Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2014 Aug;33(8):1383-90.
doi: 10.1377/hlthaff.2014.0148.

Geographic clustering of diabetic lower-extremity amputations in low-income regions of California

Carl D Stevens  1 , David L Schriger  2 , Brian Raffetto  3 , Anna C Davis  4 , David Zingmond  5 , Dylan H Roby  6
Affiliations

Geographic clustering of diabetic lower-extremity amputations in low-income regions of California

Carl D Stevens et al. Health Aff (Millwood). 2014 Aug.

Abstract

For patients suffering from diabetes and other chronic conditions, a large body of work demonstrates income-related disparities in access to coordinated preventive care. Much less is known about associations between poverty and consequential negative health outcomes. Few studies have assessed geographic patterns that link household incomes to major preventable complications of chronic diseases. Using statewide facility discharge data for California in 2009, we identified 7,973 lower-extremity amputations in 6,828 adults with diabetes. We mapped amputations based on residential ZIP codes and used data from the Census Bureau to produce corresponding maps of poverty rates. Comparisons of the maps show amputation "hot spots" in lower-income urban and rural regions of California. Prevalence-adjusted amputation rates varied tenfold between high-income and low-income regions. Our analysis does not support detailed causal inferences. However, our method for mapping complication hot spots using public data sources may help target interventions to the communities most in need.

Keywords: Chronic Care; Disparities; Health Promotion/Disease Prevention; Public Health; Safety-Net Systems.

PubMed Disclaimer

Figures

EXHIBIT 2
EXHIBIT 2
Rate of Lower Extremity Diabetic Amputations per 1000 Adults Age 45 and Older with Diabetes, Los Angeles County, 2009 SOURCE: The numerator is based on analysis of the California Office of Statewide Health Planning and Development, 2009 Patient Discharge Data and 2009 Ambulatory Surgery Center Data. The denominator is based on the 2009 California Health Interview Survey. NOTES: Data are mapped at the ZCTA/multiZCTA level, and represent the rate of non-traumatic lower extremity amputations associated with a diagnosis of diabetes per 1000 diabetic adults age 45 and older. The rate is presented in quartiles for the region.
EXHIBIT 3
EXHIBIT 3
Proportion of Households with Income Below 200% of the Federal Poverty Level, Los Angeles County, 2003–2009 SOURCE: 2003–2009 American Community Survey pooled estimates of household income from the United States Census Bureau. NOTES: Data are mapped at the ZCTA/multiZCTA level, and represent proportion of households with income below 200% of the Federal Poverty Level. The rate is presented in quartiles for the region.
EXHIBIT 4
EXHIBIT 4
Association between Proportion of the Population with Low Income and Amputation Rate Among Diabetic Adults, California Overall and Four Urban Areas, 2009 SOURCE: Amputation data are based on California Office of Statewide Health Planning and Development, 2009 Patient Discharge Data and 2009 Ambulatory Surgery Center Data and the 2009 California Health Interview Survey. Poverty data are based on 2003–2009 American Community Survey pooled estimates of household income from the United States Census Bureau. NOTES: This is a plot of amputation rate and proportion of the population below 200% of the federal poverty level by ZCTA/multiZCTA. Fitted lines are provided for each geographic region of interest. This plot represents a simple association and does not adjust for possible confounders.
See this image and copyright information in PMC

References

    1. Johnson S. The ghost map: The story of London's most terrifying epidemic--and how it changed science, cities, and the modern world. New York: Penguin; 2006.
    1. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990 May;13(5):513–521. - PubMed
    1. Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev. 2000 Sep-Oct;16(Suppl 1):S75–S83. - PubMed
    1. Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM. Preventive foot care in people with diabetes. Diabetes Care. 2003 Jan;26(Suppl 1):S78–S79. - PubMed
    1. Patout CA, Jr, Birke JA, Horswell R, Williams D, Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population. Diabetes Care. 2000 Sep;23(9):1339–1342. - PubMed

Publication types