TULSA, OKLA. – After years of decreasing amputations in the United States , rates of non-traumatic lower extremity amputations due to diabetes and related conditions are rising, and Oklahoma is among the states with the most pronounced increase, a new University of Oklahoma study has found .
Between 2008 and 2019, the statewide amputation rate nearly doubled, with both major and minor amputations spiking, said Kelly Kempe , M.D., an associate professor of vascular surgery at the OU School of Community Medicine in Tulsa and lead author of the study, published in the Journal of Vascular Surgery.
"Major amputations, such as the removal of a leg below or above the knee, are rising, and significantly so," Kempe said. "No matter how you look at the data, the results are troubling."
When diabetes is poorly managed, reduced blood flow can damage toes, feet or legs, raising the risk of removal. Peripheral arterial disease, the narrowing or blockage of blood vessels from the heart, is another common condition often associated with diabetes that, if left undiagnosed, can also result in lower limb loss.
To develop a baseline of state-specific risk factors for disease-related amputations, Kempe and colleagues collected more than 1.3 million anonymized discharge records of Oklahoma patients with diabetes or peripheral arterial disease released over a 12-year period.
By analyzing disease codes, the researchers found that 15,642 of those discharged with either disease had also undergone amputations, an average of 12 amputations per 1,000 patients. Using a year-over-year comparison, Kempe calculated that the proportion of amputations climbed dramatically during the study period – from 8.1 per 1,000 in 2008, to 16.2 per 1,000 in 2019.
The U.S. average is 4.9 for every 1,000 adults , according to the Centers for Disease Control and Prevention.
By pairing results with demographic and insurance coverage data, Kempe found that rates of amputation were the highest among males, American Indians, the uninsured, non-married and those between 45 and 49 years of age. Uniquely, married status played a mitigating role, highlighting social support as a possible protective effect.
Kempe said there are several theories that might explain the spike in amputations. While careful management of conditions like diabetes can guard against limb loss, the high rate of uninsured in the state – nearly 14% in 2021 – means many at-risk patients cannot access quality preventive care.
"Having your blood sugar checked frequently does make a difference; that's proven," Kempe said. "Unfortunately, Oklahoma is known for having health care access issues, in part because we have one of the highest uninsured rates in the country and because we are a rural state. That may explain why the uninsured are so strongly associated with amputations in our study."
The other factor is structural, Kempe said. Research has shown that multidisciplinary health systems – clinics where patients can access primary care physicians as well as specialists, such as podiatrists and vascular surgeons – improve limb preservation outcomes. Yet in many states, including Oklahoma, this model of care is rare.
Kempe, herself a vascular surgeon, said her team's recent pilot project, to train Chickasaw Nation primary care providers about lower limb disease detection and prevention, demonstrates the effectiveness of a multidisciplinary approach. Preliminary findings from that study were published in the Journal of Vascular Surgery in June. Expansion of this work was then performed with Muscogee Creek Nation's providers, and the final study is being analyzed.
As health care experts and leaders seek to reduce the rate of preventable amputations in Oklahoma, Kempe said there's an urgent need to implement limb preservation programs and redouble efforts to direct interventions toward those at increased risk.
"To be effective in any health care measure, you must tackle challenges at all levels, including policy," she said. But the first step is awareness. "A good place to start is simply talking about the dangers, and the solutions."
