Project Summary Social disadvantage, unequal access to care and systemic racism are identified as primary culprits leading to poor health outcomes among Black Americans. Further exacerbating the problem are budget cuts to public health funding for health care and social service programs that serve a large segment of the Black community. Empirical findings confirm disparities in health care for Black patients with complicated PAD and lower limb ischemia. The literature well-explains the diabetes disease process that leads to PAD and identifies those at greatest risk for the devastating outcome, limb amputation. One of the gaps in the research is the identification of factors leading to the earlier onset of co-occurring PAD in individuals with diabetes and the identification of contributing factors (on the part of patients and health care providers) that lead to the decision to amputate a limb more often in Black patients than other populations. The proposed research addresses these two gaps. The proposed research seeks to utilize the case of diabetes with PAD and a limb amputation epidemic to not only shed new light on a long-established and well-documented problem, but also to provide evidence in support of adherence to practice guidelines and preventive efforts to improve PAD, minimize loss of limb, and enhance overall quality of life for Black patients. Inconsistent adherence to guidelines in clinical practice is, according to the United States Preventive Services Task Force, at the heart of excessive limb amputation among Blacks with diabetes and concomitant PAD. Generally, accepted practice and prevention guidelines support the use of simple, diagnostic measures for screening and monitoring of PAD progression, and yet, documented by our research, the rate of limb amputation continues to climb, particularly in geographic regions of the United States with large proportions of Black persons. This is particularly unfortunate because revascularization and other therapeutic alternatives are available that should be considered before the decision is made to amputate a limb. Using the All of Us (AoU) Data, this study aims to understand cultural, environmental, and decision-making factors that contribute to disparities in diagnosis and treatment for PAD with diabetes and subsequent limb loss. Aim 1: Compare the factors influencing early onset (before age 45), co-morbid peripheral artery disease in Black and White patients with diabetes. Aim 2: Examine the relationship between the screening practices and limb amputation in patients with diabetes and concomitant peripheral artery disease. Aim 3: Examine factors influencing practice decisions to amputate a lower limb in Black and nonblack patients in the United States.