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This analysis found large inequalities related to sex and to neighbourhood-level income, high school completion and social deprivation.

Notes
Based on analysis of age-standardized rates per 100,000 people age 18 and older in the general population. Income, high school completion and social deprivation were defined at the neighbourhood level using the patient’s residential postal code. Refer to the methodology notes for more information on these measures. 
Quebec was not included in results for high school completion or social deprivation.

Sources
Discharge Abstract Database, National Ambulatory Care Reporting System and Hospital Morbidity Database, 2020–2021 to 2022–2023, Canadian Institute for ºìÁì½í¹Ï±¨ Information.

Results for income, high school completion and social deprivation compare the least and most disadvantaged neighbourhood levels (i.e., quintiles). 

Social deprivation is a combined measure that aims to identify those with less extensive social networks, based on the population who lived alone, were single parents or were separated, divorced or widowed.Reference1

Inequalities were similar for diabetes-associated ankle, foot or toe amputations and hospitalizations for ulcers, gangrene and infections (UGI). Results at the national, provincial and territorial levels can be found in the data tables on the Download the data page. 

People have intersecting identities and social positions (e.g., sex and gender, socio-economic status, racial identity).Reference2 Examining interactions between equity stratifiers can provide a better reflection of an individual’s lived experience and the layered inequalities they may face. Our analysis focused on the interactions of income, geography, education and social deprivation with sex and age.

As neighbourhood income level increased, amputation rates decreased for both males and females. Males living in the lowest-income neighbourhoods had very high amputation rates. At 24 per 100,000, the age-standardized rate of leg amputations for males living in the lowest-income neighbourhoods is 8 times higher than the rate for females in the highest-income neighbourhoods (3 per 100,000).

We observed similar patterns for neighbourhood-level income and age, as well as by sex for neighbourhood-level high school completion and social deprivation. 

Urban and rural/remote communities can be defined using a range of measures. This report uses 2 different measures from Statistics Canada: the Index of Remoteness and the Statistical Area Classification type. Refer to the methodology notes for more information on how these measures were used.

Using the Index of Remoteness, which combines estimates of travel cost and population size, rates of leg amputation ranged from a low of 7 per 100,000 in easily accessible major urban centres to a high of 49 per 100,000 in very remote communities. Across Canada, more than three-quarters (77%) of the total population live in easily accessible urban areas, and about 2% live in either remote or very remote areas, as defined by the 5 categories in the Index of Remoteness. 

Fewer health providers practising in rural and remote communities contributes to higher travel costs and longer wait times to access services. Recent analysis shows that per capita provider rates in rural and remote areas of Canada are decreasing over time.Reference3

For diabetes foot care, providers who deliver critical preventive services — such as chiropodists, podiatrists, foot care nurses and physician specialists (e.g., vascular surgeons) — are concentrated in large urban centres.Reference4 Reference5 A study in Ontario found that higher leg amputation rates in rural and remote regions were correlated with lower rates of vascular services (assessments and procedures). Reference5

CIHI’s Rural ºìÁì½í¹Ï±¨ Systems Model provides contextual considerations when planning health services for rural regions or health systems, such as the socio-demographic characteristics of a rural population and opportunities to partner with community organizations.

Diabetes is more prevalent among males and populations with lower neighbourhood income and education. Reference6

To account for these differences in prevalence, we also calculated rates of lower limb amputation relative to the number of people diagnosed with diabetes. This analysis found significant, though smaller, inequalities by sex and neighbourhood-level income, education and social deprivation, compared with the inequalities using the general population. For example, the age-standardized rates of leg amputation were

• 2.8 times higher for males than females (14 versus 5 per 100,000) in the general population 
• 2 times higher for males than females (86 versus 42 per 100,000) when using diabetes-specific population estimates from the Canadian Chronic Disease Surveillance System

This suggests that inequalities in diabetes lower limb complications are not solely due to differences in diabetes prevalence, and that differences in diabetes management may also contribute to inequalities.

There is limited variation in diabetes prevalence between urban and rural/remote communities;Reference6 however, these survey-based estimates may be affected by who is included in the data and other limitations. 

For this analysis, we focused on inequalities between population groups for which the required socio-demographic data (i.e., equity stratifiers) was readily available. As such, we were not able to examine all inequalities relevant for advancing equity in diabetes prevention and management.

For example, higher diabetes prevalence and poorer outcomes, including lower limb amputations, are well documented for First Nations and Métis Peoples in Canada.Reference7 Evidence also suggests that other populations, including Black and South Asian populations, have a higher prevalence of diabetes and may face challenges with effective diabetes management, such as language barriers in health care settings.Reference8 Reference9 Reference10 Reference11 For Canadian hospital data, socio-demographic information — including patients' race, ethnicity and language — is not routinely collected, limiting the potential to analyze inequalities. 

• Measuring ºìÁì½í¹Ï±¨ Inequalities: A Toolkit
• Equity stratifiers
• ºìÁì½í¹Ï±¨ equity and population health
• Rural ºìÁì½í¹Ï±¨ Systems Model