Wound healing in diabetes. Outcome and costs

Healing of foot ulcers is limited by multiple factors that necessitate a multifactorial and multidiciplinary approach. Patients with diabetes with previous foot ulcers have a high risk for new ulcerations and further amputations and have increased mortality rates. These findings stress the need for lifelong observation of the diabetic foot. The diabetic foot is a large economic problem, and management of ulcers has not always been performed in a most cost-effective way. Cost for amputation is high to society because of prolonged hospitalization, rehabilitation, and need for home care and social service for disabled patients. A cost-effective management plan should focus not only on short-term cost until healing but also on long-term costs, because foot ulcer and especially amputation are related to increased high reulceration rate and lifelong disability. The most important action to reduce cost in management of the diabetic foot is to avoid amputations.

Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.

[Diabetic foot syndrome and its risks: amputation, handicap, high-cost sequelae]

Amputation, Handicap, High Subsequent Costs. Lack of "Outpatient Wards for Diseases Involving the Feet" in German hospitals. A Challenge to Prevention: In consequence of diabetic polyneuropathy, about 25% of all diabetics develop neuropathic foot complications often resulting in amputation (about 30,000 cases in Germany per annum). Suffering and handicaps of the patients, as well as the high costs involved (estimated at 800 million Deutsche Mark per annum) systematic prophylaxis and early identification of patients at risk are imperative. According to experts every second amputation could be avoided if treatment of diabetic foot complications is started as early as possible. To prevent expensive in-hospital treatment, an outpatient clinical treatment may be offered on an interdisciplinary basis (internist, neurologist, orthopaedist, surgeon, radiologist). About 50 "outpatient wards for diseases involving the feet" exist up to now in German hospitals. Appropriate fees, subsidy by sick funds (and if necessary by politicians) and co-operation with general practitioners, internists etc. are indispensable. Other important co-operators are the family doctors. With regard to health care, preventive activities and publicity, co-operation of the local Public Health departments would also be feasible.

Routing through the health care system and level of functioning of lower limb amputees

OBJECTIVES

To describe the routing through the health care system and the level of functioning of a consecutive series of lower limb amputees at a general Dutch hospital.

METHODS

A descriptive cohort study (medical records examination) with a follow-up interval of 11.7 months. All 124 major lower limb amputations (ankle to hip) between 1 July 1989 and 31 December 1992 are included in the study: 123 patients, average age 73.8 years, 96% vascular disease. Amputation levels are 55.3% transfemoral, 12.2% knee disarticulation and 32.5% transtibial. At follow-up two patients are missing.

RESULTS

Before admission to hospital 75.6% of patients are able to walk and 79.9% live independently. Discharge destinations from hospital are 22.5% home, 42.3% inpatient rehabilitation and 32.4% nursing home. At follow-up, 59% of surviving patients have a prosthesis, 47.7% are able to walk and 70.5% live independently. Mortality after one year is 28.5%. Poor preoperative walkers seem to die more often within the first year and have less chance of being fitted with a prosthesis. Poor walkers, older than 75, with diabetes mellitus and a transfemoral amputation seem to stay more often in a nursing home after one year.

DISCUSSION

Although the results are largely comparable with other studies, there appear to be differences in age, amputation level and course and duration of treatment. The predicting factors found here may help the rehabilitation specialist in advising on the best moment and level of amputation and course of treatment.

The cost-effectiveness of limb salvage for bone tumours

The use of endoprostheses for limb salvage in primary bone tumours is highly specialised. Studies have shown no significant difference in survival, function or quality of life between patients with limb salvage and those with amputation. We have derived a formula for calculating the ongoing costs of limb salvage with an endoprosthesis which is based on actual costs and uses historical data to show the likelihood of further surgery or revision. Comparative data for amputation are also shown. Using current prices, the cost-effectiveness of surgery with an endoprosthesis is clearly demonstrated.

Surgical treatment for chronic critical leg ischaemia: a 5 year follow-up of socioeconomic outcome

OBJECTIVES

To evaluate the costs of amputation and arterial reconstruction for chronic critical leg ischaemia (CLI).

