), American Diabetes

Association and the National Institute of Diabetes and Digestive and Kidney Diseases were

consulted. The review was limited to full-text articles published between 2011 and 2021,

available in English only.

Findings

Results of Literature Review

My literary search yielded approximately 61 articles, 25 of which were accessible for

review after the titles and abstracts were screened to address the intersection of race,

socioeconomic status, insurance status and diabetes-related limb amputations. A sampling of six

articles utilized is displayed in Table 2. Two government official overviews, or grey literature,

were also included in this analysis.

Authors Title Year

Hughes K, Mota L, Nunez M,
Sehgal N, Ortega G.
Lefebvre KM, Lavery LA.
Holman KH, Henke PK, Dimick
JB, Birkmeyer JD.
Lobo JM, Kim S, Kang H, et al.
Journal of the American Heart
Association
Durazzo TS, Frencher S,
Gusberg R.
The Effect of Income and Insurance on the Likelihood of 2019
Major Leg Amputation
Disparities in Amputations in Minorities 2011
Racial Disparities in the Use of Revascularization Before 2011
Leg Amputation in Medicare Patients
Trends in Uninsured Rates Before and After Medicaid 2020
Expansion in Counties Within and Outside of the
Diabetes Belt
Race and Socioeconomic Status Independently Affect 2021
Risk of Major Amputation in Peripheral Artery Disease
Influence of Race on the Management of Lower 2013
Extremity Ischemia: Revascularization vs Amputation

Aim 1. Intersection of race, socioeconomic factors, geography and healthcare access on

diabetes care management and diabetes-related limb amputations.

Race and socioeconomic influences

Race and socioeconomic status independently affect both diabetes prevalence and patient

risk of major amputation. Consistent with other studies, Arya et al. found that independent of

race, lower socioeconomic status increases amputation risk. 21,22 In California, Stevens et al.
mapped amputations based on residential zip codes, using statewide facility discharge data and

Census Bureau data, and found that lower-income urban and rural areas of the state overlapped

with amputation “hotspots”.23 Regions with higher amputation rates were geographically

clustered into hotspots that corresponded with high concentration of low-income households.

Although the ecological study lacked individual-level data, forcing researchers to associate

between poverty and amputation rates based on geographic distribution, they found that people

with diabetes in low-income neighborhoods had nearly double the amputation rate than people in

higher-income neighborhoods. They qualified low-income neighborhoods as areas in which

more than 40% of households had incomes below 200% of poverty. Evidence suggests that low-

income neighborhood residents are more likely to utilize under-resourced safety-net hospitals

that also limit access to vascular specialists and less-invasive limb salvage care.24

Biological risk factors, such as insulin resistance, hyperglycemia, obesity, and potentially

genetics, are regularly examined as the major contributors to racial and ethnic disparities in

diabetes development, prevalence, and mortality. In addition, social and environmental

contributors play a role in access to healthy food sources, safe and accessible spaces to exercise,

and psychosocial stressors associated with crime.25 Low socioeconomic areas have limited

choices of groceries stores and supermarkets and decreased walkability – all of which are linked

to poorer health outcomes. There are limitations in approaching public and clinical health and

chronic disease prevention on a individual-level when evidence suggests SDOH play a major

role in health outcomes, even when desired health behaviors are upheld6 That narrow approach

fails to take into account environmental and social elements like transportation, culturally

competent health providers, sub-standard housing, and limited recreational facilities.

 Ecological studies have found clusters of diabetes prevalence spikes within communities

characterized by specific racial/ethnic population, poverty, and food environment measures.16,18

Notable independent variables in these studies included: percentage of poor population,

percentage of uninsured population and percentage of African American population. Lefebvre

and Lavery found that African- American populations, regardless of geographic region, have a

higher incidence of amputation compared to white populations (5.0-6.5 per 10,000 individuals

versus 1.2-2.5 per 10,000).26 Researchers found this disparity among nonwhite, low-income and

underinsured as a consequence of delay in PAD diagnosis, most likely due to lack of access to

adequate primary care and/or specialized vascular services. In Arya et al.’s study, even after

accounting for comorbidities and chronic limb infection at presentation, black race

disproportionately affected health outcomes for diabetes and PAD-related complication.21 Simply

put, African Americans are more likely to undergo life-altering amputation than

revascularization techniques that could potentially improve blood flow in limb arteries.27

In a retrospective analysis of the National Surgical Quality Improvement Program’s

database for the years 2011 to 2017, multivariate models isolated the effect of race and ethnicity

on the likelihood of below-knee (BKA) and above-knee (AKA) amputations. Traven et al. found

that across all diagnoses, non-Hispanic African American were 93.3% more likely to undergo a

BKA than white patients (P<0.001).28 Out of 111,461 patients, of which 9,190 (8.2%) underwent

a BKA, 12.3% of amputations were performed on Black patients, despite representing only

20.7% of the study population. Similarly to other studies and real-world prevalence statistics,

African American patients make up the minority of the population yet account for the majority of

amputees. Table 3 shows the demographic data of surgery types and limb salvage procedures

performed on the study population, based on race.

