Diabetes-related amputations have reversed a decade-long trend and are now on the rise, according to the American Diabetes Association (ADA).
ADA’s Amputation Prevention Alliance reports that 154,000 diabetes sufferers now undergo amputations annually, and up to 80 percent of all non-traumatic lower-limb amputations are the result of uncontrolled diabetes. Limb amputations due to diabetes occur every three minutes and 30 seconds in the United States. Amputations are more prevalent among patients of color. More than half of patients with diabetes-related amputations will die within five years.
Downward Trend Reverses
A study published by the ADA in 2019 of all non-traumatic lower extremity amputations among young and middle-aged people in all demographic groups found a 43 percent decrease from 2000 to 2009, but a rebound of 50 percent from 2009 to 2015.
Another study on diabetes-related amputations, led by Jessica Harding, Ph.D., found that while amputations per thousand diabetes patients fell by half from 2000 to 2009, dropping from 8.5 to 4.4 percent, the rate ticked back upward after 2009, to 4.8 percent. Similarly, Bruce A. Perkins, M.D., reported in a paper a decline from 2005 to 2010, followed by an uptick from 2010 to 2016.
The ADA noted that the trend varied by state, with a handful of states leading the trend, while others maintained lower rates.
Ethnic Disparity
A January 16, 2024, article in The New York Times, titled “Diabetes Is Fueling an Amputation Crisis for Men in San Antonio,” focused on the explosion of diabetes-related amputations in the heavily Hispanic-populated Texas city. It also cited the existence in Latino and Native American populations of genes that predispose the pancreas to make insufficient insulin, and other genes that cause tissues to become insulin-resistant.
A fact sheet from the Amputee Coalition similarly cites a one-and-a-half times greater likelihood of Latino Americans suffering amputation of any kind compared with other ethnicities in the United States, and a 30 percent greater risk of diabetes-related amputation compared to “white Americans,” suggesting that changing demographics may be a factor in the recent upward trend in amputations.
Risk-Reducing Care
John Abramson, M.D., family physician and author of Sickening: How Big Pharma Broke American Health Care and How We Can Repair It, says the rise is not just a matter of ethnicity, but other societal factors.
“Preventing amputations among Americans with type 2 diabetes will require a multipronged approach,” said Abramson. “First, participation in healthy lifestyle modification programs can reduce the risk of developing diabetes by more than 50 percent.
“Second, good medical care of lower leg and foot ulcers can prevent amputations. This is especially true in the higher-risk populations: black and non-black Hispanic patients as well as those with less education. The risks of amputation are primarily socially-determined and the most effective prevention will address the upstream causes.”
‘Care When They Need It’
Beyond the issue of ethnicity, some experts see the increasing role of government insurance plans, including Medicare-Medicaid and plans under the Affordable Care Act, as contributing to poor access and follow-through.
Deane Waldman, M.D., a professor emeritus of Pediatrics, Pathology, and Decision Science at the University of New Mexico, cites disincentives for timely care under government health plans as a contributing factor.
“The fundamental problem is a seesaw effect,” said Waldman. “As government-insured patients—Medicaid and Tricare—go up, access to care goes down. So, as more diabetics enroll in Medicaid, especially—though Medicare will soon face the same problem when bankruptcy stops Medicare paying for hospital care—they simply don’t get care when they need it. This is well documented in our veterans. Patients wait longer and longer for care, and diabetes progresses to the point where amputation cannot be avoided.
‘More Death-By-Queue’
As more Americans enroll in government health care programs, access to care falls, says Waldman.
“Most of the complications of diabetes can be avoided or at least dramatically delayed, by timely care, including close monitoring of diet and glucose levels by professionals, and drugs, when necessary, with close follow-up,” said Waldman. “That is precisely what they don’t get with government insurance. Look up the section on Joel Brenner in my book, Curing the Cancer in U.S. Healthcare, to see what good care, that is, timely care, can do for diabetics.
“As the regulatory burden increases and payments to providers decrease, provider shortages get worse, further extending the wait times so there is more death-by-queue,” said Waldman.
High Copays and Medicaid
High copays—up to 20 percent of treatment and medication costs under Medicaid for higher-income enrollees—may provide a disincentive for patients to seek timely care.
Robert Koshnick, M.D., family medicine specialist and author of Patient-Directed NIMBLE Healthcare: Reduce Health and Financial Disparities in the U.S. with Tax Credits for Direct Primary Care and HSAs, said lack of an incentive to seek direct primary care likely plays a role in increasing diabetes complications for some demographics.
“People need to have incremental care by a primary care physician to address obesity issues and treat diabetes appropriately,” said Koshnick. “One solution to assure primary care access would be for the government to give a tax rebate to people for the cost of establishing a direct primary care relationship.”
Kevin Stone (kevin.s.stone@gmail.com) writes from Arlington, Texas.
.){kind=link}