DESIGN

A 5 year follow-up study of patients with primary intervention for CLI.

SETTING

One regional and two district hospitals serving a defined population.

MATERIAL

One hundred and seventeen consecutive patients undergoing reconstructive arterial surgery or amputation for CLI.

CHIEF OUTCOME MEASURES

Additional procedures, treatment resources and costs related to the treatment of CLI.

MAIN RESULTS

Reconstruction patients needed frequent reinterventions due to graft problems, additional CLI symptoms and revisions of ischaemic tissue. The mean costs for a reconstruction were 240,000 FIM/patient and 70,000 FIM/survival year including costs for later amputations. Patients with a reconstruction without later amputation had costs of 175,000/ patient and 47,000/survival year. A reconstruction with a later amputation had the highest costs, 402,000/patient and 148,000/survival year. Contralateral leg ischaemia caused a new intervention in 25% of all patients. For non-institutionalised patients an amputation resulted in institutional treatment in over 20% of the remaining surviving days with a cost of 313,000 FIM/patient and 150,000 FIM/survival year. CLI in institutionalised patients with a primary amputation had a short stay in hospital, needed little additional resources and caused only low additional costs.

CONCLUSIONS

Costs for a reconstruction in potentially mobile, independently living patients with CLI is similar to those of an amputation. It often demands repeated interventions to achieve good results. On a cost/survival year basis, amputations carry higher costs. For institutionalised, immobile patients with CLI an amputation is often the only possible and cheapest treatment.

Measuring quality and cost of care: evaluation of an amputation clinical pathway

This study was based on nursing literature supporting the use of clinical pathways in case management systems to improve quality, reduce cost, and increase efficiency. Its purpose was to provide a descriptive analysis of outcomes in lower-extremity amputation caused by arterial occlusive disease. Patients were admitted between Jan. 1, 1989, and Sept. 1, 1995, with arterial occlusive disease for an above- or below-knee amputation and were cared for in three consecutive phases of nursing case management: (1) without a clinical pathway (group I), (2) with a consultation to rehabilitation services in the postoperative stay (group II), and (3) with a rehabilitation-focused clinical pathway (group III). The results of the study indicated more patients were able to return home from acute care and rehabilitation (52%) in group III than in group I and group II (40% and 44%, respectively). In addition, the hospital length of stay was reduced from 11 days to 8 days (geometric mean) once a rehabilitation consultation was included in the plan of care (group II). Although hospital charges rose initially with rehabilitation consultation ($18,627), they were reduced significantly when the pathway was used ($12,629; adjusted for rate increases). When patients were separated by level of amputation, those with below-knee amputations in group III had a significantly shorter length of stay and lower hospital charges than those in the other two groups, but comorbidity remained high. Nurse case managers can use this clinical pathway as a model for care as the findings support its cost effectiveness. They also demonstrate its effectiveness in enhancing the of quality care through a rehabilitation-focused, goal-oriented plan to return patients home.

The costs of managing lower limb-threatening ischaemia

One hundred and fifty consecutive patients presenting with limb-threatening ischaemia were studied prospectively to determine treatment and rehabilitation costs in the first year. Limb salvage was attempted in 104 (69%) patients but failed in 13%. Mortality at 1 year was 27%. The cost of treatment, inpatient stay, occupational therapy, physiotherapy, convalescence, disablement services, home adaptations, home care, district nursing, transportation and outpatient visits were determined for each patient. The patients were classified according to their presentation and initial treatment into five groups (number of patients) whose median management costs (interquartile range) for 12 months were: Gp 1 (23 - Revascularisation for acute ischaemia = 3970 pounds (2984-5511) Gp 2 (29) - Angioplasty for critical ischaemia = 6611 pounds (3630-10,200) Gp 3 (52) - Reconstruction for critical ischaemia = 6766 pounds (4337-9677) Gp 4 (34) - Primary amputation = 10,162 pounds (7894-13,026) Gp 5 (12) - Primary bilateral amputations = 13,848 pounds (11,440-18,056) At 1 year, there was no significant difference in the cost of managing a patient with a critically ischaemic limb by angioplasty or surgical reconstruction. The cost of revascularisation for acute ischaemia was comparatively low because these patients required minimal rehabilitation. The median cost of managing a patient following amputation was almost twice that of successful limb salvage justifying an aggressive revascularisation policy. However, justification of such a policy on economic grounds requires salvage failure episode to be minimised as they increase costs considerably.