Table 3: Demographic Data

Surgery Type All Patients White Black

N 111,461 88,346 (79.3%) 23,115 (20.7%)

BKA 8.2% 7.2% 12.3%
AKA 5.9% 4.8% 9.9%
Limb Salvage Procedure 85.9% 88.0% 77.8%
Traven, S. A., Synovec, J. D. , Walton, Z. J. , Leddy, L. R. , Suleiman, L. I. & Gross, C. E. (2020). Notable Racial
and Ethnic Disparities Persist in Lower Extremity Amputations for Critical Limb Ischemia and Infection. Journal of
the American Academy of Orthopaedic Surgeons, 28(21), 885–892. doi: 10.5435/JAAOS-D-19-00630.

This cohort-based study showed that black race was associated with both elevated AKA and

BKA risk, and was the most predictive factor for AKA.25 Of note, AKAs can cause more difficult

recoveries after surgery and lead to the most limited mobility.12 Even considering demographic

data and comorbidities, researchers could not account for the up to 90.2% of amputation

disparity rates between black, Hispanic, and white patients. Decreased access to care and health

literacy may contribute to differential care management outcomes; barriers to adequate care leads

to differences in the severity of disease at the time of presentation between black and white

patients.22

Geographic Variability

Compared to non-diabetes belt regions, and the national average, diabetes belt counties

have higher mean percentages of poor, uninsured, obese, African-American individuals.16

However, statistical results from Barker et al. suggests that even residents of the diabetes belt

with few risk factors were at greater risk than people outside of the belt.29 In comparison to the

rest of the country, residents within region have lower education levels, higher obesity rates, and

higher non-Hispanic African American populations. Interestingly, although Hispanic populations

also have a higher prevalence of diabetes in national statistics, they make up a small proportion

of the population of belt region counties. This suggests that interventions specifically targeting
the most at-risk racial/ethnic groups within a city or region should be considered and not an “all-

minority” approach.29 In addition, since evidence suggests local southern dietary habits; social,

cultural and lifestyle variations play a role in this regional disparity, conducting diabetes

prevalence research by region supports more cost-effective, public health interventions.

Focusing on community-level factors rather than individual factors, Myers et al. posited

that the associations between county-level diabetes prevalence and community characteristics

make the diabetes belt region ecologically unique. Researchers found that counties in the region

were more likely to be surrounded by counties with similarly high prevalence rates.16

Paradoxically, however, their evidence also found that compared to the rest of the country,

greater presence of natural amenities and green space was related to higher prevalence pf

diabetes. A multitude of obesity studies normally link increased access to natural amenities to

reduced obesity prevalence. In an overlapping of aims, counties within the diabetes belt face

more persistent poverty compared to the variances in income levels outside of the region.16 In

the same way Stevens et al. exposed geographic clustering of high diabetes prevalence in low-

income neighborhoods in California, evidence in this region suggests that geographic patterns

and income levels link to health outcomes.23

The Impact of Insurance

Health insurance and healthcare access are critical factors that determine if people with

diabetes are able to receive regular and timely medical care. In the last decade, researchers have

begun examining the adverse effects of race, income and insurance status on the quality of

diabetic care and the impact of these indicators on the rate of lower limb amputations. Studies

have shown that individuals with private insurance, Medicare or Medicaid coverage are more

likely to receive quality diabetes care than uninsured individuals regardless of race, ethnicity or
socioeconomic status, however the individuals who cannot qualify for or afford the

aforementioned coverage options tend to be African-American and Hispanic.30,31

Lacking health insurance forces individuals to turn to often under-resourced and

understaffed safety net facilities that cater to uninsured populations or rely on hospital

emergency departments for diabetic complications and crises, the latter could cost uninsured

patients exorbitant out of pocket fees and strains hospital and state budgets.31 In a 2019 cohort

