Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

Key Points

Question

Is the intersection of race, ethnicity, rurality, and/or neighborhood disadvantage associated with outcomes among US patients with diabetic foot ulcers?

Findings

In this cohort study of 124 487 patients hospitalized with diabetic foot ulcers, 17.6% underwent major (above-ankle) leg amputation or died within 30 days of hospital discharge; proportions increased to 18.3% for rural patients and 21.9% for those identifying as Black. The proportion increased to 28.0% for patients who identified as both rural and Black, suggesting a role for intersectionality.

Meaning

This study suggests that the intersection of rural residence and identifying as Black is associated with an amplified risk of major leg amputation or death among US patients with diabetic foot ulcers.

Abstract

Importance

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

Objective

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

Design, Setting, and Participants

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

Exposures

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

Main Outcomes and Measures

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

Results

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% − 17.6% = 0.7%) plus those identifying as Black (21.9% − 17.6% = 4.3%) by more than 2-fold (28.0% − 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

Conclusions and Relevance

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

Abstract

This cohort study assesses whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.