Reduction in Diabetic Amputations Over 11 Years in a Defined U.K. Population

Abstract

OBJECTIVE -To assess changes in diabetic lower-extremity amputation rates in a defined relatively static population over an 11-year period following the introduction of a multidisciplinary foot team.RESEARCH DESIGN AND METHODS -All diabetic patients with foot problems admitted to Ipswich Hospital, a large district general hospital, were identified by twice-weekly surveillance of all relevant in-patient areas and outcomes including amputations recorded.RESULTS -The incidence of major amputations fell 62%, from 7.4 to 2.8 per 100,000 of the general population. Total amputation rates also decreased (40.3%) but to a lesser extent due to a small increase in minor amputations. Expressed as incidence per 10,000 people with diabetes, total amputations fell 70%, from 53.2 to 16.0, and major amputations fell 82%, from 36.4 to 6.7.CONCLUSIONS -Significant reductions in total and major amputation rates occurred over the 11-year period following improvements in foot care services including multidisciplinary team work. Diabetes Care 31:99-101, 2008A mputation is one of the most feared diabetes complications. The economic burden is immense, and survival is bleak, with a 2-year mortality up to 50% (1-6). There is an urgent need to reduce amputation rates, which vary considerably globally and nationally (7-13). Though often attributed to differences in ethnicity and local practice, such variability could be due to other factors. These include differences in defining minor versus major amputations and in assessing the denominator, i.e., 1) the size of the general population (often ill defined, particularly in cities because of overlap with other institutions) and 2) the diabetic population (sometimes simply estimated from the expected prevalence) (14). Finally, of considerable importance is the accuracy of ascertainment. Nearly all studies have been retrospective, collected from a variety of sources including theater and limb-fitting records, anesthetic databases, and hospital activity coding. In 2004, we demo n s t r a t e d t h a t c o m p a r e d w i t h prospective data collection, such methods underestimated the incidence by 4.2-90.6% and misclassified 4.5-17.4% of amputations (15). Others have reported similar inaccuracies (16,17). We therefore recommended that future studies should be prospective.This study of the impact of improvements in foot care on lower-extremity amputations (LEAs) addresses these problems; it is prospective, amputation levels are made clear, and the population is well defined.RESEARCH DESIGN AND METHODS -The survey was conducted between 1995 and 2005 in a defined, predominantly Caucasian (95%), mixed rural/urban population served by Ipswich Hospital from which there are few cross-boundary referrals. Over the period, the population grew from 330,462 to 345,890. In contrast, the diabetic population rose dramatically from 6,768 to 11,906. The largest increase followed introduction of the Quality and Outcomes Framework in 2005, whereby practitioners are paid to achieve diabetes targets (18).An LEA was de...

Association between glycated haemoglobin and the risk of lower extremity amputation in patients with diabetes mellitus—review and meta-analysis

“…If lowering blood glucose translates into a lower incidence of LEA, for a population with a 10 year incidence of LEA of 5% [47] and an average HbA 1c of 9.5%, an improvement to an average HbA 1c of 7.5% would reduce the rate of LEA to roughly 3%, all other things being equal. Hyperglycaemia may increase the risk of LEA through various mechanisms.…”

Diabetes-related foot disorders among adult Ghanaians

“…Besides, management involves significant cost inputs regarding investigations and therapy [4]. Among high-income countries, an evident reduction in the incidence of the diabetic foot has been recorded over the past three decades [5–8]. These achievements were mostly through a campaign of increased screening, widespread adoption of multidisciplinary foot clinics and stringent vascular risk factor management [9,10].…”

Diabetes‐related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South‐West of England

“…A sustained reduction in diabetes‐related lower limb amputation was observed after the institution of job‐planned multidisciplinary secondary care diabetic foot clinics 13, 14, 15, while an earlier report showed a continued high amputation incidence over a decade where no restructuring of services was undertaken 16. Diabetes foot care services in England are commissioned by Clinical Commissioning Groups (CCGs).…”