study, researchers found that having Medicaid or no insurance was a notable predictor for PAD

and diabetes-related amputation. Studying the incidence of hospital admission, minor and major

amputations, endovascular interventions and open surgeries between 2003 and 2015 among

racial groups with diabetic foot infections, Tan et al. found that the minority patients studied

were less likely to have commercial insurance and more likely to be Medicaid/Medicare

beneficiaries. In comparison to the white patient population, the minority patients were more

likely to live in low-income areas and undergo major amputation without any revascularization

attempts.9,27 Combining both lower median household income level and Medicaid or no

insurance status, Hughes et al. stratified patients into four income quartiles, finding a significant

decrease in the odds ratio for amputation as patients progressed from one median household

income to a higher bracket.32 Consistent with the previous studies, Hughes et al.’s evidence

suggests that low income, as well as Medicaid/uninsured status associated with higher odds of

leg amputation, and among African American patients, lower odds of revascularization.

However, this study was unable to determine causality, just association.

Insurance status impacts quality of care despite certain facilities’ obligation to provide

health services to low-income and uninsured populations. Gold et al. found that even patients

that access safety net clinics receive diabetic preventive care at varying levels depending on
insurance coverage. Out of 3,384 diabetic adults in a 3-year retrospective cohort study, all

patients with partial insurance coverage, regardless of the length of time insured, had decreased

chances of receiving preventative lipid, nephropathy, and HbA1c screenings.24 This underlines

not only the importance of having expanded and affordable public insurance coverage for low-

income adults, but continuous coverage to ensure uninterrupted primary care.

Aim 2: Examine advantages and disadvantages of potential strategies for reducing racial
disparities in diabetes-related limb amputations.

Recent U.S. initiatives and approaches from the medical community have focused on

systematic programming to reduce disparities in diabetic management, screening and treatment.

Examples of programs include the submission of disparity-reducing legislation, public health

initiatives targeting at-risk communities, and individual states’ expansion of insurance coverage.

These approaches impact access to vascular services that could mitigate lower-extremity

amputations.

Expansion of Medicaid/Health Insurance

The Medicaid program provides important coverage for low-income adults with diabetes.

In 2014, the District of Columbia and twenty-six states expanded Medicaid under the Affordable

Care Act (ACA). Researchers found a 23 percent increase, or 3,395 newly diagnosed diabetics in

Medicaid expansion states, within the first 6 months of 2013 (control period) and 2014 (study

period). In comparison, non-expansion states saw an increase of 0.4 percent, or 41 patients.33

New diagnoses mean more patients seeking and receiving primary care and testing. Tan et al.

analyzed 19 state inpatient databases to identify people with diabetic foot ulcers who were either

uninsured or on Medicaid from 2013 to 2015. This study found that states that expanded ACA

Medicaid experienced substantial positive health outcomes for racial and ethnic minorities

compared to non-adopter states.34 Expanded states saw a reduction in uninsured residents with
diabetic foot ulcers and a 17.3 percent decrease in the odds of major amputation among non-

white Medicaid beneficiaries.34

Expanding insurance coverage in Massachusetts decreased the amputation disparity gap

between white and non-white patients.35 The state increased insurance coverage to approximately

98% of its residents, and Loehrer et al.’s evaluation of the expansion found that disparities in

severe PAD were no longer statistically significant, whereas disparities in control states

remained. Severe PAD probability for nonwhite patients in Massachusetts was 12-13% prior to

the 2006 expansion; this probability decreased by 11.2%.35 This reduction suggests that given

access to insurance, and thus adequate primary and vascular services, patients can experience the

same probability of chronic disease regardless of race.

In contrast, state lawmakers chose not to expand Medicaid that would have increased

access to low-income adults in Mississippi, a Diabetes Belt state with some of the highest

diabetes prevalence rates in the United States. This decision left 176,000 Mississippians without

access to healthcare.31 According to the Kaiser Family Foundation, 19.5 percent of

Mississippians ages 19-64 are uninsured, compared to 12.9 percent nationally. This leaves a

substantial population of disadvantaged people, in a state with the some of the highest rates of

diagnosed and undiagnosed diabetes as well as the third largest African-American population,

without access to primary care. Without access to regular primary care, complications like foot

ulcers can go unidentified until they become potentially life-threatening infections or acute limb

ischemia, which is the complete blockage of blood vessels that manifests as burning pain at rest,

non-healing wounds and gangrene.18,30

Preventing Amputations in Veterans Everywhere (PAVE)