Replantation-revascularization and primary amputation in major hand injuries. Resources spent on treatment and the indirect costs of sick leave in Sweden

Thirty consecutive patients with amputation or devascularizing injuries of the thumb or two or more fingers proximal to the PIP joint were reviewed. Replantation or revascularization had been done in 27 patients, in 24 successfully. Three patients had primary amputation. The distribution of calculable costs was dominated by those for sick leave (49%), operation (26%) and ward costs (20%). Out-patient care, physiotherapy and travel together constituted only 6%. The cost of a successful replantation was equal to 1.6 times the mean annual salary of these patients and that of primary amputation about half as much. Mobility, power and performance of a standardized grip test were better for the successfully replanted or revascularized patients. Subjective evaluation of 23 parameters of function, cosmesis and quality of life did not disclose any differences. All patients except three had returned to their original work within 2 years.

Amputation versus reconstruction in traumatic defects of the leg: outcome and costs

This retrospective review covers global aspects of reconstructive efforts to salvage severely injured legs. Eighteen patients with traumatic lower leg amputation were compared to 21 patients who underwent complex microvascular reconstruction. The mean number of interventions was 3.5 for amputation and 8 for reconstruction (p < 0.009). Total rehabilitation time was 12 months for amputation and 30 months for reconstruction (p < 0.009). Changes in lifestyle were consistently more important in the amputee group. The mean annual hospital costs for amputated patients were 15,112 Swiss Francs (SD 7,094 SF) for the first 4 years. The mean annual hospital costs for reconstructed patients were 17,365 Swiss Francs (SD 8,702 SF) for the first 4 years. Fifty-six percent of the amputees and 19% of the reconstructed patients were retrained to a different profession (p < 0.025). Fifty-four percent of the amputees and 16% of the reconstructed patients were drawing an extremely costly and life long invalidity pension (p < 0.02). We conclude that for potentially salvageable legs reconstruction is advisable because the functional outcome was better than for amputation and there was no permanent social disintegration due to the long treatment. Total costs (including pensions) for reconstruction were far lower than for amputation.

Scapulothoracic dissociation: a devastating injury

Scapulothoracic dissociation, although rare, causes significant morbidity and mortality by completely disrupting the attachments of the scapula to the axial skeleton with the skin remaining intact. The defining constellation of injuries is subclavian or axillary vascular disruption, lateral displacement of the scapula, separation of the clavicular articulations with or without fracture of the clavicle, and cervical nerve root avulsion or brachial plexus injury. Orthopedic stabilization, vascular repair, and brachial plexus exploration are mandatory. Above elbow amputation, either primarily or within 24 hours, is recommended for the flail extremity.

[Vascular reconstruction and/or amputation in severely handicapped patients]

In the course of demographic ageing with a growing number of handicapped and people in need of care the vascular surgeon will be confronted more and more with the question whether to perform a leg-saving vascular reconstruction or a primary amputation, when treating such patients. This question is discussed by analyzing the parameters benefit, risk and costs. On balance the conclusion is made, that considering nursing, medical and psychological aspects also the seriously handicapped will benefit from the leg-saving procedure. Also the risk of a vascular reconstruction is justifiable, when the procedure has a real chance of success. Concerning the costs the question is still unanswered, if in consideration of the dictated economical commulsions it is allowed to perform an expensive reconstructive procedure, when the primary amputation is the substantially "cheaper" solution.

