{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:57:21Z","timestamp":1790751441313,"version":"4.1.0"},"reference-count":35,"publisher":"American Diabetes Association","issue":"10","license":[{"start":{"date-parts":[[2020,9,21]],"date-time":"2020-09-21T00:00:00Z","timestamp":1600646400000},"content-version":"vor","delay-in-days":55,"URL":"https:\/\/www.diabetesjournals.org\/content\/license"}],"content-domain":{"domain":["diabetesjournals.org"],"crossmark-restriction":true},"short-container-title":[],"published-print":{"date-parts":[[2020,10,1]]},"abstract":"<jats:sec>\n                  <jats:title>OBJECTIVE<\/jats:title>\n                  <jats:p>Diabetes is a leading cause of nontraumatic lower-extremity amputation (NLEA) in the U.S. After a period of decline, some national U.S. data have shown that diabetes-related NLEAs have recently increased, particularly among young and middle-aged adults. However, the trend for older adults is less clear.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>RESEARCH DESIGN AND METHODS<\/jats:title>\n                  <jats:p>To examine NLEA trends among older adults with diabetes (\u226567 years), we used 100% Medicare claims for beneficiaries enrolled in Parts A and B, also known as fee for service (FFS). NLEA was defined as the highest-level amputation per patient per calendar year. Annual NLEA rates were estimated from 2000 to 2017 and stratified by age-group, sex, race\/ethnicity, NLEA level (toe, foot, below-the-knee amputation [BKA], or above-the-knee amputation [AKA]), and state. All rates were age and sex standardized to the 2000 Medicare population. Trends over time were assessed using Joinpoint regression and annual percent change (APC) reported.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>RESULTS<\/jats:title>\n                  <jats:p>NLEA rates (per 1,000 people with diabetes) decreased by half from 8.5 in 2000 to 4.4 in 2009 (APC \u22127.9, P &amp;lt; 0.001). However, from 2009 onward, NLEA rates increased to 4.8 (APC 1.2, P &amp;lt; 0.01). Trends were similar across most age, sex, and race\/ethnic groups, but absolute rates were highest in the oldest age-groups, Blacks, and men. By NLEA type, overall increases were driven by increases in rates of toe and foot NLEAs, while BKA and AKA continued to decline. The majority of U.S. states showed recent increases in NLEA, similar to national estimates.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>CONCLUSIONS<\/jats:title>\n                  <jats:p>This study of the U.S. Medicare FFS population shows that recent increases in diabetes-related NLEAs are also occurring in older populations but at a less severe rate than among younger adults (&amp;lt;65 years) in the general population. Preventive foot care has been shown to reduce rates of NLEA among adults with diabetes, and the findings of the study suggest that those with diabetes\u2014across the age spectrum\u2014could benefit from increased attention to this strategy.<\/jats:p>\n               <\/jats:sec>","DOI":"10.2337\/dc20-0586","type":"journal-article","created":{"date-parts":[[2020,7,29]],"date-time":"2020-07-29T02:27:50Z","timestamp":1595989670000},"page":"2453-2459","update-policy":"https:\/\/doi.org\/10.2337\/ada-journal-policies","source":"Crossref","is-referenced-by-count":70,"title":["National and State-Level Trends in Nontraumatic Lower-Extremity Amputation Among U.S. Medicare Beneficiaries With Diabetes, 2000\u20132017"],"prefix":"10.2337","volume":"43","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6664-8630","authenticated-orcid":false,"given":"Jessica L.","family":"Harding","sequence":"first","affiliation":[{"name":"Division of Transplantation, Department of Surgery, Emory University School of Medicine, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda J.","family":"Andes","sequence":"additional","affiliation":[{"name":"Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Deborah B.","family":"Rolka","sequence":"additional","affiliation":[{"name":"Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Giuseppina","family":"Imperatore","sequence":"additional","affiliation":[{"name":"Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward W.","family":"Gregg","sequence":"additional","affiliation":[{"name":"Department of Epidemiology and Biostatistics, School of Public Health, Imperial College, London, U.K."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yanfeng","family":"Li","sequence":"additional","affiliation":[{"name":"Division of Heart Disease and Stroke Prevention, Centers for Disease Control and Prevention, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ann","family":"Albright","sequence":"additional","affiliation":[{"name":"Division of Diabetes Translation, Centers for Disease Control and Prevention, Atlanta, GA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1167","published-online":{"date-parts":[[2020,7,28]]},"reference":[{"key":"2022031223565815400_B1","doi-asserted-by":"crossref","first-page":"1029","DOI":"10.2337\/diacare.22.7.1029","article-title":"Lower-extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers","volume":"22","author":"Adler","year":"1999","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B2","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1177\/1479164116651390","article-title":"The