In 2009, California hospitals collectively documented 7,973 lower-extremity amputations in diabetic adults. Dr. Carl Stevens at Harbor-UCLA decided to ask a question most people in medicine had quietly avoided: where do these patients live?
The answer, published five years later in Health Affairs, was the kind of finding that is simultaneously obvious in retrospect and genuinely shocking when you see it on a map. Amputation rates varied tenfold between the wealthiest and poorest ZIP codes in California. In LA County, the map had a shape: South LA, Watts, Compton, and the Gateway Cities glowed red. Beverly Hills and Santa Monica barely registered. Same county. Same hospitals within driving distance. Radically different outcomes.
Stevens called it plainly in a PBS NewsHour interview: neighborhoods have characteristics that allow households to produce good health outcomes. When those characteristics are absent, people suffer. That was 2014. The question worth asking in 2026 is: what have we done with 15 years of evidence since then?
The National Confirmation
If Stevens established the pattern in California, Fanaroff and colleagues confirmed it everywhere. In a 2021 paper in the Journal of the American Heart Association, they analyzed Medicare claims from 2010 to 2018 — nearly 189,000 patients across more than 31,000 ZIP codes nationwide. More than three-quarters of amputees lived in metropolitan areas. For every $10,000 drop in median household income, amputation rates rose 4.4% — after controlling for diabetes, hypertension, smoking, and every clinical variable measurable. And 32% of patients who underwent amputation had received zero diagnostic arterial testing in the 12 months before the procedure.
The Community Layer
A 2023 analysis in JAMA Surgery examined the 100 most populous US counties: which community-level factors actually drive amputation rates? Measuring 28 metrics across five CDC-defined health domains, the answer was not glycemic control. It was food security, educational attainment, primary care density, and transportation infrastructure. Counties with high amputation rates had systematically worse scores across every community health dimension measured.
The Mortality Reframe
The five-year mortality rate after major lower-extremity amputation is 56.6% — between colorectal and lung cancer in terms of lethality (Armstrong et al., JFAR 2020). Diabetic foot ulceration alone carries a five-year mortality (30.5%) that matches the pooled five-year mortality for all reported cancers (31%). People with a history of DFU have a life expectancy fully five years lower than age- and disease-matched controls. Yet federal funding for diabetic foot research operates at a 600-fold disadvantage relative to other diabetes research.
The Recurrence Problem
Armstrong and colleagues proposed in a 2017 NEJM paper that patients with healed diabetic foot ulcers should be considered in remission rather than healed — because the greatest risk factor for a new ulcer is a previously healed one. Recurrence rates: 40% within one year, 65% within five years, greater than 90% within ten years. A 2025 paper in the International Wound Journal confirmed that three-year DFU recurrence (58%) and CLTI reintervention (50%, BEST-CLI trial) meet or exceed recurrence rates of advanced breast, prostate, and colorectal cancers. Healed is not the same as safe.
But It Is Solvable
At a county safety-net hospital in Los Angeles serving an 89% Hispanic population, an interdisciplinary Limb Preservation Service with a single-call hot foot line for rapid triage cut major amputations from 15.4% to 8.4% — a 45.5% reduction, OR 0.5 (Bazikian, Khan, Armstrong et al., JFAR 2024). Length of stay fell. Outpatient procedures increased more than fivefold. Every $1 invested in podiatric care for patients with diabetes returns an estimated $27 to $51 in healthcare savings. The same 20 ZIP codes appear in every analysis as the epicenter of preventable amputations in LA County — and mobile clinics, satellite podiatry offices, and rapid-triage protocols are high-leverage, evidence-backed, and fiscally rational.
Why We Built This Narrative
The evidence has been there for 15 years. What the literature does not produce by itself is a way to hand all of that to someone who is not a vascular surgeon or health policy researcher and have them immediately understand what is at stake. This narrative is that attempt — a scrollable synthesis designed to do its work in a single sitting in front of a funder, a hospital CEO, a community health worker, or a city council member.
The ZIP code lottery is real, documented beyond reasonable dispute. The human cost — measured in limbs, life expectancy, dollars, and dignity — is staggering and preventable. And it is solvable. The tools exist. The question is whether we choose to deploy them where they are needed most.
Sources: Stevens et al., Health Affairs 2014; Armstrong DG et al., NEJM 2017; Armstrong DG et al., JFAR 2020; Fanaroff et al., JAHA 2021; Armstrong DG et al., JAMA 2023; JAMA Surgery 2023; Bazikian, Khan, Armstrong et al., JFAR 2024; Armstrong NS et al., IWJ 2025; Farber et al. (BEST-CLI), NEJM 2022.
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