Counting the cost of diabetic hospital admissions from a multi-ethnic population in Trinidad

Many middle-income countries are experiencing an increase in diabetes mellitus but patterns of morbidity and resource use from diabetes in developing countries have not been well described. We evaluated hospital admission with diabetes among different ethnic groups in Trinidad. We compiled a register of all patients with diabetes admitted to adult medical, general surgical, and ophthalmology wards at Port of Spain Hospital, Trinidad. During 26 weeks, 1447 patients with diabetes had 1722 admissions. Annual admission rates, standardized to the World Population, for the catchment population aged 30-64 years were 1031 (95% CI 928 to 1134) per 100,000 in men and 1354 (1240 to 1468) per 100,000 in women. Compared with the total population, admission rates were 33% higher in the Indian origin population and 47% lower in those of mixed ethnicity. The age-standardized rate of amputation with diabetes in the general population aged 30-64 years was 54 (37 to 71) per 100,000. The hospital admission fatality rate was 8.9% (95%CI 7.6% to 10.2%). Mortality was associated with increasing age, admission with hyperglycaemia, elevated serum creatinine, cardiac failure or stroke and with lower-limb amputation during admission. Diabetes accounted for 13.6% of hospital admissions and 23% of hospital bed occupancy. Admissions associated with disorders of blood glucose control or foot problems accounted for 52% of diabetic hospital bed occupancy. The annual cost of admissions with diabetes was conservatively estimated at TT+ 10.66 million (UK 1.24 million pounds). In this community diabetes admission rates were high and varied according to the prevalence of diabetes. Admissions, fatalities and resource use were associated with acute and chronic complications of diabetes. Investing in better quality preventive clinical care for diabetes might provide an economically advantageous policy for countries like Trinidad and Tobago.

Cost-efficacy issues in the treatment of peripheral vascular disease: primary amputation or revascularization for limb-threatening ischemia

Controlling rising health care costs represents a major challenge to our society. Due to the aging of the population and the increasing number of patients with vascular disease, vascular specialists will be under mounting pressure by the managed care industry to provide the most cost-effective care for these patients. One particular controversy is whether to attempt revascularization in the patient with limb-threatening ischemia or to proceed directly with primary amputation. Although it has been assumed that the operative risk for revascularization procedures is high in elderly patients with a severely ischemic limb, mortality rates in the sickest patients are actually higher for amputation. It is also incorrect to assume that the duration of hospitalization is shorter for patients undergoing amputation than for patients undergoing revascularization. For both types of procedures, it is complications that prolong the length of hospital stay, and the rate of secondary amputation following a revascularization attempt is low (8.5%), compared with the rate of operative revision in patients following primary below-knee amputation (23%). The costs for revascularization and primary amputation are similar when the costs of a prosthesis and rehabilitative therapy are included in the calculations for amputation. The rationale for primary amputation assumes that patients will ambulate successfully with a prosthesis; however, many do not, and thus costs for institutionalization must be included in the equation. Long-term costs following revascularization were $28,374 in patients with a viable limb, compared with $56,809 in those undergoing secondary revascularization. The key to minimizing health care costs in this population is careful patient selection for initial revascularization, with aggressive long-term surveillance to ensure graft patency and limb viability.

Critical limb ischaemia in patients over 80 years of age: options in a district general hospital

A total of 114 reconstructions were performed in 82 octogenarian patients and the results compared with those of 33 patients who had primary amputation. The operative mortality rate was higher after amputation (45 versus 11 per cent) and the mean survival less (25 versus 34 months). Quality of life assessment using a Rosser scale suggested that, although there was no improvement in the 38 per cent with a failed reconstruction, there was a significant improvement in the 62 per cent whose reconstruction remained patent. There was minimal improvement in quality of life after primary amputation and this was due to relief of pain. Costs (including the costs of revisions and community costs) were assessed in detail. Although the mean total operative costs of reconstruction were higher than those of amputation (10,222 pounds versus 6475 pounds) this was more than offset by the high community costs of amputation. The total cost of reconstruction was 13,546 pounds, compared with 33,095 pounds for amputation. Following reconstruction 66 per cent of those patients independent before critical limb ischaemia occurred were able to return to their own home; only 33 per cent of amputees were able to do so.

