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BACKGROUND: Lower limb amputations (LLAs) are a major debilitating complication of diabetes. The toe and flow model (TFM) describes the framework for multidisciplinary centers aiming to reduce this complication. In this study, we investigate the efficacy of the TFM to reduce diabetes-related major LLAs in comparison with the standard of care (SOC) in the Canadian health care system. METHODS: We retrospectively reviewed the anonymized diabetes-related LLA reports in two similar metropolitan health zones in Alberta, Canada from 2007 to 2017. Although both zones have the same provincial health care system and similar demographics, Calgary, our first zone operates on the basis of the TFM while the Edmonton zone operates in accordance with the provincial SOC. LLAs were divided into minor and major amputation cohorts. We used the chi-square test, linear regression, and Pearson correlation for analysis. The lower proportion of major LLAs was denoted as a positive sign for the efficacy of the TFM. RESULTS: Although the number of LLAs remained relatively comparable (Calgary zone: 2238 and Edmonton zone: 2410), the Calgary zone had both significantly lower major (45%) and higher minor (42%) amputation incidence rates compared to the Edmonton zone. The increasing trend in minor LLAs and decreasing trend in major LLAs in the Calgary zone were negatively and significantly correlated (r = -0.730, p = 0.011). No significant correlation was found in the Edmonton zone. CONCLUSIONS: A significant reduction in the incidence rate, decreasing trend of diabetes-related major LLAs and the significant negative correlation of minor and major LLAs rates in the Calgary zone (TFM) compared to its sister zone Edmonton (SOC), provides supporting evidence for the impact of the TFM. This investigation provides support for a modernization of the diabetes-related limb preservation practice in Canada through the implementation of TFMs across the country to combat major LLAs.

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