 The U.S. Department of Veterans Affairs instituted the Preventing Amputations in

Veterans Everywhere (PAVE) program in 1993 to identify diabetic veterans through risk referral

criteria. The tailored risk-based program provides services including: patient education, assistive

devices, referral to specialty clinics, diabetes education, podiatry, smoking cessation, vascular

surgery, orthotics, rehabilitation, nutrition services and Telehealth programs.36

This program does not directly address racial disparities in LEA, but serves as an

example of a comprehensive and multidisciplinary plan to prevent the unnecessary loss of lower

limbs and rehabilitates patients after unavoidable amputations. There is also limited evidence

examining the impact of the program on complication outcomes of veterans with diabetes;

however a 2015-2020 clinical trial tested effectiveness of the program’s behavioral interventions

to improve self-management and modifiable risks. Study findings are not yet published.37

Everyone with Diabetes Counts Program

In 2008, the Centers for Medicare & Medicaid Services (CMS) launched a national

diabetes health disparities reduction program, Everyone with Diabetes Counts (EDC), to improve

outcomes among disparate and medically underserved racial/ethnic minority and/or rural

Medicare populations.38 This diabetes self-management education (DSME) program taught

participants healthy lifestyle changes, the importance of monitoring/testing and self-foot exams.

Importantly, the program took diabetes care management out of the clinical setting and into the

community. Community health workers were a major factor in program delivery, as well as

partnerships with local faith-based organizations and private businesses. One notable program

goal included engaging both beneficiaries and providers to decrease the disparity in preventative

diabetes testing like foot exams and lipid screenings.38 Silveira et al. evaluated the West

Virginian EDC pilot program.39 The study showed that participants who completed the program
were more likely to receive monitoring tests in both pre- and post-intervention time periods than

diabetics who had not completed the program.39 EDC was limited to 7 states and ended in 2012.

Researchers named cost containment, scalability, and time as major limitations, and limited

studies examined the overall outcomes of the program.

Although DSME programs are evidence-based and proven to improve health outcomes

for populations with diabetes, they often fail to meet the needs of the un- or underinsured

population. Shaw et al. found that only 42% of uninsured adults ever attended a diabetes

education class.40 In addition, Medicare reimbursement is determined at state level and many

individual states do not cover diabetes self-management program reimbursement for individuals

at the poverty level.40 An overlapping theme within the implementation of these programs is the

importance of clinician, community and private entity partnership.38 Evidence shows that

increasing health literacy improves health outcomes and equity, however, participants need to

have a willingness to follow program guidelines.

Aim 3: Current US policies and policy recommendations to address racial and socioeconomic
disparities in lower-extremity amputations.

Current Policy and Legislation

In a legislative move that would reduce financial hardship for beneficiaries, the

Amputation Reduction and Compassion (ARC) Act H.R. 2631 was introduced in October 2020.

The bill would cover the costs of PAD screening tests for at-risk Medicate/Medicaid and federal

healthcare exchange beneficiaries.41 If passed, at-risk patients, including 30 million Americans

living with diabetes and the estimated 84 million living with prediabetes, would not be eligible

for amputation prior to arterial testing to determine if alternative measures could be utilized. The

bipartisan bill also includes education for both health care professionals and public, especially

targeted at-risk minorities, on methods to reduce amputations.

 A leading advocate for ARC, Rep. Payne, Jr. also co-founded the first ever Congressional

PAD Caucus to push forward the aforementioned policy initiatives and others, including

incentivizing multidisciplinary review of PAD patients in Medicare.41 This type of prioritization

by the federal government is crucial for policies to be enforced and guide desired health

outcomes, ensuring more equitable and cost-effective delivery of quality care.

Policy Recommendations

Research has shown that a decrease in amputation rates is possible with adequate primary

care, timely referral to vascular services, consistent foot and wound care, and aggressive limb

revascularization therapies. As evidenced in this analysis, however, people of certain

racial/ethnic groups, people living in lower-income areas, and people with subpar medical

insurance status bear a disproportionate share of disability from amputation. A successful policy

response would take into account the complex web of patient/provider, social and delivery

systems that all impact amputation rates in poorer, un- and underinsured and predominantly

African American communities.