The costs of diabetes-related lower extremity amputations in the Netherlands

Diabetes mellitus is a common problem in the Netherlands and in the rest of the world. A complication seen in association with diabetes is peripheral neuropathy which can lead to lower extremity amputation. The purpose of this study is to identify the duration of hospital stay and the direct costs associated with diabetes-related lower extremity amputations in the Netherlands in 1992. Total direct costs included costs associated with hospital stay and the average procedure specific costs (surgeons' fees, anaesthetists' fees, and operating room fees) for the specific level of amputation. In the Netherlands in 1992, 1575 hospitalizations for 1810 diabetes-related lower extremity amputations occurred. The total number of days in the hospital for the diabetic population was 65,778 days with a mean of 41.8 days per hospitalization. Mean costs associated with diabetes-related hospitalizations for amputation were pounds 10,531 (Dfl. 28,433) per hospitalization. Persons who underwent multiple amputations during their hospitalization stayed in the hospital longer and the costs associated with these hospitalizations were higher when compared to hospitalization with a single amputation. An increase in length of stay and costs with increasing age and higher level of amputation was identified.

Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting

The purpose of this study was to analyze long-term costs for foot ulcers in diabetic patients. Patients were treated and followed prospectively by a foot care team. A retrospective economic analysis was performed of costs for 274 patients during 3 years from healing of an initial foot ulcer, with or without amputation. Costs were estimated for inpatient care, outpatient care, home care, and social service. The cost calculations include costs due to complications and disability related to the initial ulcer, costs related to recurrence of ulcer, and costs for prevention of new ulcers. Expected total present value cost per patient during 3 years of observation was $26,700 (U.S. dollars) for primary healed patients with critical ischemia and $16,100 for primary healed patients without critical ischemia. For patients who healed with an amputation, the corresponding costs were $43,100 after a minor amputation and $63,100 after a major amputation. When estimating the costs for diabetic foot ulcers, it is not sufficient to calculate short-term costs. Long-term costs are high, mainly due to the need for increased home care and social service, but also due to costs for recurrent ulcers and new amputations.

Foot infections in diabetic patients. Decision and cost-effectiveness analyses

OBJECTIVE

To examine the cost-effectiveness of approaches to the diagnosis and treatment of patients with type II (non-insulin-dependent) diabetes mellitus (NIDDM) who have foot infections and suspected osteomyelitis.

DESIGN

Decision and cost-effectiveness analyses were performed using a Markov model. We examined the prevalence of osteomyelitis, the major complications and efficacies of long-term antibiotic therapy and surgery, and the performance characteristics of four diagnostic tests (roentgenography, technetium Tc 99m bone scanning, indium in 111-labeled white blood cell scanning, and magnetic resonance imaging). Data were drawn from the English-language literature using MEDLINE searches and bibliographies from selected articles.

SETTING

Primary care.

PATIENTS

Patients with NIDDM who had foot infections and suspected osteomyelitis but no signs of systemic toxicity.

INTERVENTIONS

Following hospitalization for surgical débridement and intravenous antibiotic therapy: (1) treatment for presumed soft-tissue infection, (2) culture-guided empiric treatment for presumed osteomyelitis, (3) 71 combinations of diagnostic tests preceding antibiotic therapy for osteomyelitis, (4) 71 combinations of tests preceding amputation, and (5) immediate amputation.

MAIN OUTCOME MEASURES

Quality-adjusted life expectancy, average costs.

RESULTS

Culture-guided empiric treatment for osteomyelitis with 10 weeks of oral antibiotic therapy has similar effectiveness to testing followed by a long course of antibiotic therapy if any test result is positive. However, empiric treatment is the least expensive strategy.

CONCLUSIONS

Noninvasive testing adds significant expense to the treatment of patients with NIDDM in whom pedal osteomyelitis is suspected, and such testing may result in little improvement in health outcomes. In patients without systemic toxicity, a 10-week course of culture-guided oral antibiotic therapy following surgical débridement may be as effective as and less costly than other approaches.

Surgery for limb threatening ischaemia: a reappraisal of the costs and benefits

OBJECTIVES

To study the quality of life of patients following surgery for critical limb is ischaemia.

DESIGN

Part retrospective, part prospective open study.

SETTING

Vascular unit of a University Hospital.

