Background: Lower extremity amputation (LEA) is defined as the complete loss in the transverse anatomical plane of any part of the lower limb. The objective of this study is to look at the trend and mortality trend of LEA performed in diabetes patients from 2008 to 2013. Methods: All patients age 15 and above with diabetes mellitus who had undergone LEAs (both major and minor) in Tan Tock Seng Hospital, Singapore from 1 January 2008 to 31 December 2013 were included. The outcomes of interest were deaths from all causes within 30 days and within 1 year. Results: Major LEA rate has increased from 11.0 per 100,000 population in 2008 to 13.3 per 100,000 population in 2013. The 30-day mortality rate ranges from 6.0% to 11.1% and the 1-year mortality rate ranges from 24.3% to 30.6%. Minor LEA rate has increased from 10.8 per 100,000 population in 2008 to 13.9 per 100,000 population in 2013. The 30-day mortality rate ranges from 1.5% to 3.7% and the 1-year mortality rate ranges from 9.7% to 18.3%. Conclusions: The trends in major and minor LEA are increasing. The 30-day and 1-year mortality for both major and minor LEA are comparable to figures reported worldwide. There is a need to re-look at preventive strategies to reduce LEA in diabetes patients in Singapore.

HighlightsWe followed up a cohort of 3008 Type 2 DM patients with diabetic kidney disease.We estimated the annual mortality rate by CKD stages.Predictors of mortality were age, male gender, CKD stages and albuminuria.Certain comorbid conditions and use of antiplatelet agents were predictors too.

Introduction Chronic kidney disease (CKD) is a significant public health problem, with rising incidence and prevalence worldwide and is associated with increased morbidity and mortality. Early identification and treatment of CKD can slow its progression and prevent complications, but it is not clear if CKD screening is cost-effective. The aim of this study is to conduct a systematic review of the cost-effectiveness of CKD screening strategies in general adult populations worldwide, and to identify factors, settings and drivers of cost-effectiveness in CKD screening. Methods Studies examining the cost-effectiveness of CKD screening in general adult population were identified by systematic literature search on electronic databases (MEDLINE OVID, Embase, Cochrane Library and Web of Science) for peer-reviewed publications, hand-searched reference lists and grey literature of relevant sites, focusing on the following themes: (i) CKD, (ii) screening and (iii) cost-effectiveness. Studies comprising of health economic evaluations performed for CKD screening strategies, compared against no CKD screening or usual-care strategy in adult individuals, were included. Study characteristics, model assumptions and CKD screening strategies of selected studies were identified. The primary outcome of interest is the incremental cost-effectiveness ratio (ICER) of CKD screening, in cost per quality-adjusted life year (QALY) and life-year gained (LYG), expressed in 2022 US dollars equivalent. Results 21 studies were identified, examining CKD screening in general and targeted populations. The cost-effectiveness of screening for CKD was found to vary widely across different studies, with ICERs ranging from ${\$}$113 to ${\$}$430 595, with a median of ${\$}$26 662 per QALY and from ${\$}$6516 to ${\$}$38 372, with a median of ${\$}$29 112 per LYG. Based on the pre-defined cost-effectiveness threshold of ${\$}$50 000 per QALY, majority of the studies found CKD screening to be cost-effective. CKD screening was especially cost-effective in those with diabetes (${\$}$113 to ${\$}$42 359, with median of ${\$}$27 471 per QALY) and ethnic groups identified to be higher risk of CKD development or progression (${\$}$23 902 per QALY in African American adults and ${\$}$21 285 per QALY in Canadian indigenous adults), as indicated by a lower ICER. Additionally, the cost-effectiveness of CKD screening improved if it was performed in older adults, population with higher CKD risk-scores, setting higher albuminuria detection threshold or when increasing the interval between screening. In contrast, CKD screening was not cost-effective in population without diabetes and hypertension (ICERs range from ${\$}$117 769 to ${\$}$1792 142, with a median of ${\$}$202 761 per QALY). Treatment effectiveness, prevalence of CKD, cost of CKD treatment and discount rate were identified to be the most common influential drivers of the ICERs. Conclusions Screening for CKD is especially cost-effective in patients with diabetes and high-risk ethnic groups, but not in population without diabetes and hypertension. Increasing the age of screening, screening interval, albuminuria detection threshold or selection of population based on CKD risk-scores may increase cost-effectiveness of CKD screening, while treatment effectiveness, prevalence of CKD, cost of CKD treatment and discount rate were influential drivers of the cost-effectiveness.

The progression rate to T2DM is high in subjects with newly diagnosed IFG. Intensive lifestyle modification can be incorporated into their current yearly follow-up to prevent progression to T2DM, which is a growing problem in Singapore.

Even though T2DM patients have a lower life expectancy, T2DM is associated with substantially higher lifetime medical costs. Delaying the onset of T2DM, especially in the young, may lead to lower lifetime medical expenses. If prevention costs can be kept sufficiently low, effective T2DM prevention efforts would likely lead to a reduction in long-term medical costs.

The sensitivity of HbA1c as a screening test for DM in this study was significantly higher than that reported previously. This work provides additional evidence supporting the inclusion of HbA1c as one of the screening tests for DM.