Recommendation 1: Expansion of insurance and incentivization of service in low-

primary care physician regions

Expansion of both Medicaid and private insurance enrollment through the ACA should

be mandated nationwide to ensure consistency in care and reduce dependency on emergency

departments for late stage health services. The economic burden of diabetic care and

complications already costs the United States more than $325 billion, according to a 2017 study

commissioned by the American Diabetes Association, including $237 billion in direct medical

costs and $90 billion in reduced productivity.42 These costs rose by 26% between 2012 and 2017,

including absenteeism, for the employed population, inability to work due to disease-related
disability and lost productivity due to premature death. As diabetes prevalence continues to

increase annually nationwide, so will these costs on patients, healthcare systems, and American

taxpayers. Funding this expansion and increasing access to care could be a cost-benefit savings,

compared to the costs of, usually delayed, care of at-risk populations.

Expanding health insurance coverage to all state residents, however, does not take into

account the lower supply of primary care providers in rural regions and low-income

neighborhoods. To account for these primary care shortage areas and geographic maldistribution,

the federal government and medical schools can incentivize service in underrepresented regions

through student loan forgiveness or incremental pay increases, as primary care physicians

already earn substantially lower than physicians who specialize. The National Health Service

Corps works in this way, but is underfunded - only granting limited applicants with scholarships

or loan repayment awards. Prior to ACA, the program was funded with discretionary

appropriations; between FY2011 and FY2017, its funding was supplemented by the mandatory

Community Health Center Fund.43 The amount of funds the program receives determines the

number of awards dispersed, so major increases in funding could place more primary care

physicians in underserved regions.

Recommendation 2: Standardize insurance reimbursement rates and fund mandatory

preventative screenings for at-risk patients

Healthcare financing plays a major role in the amount of patients a physician can assess

and the quality of care that patient receives. Many physicians turn away or limit their Medicare

and Medicaid patients due to the rising operating costs and poor reimbursement rates in

comparison to private insurers. The federal government can expand funding in order to

standardize reimbursement rates among both public and private insurers, as well as increase
funding towards community health centers, rural health clinics and Indian Health Service clinics.

If each state expanded insurance coverage, these intuitions would see an increase in patients and

need improved financial capacity to support this surge. They also already serve a critical role in

healthcare delivery for at-risk populations and in geographic regions that are medically

underserved. Not only that, but increased funding would allow the hiring of more specialized

vascular physicians, increasing a multidisciplinary approach in diabetic care management.

Evidence has suggested that people with diabetes of low SES and those with Medicaid or

no insurance are more likely to have advanced stage PAD and have it treated with amputation

instead of limb salvaging revascularization.30,32 Funding PAD preventative screening tests for at-

risk patients, both under Medicare/Medicaid programs and ACA health plans, and requiring them

prior to amputations would improve PAD treatment and reduce disparities in diabetes

complications.

Recommendation 3: Institute free or low-cost diabetes self-management education

programs

DSME programs improve preventative practices and behaviors so that people living with

diabetes can improve decision-making and self-care. Helping individuals adhere to routine

medical visits, preventative blood glucose and lipid tests, foot and eye exams and practice health

dietary and physical lifestyle changes can delay or prevent diabetes-related complicatons.44

These programs are particularly beneficial for rural populations with challenges accessing care.

However, the limited availability of these programs for the un- or underinsured and those of low

income, particularly in non-metropolitan regions, make benefitting from them impossible.44

Ensuring the accessibility and availability of American Diabetes Association- recognized DSME

programs for all individuals is crucial for the behavior change and health literacy needed for
socially disadvantaged populations. Piloting standardized DSME programs in at-risk regions,

such as diabetes belt counties, can cause the biggest impact in both improving diabetes self-care

management and education, and reducing related complications. These programs would need to

be culturally competent, financially feasible for participants (or consistently funded by the

federal government), and staffed by DSME certified health professionals. This recommendation

could be aligned with recommendation 1, whereas federal and/or state governments provide

incentives and training for primary care physicians, dieticians, registered nurses, and health

educators to serve in facilities or DSME programs in underserved at-risk regions.

Discussion

My literature review suggests that although race/ethnicity and socioeconomic status

disparities persist, insurance coverage plays a major role in impacting diabetes care and

management. 24,30,32,35 While unmodifiable patient factors contribute to differences in health

outcomes, researchers are starting to delve into the impact of systems. Findings show that

insurance coverage has an equally and sometimes greater impact on ensuring at least minimum

diabetes care is met. Untreated or poorly controlled diabetes can lead to LEA, however without

accessible and adequately funded specialty care and education, that access to care is not feasible

for all Americans. In the US, unfortunately, the un- and underinsured population overlap with

racial/ethnic minorities and low-income populations. This creates a particularly vulnerable

patient population with unmet needs and lower health literacy. In the last two decades, advances

in diabetes management have ushered in new protocols, medications, and medical devices;

however the playing field is not level for those without insurance to receive optimal care for

preventable complications.

