Income-related disparities in access to preventive care have been found in patients diagnosed with diabetes and other chronic conditions, according to a study published in Health Affairs.

Geographic analyses of illness patterns have supported major public health initiatives, and can be attributed in large part to the control of communicable conditions in developed countries.

The availability of geographic information systems and public population-based data has developed new opportunities for scientists to identify causes and craft interventions for chronic illnesses.

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“Few studies have assessed geographic patterns that link household incomes to major preventable complications of chronic diseases,” wrote Card D. Stevens, MD, of the David Geffen School of Medicine at the University of California, Los Angeles.

To study income-disparity among patients with chronic conditions, the investigators used statewide facility discharge data for California in 2009 to identify 7,973 lower-extremity amputations in 6,828 adult patients with diabetes. The investigators mapped amputations based on residential zip codes and used data from Census Bureau to produce maps of poverty rates.

The maps revealed amputation “hot spots” in lower-income urban and rural regions of California. Prevalence-adjusted amputation rates vary tenfold between high-income and low-income regions.

Association Between The Low-Income Proportion Of The Population And The Amputation Rate Among Adults In California With Diabetes, 2009.

Patients diagnosed with diabetes who underwent a nontraumatic lower extremity amputation were more commonly male, aged 65 years and older, and non-English speaking.

“People with diabetes who live in lower-income neighborhoods in California have higher rates of lower-extremity amputation than those who reside in more affluent areas,” wrote the researchers. “Our hot-spot method of displaying complication rates may assist providers and public health agencies in targeting interventions to the populations that are the most affected.”


  1. Stevens C et al. Health Affairs. 2014; doi: 10.1377/hlthaff.2014.0148