prevalence of major lower limb amputation in the diabetic and non-diabetic population of England 2003-2013","volume":"13","author":"Ahmad","year":"2016","journal-title":"Diab Vasc Dis Res"},{"key":"2022031223565815400_B3","doi-asserted-by":"crossref","first-page":"825","DOI":"10.1007\/s00592-016-0879-4","article-title":"Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD)","volume":"53","author":"Carinci","year":"2016","journal-title":"Acta Diabetol"},{"key":"2022031223565815400_B4","doi-asserted-by":"crossref","first-page":"2051","DOI":"10.1007\/s00125-004-1584-3","article-title":"Amputation as a marker of the quality of foot care in diabetes","volume":"47","author":"Jeffcoate","year":"2004","journal-title":"Diabetologia"},{"key":"2022031223565815400_B5","doi-asserted-by":"crossref","first-page":"1514","DOI":"10.1056\/NEJMoa1310799","article-title":"Changes in diabetes-related complications in the United States, 1990-2010","volume":"370","author":"Gregg","year":"2014","journal-title":"N Engl J Med"},{"key":"2022031223565815400_B6","doi-asserted-by":"crossref","first-page":"50","DOI":"10.2337\/dc18-1380","article-title":"Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population","volume":"42","author":"Geiss","year":"2019","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B7","unstructured":"Centers for Medicare & Medicaid Services\n          . Original Medicare (Part A and B) Eligibility and Enrollment, 2019. Accessed 22 July 2020. Available from https:\/\/www.cms.gov\/Medicare\/Eligibility-and-Enrollment\/OrigMedicarePartABEligEnrol"},{"key":"2022031223565815400_B8","unstructured":"Centers for Medicare & Medicaid Services\n          . Inpatient or outpatient hospital status affects your costs, 2020. Accessed 22 July 2020. Available from https:\/\/www.medicare.gov\/what-medicare-covers\/what-part-a-covers\/inpatient-or-outpatient-hospital-status-affects-your-costs"},{"key":"2022031223565815400_B9","unstructured":"Centers for Medicare & Medicaid Services\n          . Chronic Conditions Data Warehouse, 2020. Accessed 22 July 2020. Available from https:\/\/www2.ccwdata.org\/web\/guest\/condition-categories"},{"key":"2022031223565815400_B10","unstructured":"National Cancer Institute Division of Cancer Control & Population Sciences National Cancer Institute\n          . Joinpoint trend analysis software. Accessed 22 July 2020. Available from https:\/\/surveillance.cancer.gov\/joinpoint\/"},{"key":"2022031223565815400_B11","doi-asserted-by":"crossref","first-page":"1430","DOI":"10.2337\/dc19-0296","article-title":"Trends of nontraumatic lower-extremity amputation in end-stage renal disease and diabetes: United States, 2000-2015","volume":"42","author":"Harding","year":"2019","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B12","unstructured":"Diabetes UK\n          . 26,378 diabetes-related lower limb amputations in the last three years, 2018. Accessed 22 July 2020. Available from https:\/\/www.diabetes.org.uk\/about_us\/news\/lower-limb-amputations"},{"key":"2022031223565815400_B13","doi-asserted-by":"crossref","first-page":"1966","DOI":"10.1007\/s00125-018-4655-6","article-title":"Decreasing rates of major lower-extremity amputation in people with diabetes but not in those without: a nationwide study in Belgium","volume":"61","author":"Claessen","year":"2018","journal-title":"Diabetologia"},{"key":"2022031223565815400_B14","doi-asserted-by":"crossref","first-page":"475","DOI":"10.2147\/CLEP.S146484","article-title":"Lower-extremity amputations in people with and without diabetes in Germany, 2008-2012 - an analysis of more than 30 million inhabitants","volume":"10","author":"Claessen","year":"2018","journal-title":"Clin Epidemiol"},{"key":"2022031223565815400_B15","doi-asserted-by":"crossref","first-page":"1613","DOI":"10.1056\/NEJMsa1213829","article-title":"Achievement of goals in U.S. diabetes care, 1999-2010","volume":"368","author":"Ali","year":"2013","journal-title":"N Engl J Med"},{"key":"2022031223565815400_B16","doi-asserted-by":"crossref","first-page":"1769","DOI":"10.1001\/jama.2011.551","article-title":"Coronary revascularization trends in the United States, 2001-2008","volume":"305","author":"Epstein","year":"2011","journal-title":"JAMA"},{"key":"2022031223565815400_B17","doi-asserted-by":"crossref","first-page":"217","DOI":"10.1001\/jama.293.2.217","article-title":"Preventing foot ulcers in patients with diabetes","volume":"293","author":"Singh","year":"2005","journal-title":"JAMA"},{"key":"2022031223565815400_B18","doi-asserted-by":"crossref","first-page":"2252","DOI":"10.1016\/S0140-6736(12)60480-2","article-title":"Effectiveness of quality improvement strategies on the management of diabetes: a systematic review and meta-analysis","volume":"379","author":"Tricco","year":"2012","journal-title":"Lancet"},{"key":"2022031223565815400_B19","doi-asserted-by":"crossref","first-page":"2363","DOI":"10.2337\/dc11-0807","article-title":"Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes","volume":"34","author":"Margolis","year":"2011","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B20","article-title":"Variation in the care of surgical conditions: diabetes and peripheral arterial disease: A Dartmouth Atlas of Health Care