Disproportionate
rates of lower
Race & Socioeconomic extremity
Factors amputations
among
racial/ethnic
minorities.
 Insurance
Coverage/Status

Geography  Institutional racism/provider bias

 Comorbidities/biological risk factors
 Psychosocial stressors
 Reduced access to fresh foods/safe spaces

 Lack of access to adequate care

 Lack of access to specialized services
 Potential Provider bias
 Reliance on safety-net providers and EDs

 Limited health facilities/health workforce

 Regional differences in culture/lifestyle
 Concentration of poverty

Figure 1. Explanatory framework for disproportionate rates of LEAs in underinsured minority

populations

Much of the literature assessed utilized cross-sectional data which inferences association

over causation and was unable to account for selection bias in LEAs where it is possible findings

are due to physicians choosing particular patients for certain procedures based on their insurance

status.30,32 In addition, some studies were unable to account for revascularization attempts in

outpatient facilities, therefore findings were based on presentation at in-patient hospital facilities

where limbs may have already been beyond salvage.32

Public health initiatives and national strategies, such as Healthy People 2020 and the

Centers for Medicare & Medicaid Services Diabetes Health Disparities Reduction Program, have

made a concerted effort to specifically focus on high-risk populations and geographic areas to

address disparities in the frequency and rate of LEAs among minority populations, however

more studies need to be conducted to take into account the impact of Medicaid expansion, or

lack thereof, within at-risk regions of the United States on access to primary care and specialized

diabetic services. In addition, programs like the CMS reduction initiative have been limited in

their timelines and unsustainable in their financing structures.38

 In the same way that race, SES and geographic location form a risk factor web where

each individual characteristic plays a different role in quality of and access to care, each policy

recommendation provides an improvement to current options for both patients and providers.

However, they are most valuable in conjunction, improving the foundation of care management

for the most at-risk and vulnerable populations. None of these approaches or recommendations

can be successful without nationally recognized policies that: (1) target marginalized at-risk

communities with culturally competent and accessible DSME programs to avoid/mitigate the

disease; (2) adequate financial compensation from Medicare/Medicaid and private insurance

companies for providers to ensure access to necessary specialized care for already diagnosed

diabetics; and (3) bolster the primary health workforce in under-resourced and underserved

regions. Insurance expansion is most beneficial with improvements to the public insurance

system and health provider landscape in their totality. Consistent and sustainable funding at the

federal and state level is critical to the implementation of resources for at-risk communities.

Limitations

The findings in this critical analysis are subject to at least two limitations. First, this

review specifically focused on African-American, non-Hispanic populations. However

disparities exist across all minority racial/ethnic groups within the United States, particularly

Native American and Alaskan populations. Second, most of this review focuses on association

and not causality. Patient behavior that leads to delayed presentation of infection or PAD could

remove the potential for revascularization and predispose individuals to amputation. Health

behavior, non-biological risk factors, poor patient-provider communication, and a lack of

provider education on at-risk communities are additional recognized contributors to disparities in

diabetes outcomes that are not studied thoroughly in this review.

Conclusion

This analysis identified an association between disparities in diabetes-related lower limb

amputations and the intersection of race, socioeconomic status, insurance status and geographic

location. It also identified race and insurance status as particularly important indicators of

reduced access to care, preventative screenings, and presenting at later stages of disease. The

analysis presented demonstrated positive associations of increased health service utilization and

decreased LEAs with expanded access to insurance coverage. This information is useful for

guiding targeted health finance and resource allocation, as well as policy recommendations, to

benefit at-risk communities.

Appendix 1 – Search Terms

Topic: Diabetes-Related Amputations

Population: African-American, Low-Income, Insurance Status. race

 Outcome: Disparities

Policy Solutions: Universal Coverage, Medicare/Medicaid Expansion

 Disparities and amputation

 African-American and amputation and disparities

 Race and amputation

 African-American and lower extremity amputations and disparities

 Insurance status and lower limb amputations

 Insurance status and disparities and lower extremity amputations

 Low Income and diabetes and amputation

 Low Income and diabetes and disparities

 Medicare and African American and diabetes

 Medicaid Expansion and amputations and diabetes

 Diabetes Belt and Medicaid and expansion

 Diabetes Belt and disparities and low income

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