Major amputation rates for individuals with diabetes exhibited 8.6-fold variation compared with 6.7-fold variation for major amputations for individuals without diabetes. Major amputation rates exhibited a high degree of variation when compared with 11 other procedures in the Medicare population over the same time period using the same methods. Only lower-extremity re- vascularization, carotid endarterectomy, back surgery, and radical prostatectomy exhibited higher variation than amputation in individuals with diabetes (7). In The Netherlands, rates of diabetes-related amputation for the 27 health care regions varied fourfold, whereas nondiabetes-related amputation varied only twofold (8). Our study found higher rates of variability than that observed in The Netherlands but a similar pattern of higher variability in individuals with diabetes as compared with individuals without diabetes.

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