Series","author":"Goodney","year":"2014"},{"key":"2022031223565815400_B21","doi-asserted-by":"crossref","first-page":"2280","DOI":"10.2337\/diacare.28.9.2280","article-title":"Ethnic differences in mortality, end-stage complications, and quality of care among diabetic patients: a review","volume":"28","author":"Lanting","year":"2005","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B22","doi-asserted-by":"crossref","first-page":"E1579","DOI":"10.1210\/jc.2012-2043","article-title":"Health disparities in endocrine disorders: biological, clinical, and nonclinical factors--an Endocrine Society scientific statement","volume":"97","author":"Golden","year":"2012","journal-title":"J Clin Endocrinol Metab"},{"key":"2022031223565815400_B23","first-page":"23","article-title":"Insulin requirements in non-critically ill hospitalized patients with diabetes and steroid-induced hyperglycemia","volume-title":"Hosp Pract (1995)","author":"Spanakis","year":"2014"},{"key":"2022031223565815400_B24","doi-asserted-by":"crossref","first-page":"1867","DOI":"10.1001\/jama.2019.3471","article-title":"Resurgence in diabetes-related complications","volume":"321","author":"Gregg","year":"2019","journal-title":"JAMA"},{"key":"2022031223565815400_B25","doi-asserted-by":"crossref","first-page":"626","DOI":"10.1007\/s00125-017-4488-8","article-title":"Risk of lower limb amputation in a national prevalent cohort of patients with diabetes","volume":"61","author":"Gurney","year":"2018","journal-title":"Diabetologia"},{"key":"2022031223565815400_B26","doi-asserted-by":"crossref","first-page":"1460","DOI":"10.2337\/dc10-0310","article-title":"Diabetic foot prevention: a neglected opportunity in high-risk patients","volume":"33","author":"Lavery","year":"2010","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B27","doi-asserted-by":"crossref","first-page":"84","DOI":"10.1016\/j.diabres.2016.12.007","article-title":"Prevention and management of foot problems in diabetes: a Summary Guidance for Daily Practice 2015, based on the IWGDF guidance documents","volume":"124","author":"Schaper","year":"2017","journal-title":"Diabetes Res Clin Pract"},{"key":"2022031223565815400_B28","doi-asserted-by":"crossref","first-page":"537","DOI":"10.1016\/S2213-8587(16)30010-9","article-title":"The changing face of diabetes complications","volume":"4","author":"Gregg","year":"2016","journal-title":"Lancet Diabetes Endocrinol"},{"key":"2022031223565815400_B29","doi-asserted-by":"crossref","first-page":"1139","DOI":"10.2337\/dc16-2442","article-title":"Declines in the incidence of diabetes in the U.S.-real progress or artifact","volume":"40","author":"Selvin","year":"2017","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B30","first-page":"e0","article-title":"Medicare Part D insulin tiering change: impact on health outcomes","volume":"8","author":"Nguyen","year":"2016","journal-title":"Am J Pharm Benefits"},{"key":"2022031223565815400_B31","doi-asserted-by":"crossref","first-page":"929","DOI":"10.2337\/dci18-0012","article-title":"The cost of diabetes care-an elephant in the room","volume":"41","author":"Riddle","year":"2018","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B32","doi-asserted-by":"crossref","first-page":"53","DOI":"10.1111\/dme.13512","article-title":"Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England","volume":"35","author":"Paisey","year":"2018","journal-title":"Diabet Med"},{"key":"2022031223565815400_B33","doi-asserted-by":"crossref","first-page":"725","DOI":"10.2337\/diacare.29.03.06.dc05-2078","article-title":"The impact of comorbid chronic conditions on diabetes care","volume":"29","author":"Piette","year":"2006","journal-title":"Diabetes Care"},{"key":"2022031223565815400_B34","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1016\/j.diabres.2005.02.010","article-title":"Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations","volume":"70","author":"Lavery","year":"2005","journal-title":"Diabetes Res Clin Pract"},{"key":"2022031223565815400_B35","doi-asserted-by":"crossref","first-page":"961","DOI":"10.15585\/mmwr.mm6843a2","article-title":"Diabetes prevalence and incidence among Medicare beneficiaries - United States, 2001-2015","volume":"68","author":"Andes","year":"2019","journal-title":"MMWR Morb Mortal Wkly Rep"}],"container-title":["Diabetes Care"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/diabetesjournals.org\/care\/article-pdf\/43\/10\/2453\/630322\/dc200586.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/diabetesjournals.org\/care\/article-pdf\/43\/10\/2453\/630322\/dc200586.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2022,3,13]],"date-time":"2022-03-13T03:55:36Z","timestamp":1647143736000},"score":1,"resource":{"primary":{"URL":"https:\/\/diabetesjournals.org\/care\/article\/43\/10\/2453\/35939\/National-and-State-Level-Trends-in-Nontraumatic"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,7,28]]},"references-count":35,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2020,7,28]]},"published-print":{"date-parts":[[2020,10,1]]}},"URL":"https:\/\/doi.org\/10.2337\/dc20-0586","relation":{},"ISSN":["0149-5992","1935-5548"],"issn-type":[{"value":"0149-5992","type":"print"},{"value":"1935-5548","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,7,28]]}}}