MATERIALS

Seventy-nine consecutive patients, medium age 75 years (range 44 to 94), who presented with leg threatening ischaemia and who underwent successful revascularisation or a major amputation were studied.

CHIEF OUTCOME MEASURES

Six separate quality of life measures were recorded at 6 months: pain, mobility, anxiety, depression, activities of daily living (Barthel) and lifestyle (Frenchay).

MAIN RESULTS

The mortality of this group of patients after six months was 24%. Forty-seven patients were available for quality of life assessment six months after initial intervention. Overall, amputation was more costly than successful revascularisation and limb salvage. Limb salvage resulted in greater mobility (p < 0.001) and better performance in self-care (p < 0.001) and lifestyle (p = 0.006), but produced more anxiety and depression (p = 0.04) than major amputation. A subgroup of patients who had major amputation after a failed limb salvage operation consumed a disproportionate amount of resources and, although their mobility was typical of amputees, their self-care and lifestyle scores were similar to those who had successful limb salvage. OBSTRUCTIONS: Limb salvage is attempted in up to 22% of patients for whom primary amputation may provide more expeditious rehabilitation with minimal impairment of their lifestyle performance.

[Teat amputation in cattle--indications, surgical results and economy]

Based on the experience gained after the performance of 204 teat amputations with complete closure of the wound, medical as well as economic aspects were discussed. Various types of severe teat injuries leading to a teat amputation were listed. Surgery was successful in 94.6% of all animals subjected to the teat amputation. Approximately 50% of the animals had a reproductive life span after surgery of more than one year. The most common reasons for culling were inconvenience at milking and insufficient milk yield. The milk yield during a lactation period dropped by an average of 5.5%. Cost efficiency of the procedure was evaluated by partial budgeting. The result of this analysis suggested that in most cases, from the economic standpoint of view, there might be an indication for teat amputation.

Who is at risk of limb loss and what to do about it?

Lower limb amputations were performed on over 105,000 individuals in United States short-stay hospitals between 1989 and 1992. Additional amputations were performed in VA, military, Indian Health, and charitable orthopaedic hospitals. Half of all lower extremity amputations occurred in individuals with diabetes. When the causal chain leading to diabetic amputations was examined in 80 consecutive patients at the VA Medical Center, Seattle, WA, 23 unique pathways were identified. Multiple pathway components were identified for 96% of patients, while in 4% a single ischemic pathway was sufficient in itself to require amputation. The majority of the scenarios leading to amputation began when patients with absent peripheral sensation sustained a pivotal event that initiated the causal chain to amputation. In nearly half the patients, this event was foot-wear-related. The pivotal event was followed by ulceration and faulty wound healing in 73% of patients. Each year thousands of individuals with diabetes undergo amputation in VA facilities, resulting in substantial cost to the Department of Veterans Affairs and to themselves. If the VA is to address the prevention or delay of limb loss, the causal pathway information indicates that attention to the footwear of diabetic patients is necessary.

Rehabilitation of amputees with end-stage renal disease. Functional outcome and cost

A retrospective chart review was performed on 19 lower extremity amputees with end-stage renal disease (ESRD) on dialysis and 19 controls with peripheral vascular disease (PVD) without ESRD to compare functional outcome with costs of rehabilitation. The groups were similar demographically and by etiology, level and side of amputation. Functional outcome as measured by Functional Independence Measure (FIM) scores did not show a significant difference between the groups on admission (P = 0.19), discharge (P = 0.20) or change in FIM (P = 0.94). The percentage of successful prosthetic ambulators (P = 0.74) and the duration of prosthetic training (P = 0.60) were not statistically different between the groups. Cost as measured by total hospital length of stay (LOS) was not significantly different (P = 0.43), but the renal group showed a significantly longer acute hospital LOS (P = 0.02) and a trend for a shorter rehabilitation LOS (P = 0.08). Mortality, discharge setting and home care arrangements on discharge were similar for the groups. The renal group had a significantly greater number of co-morbidities than the non-renal group (P = 0.002). Despite the large number of medical problems, amputees on renal dialysis admitted to acute rehabilitation had similar outcomes with similar costs to amputees with PVD without renal failure.