Diabetes- and nondiabetes-related lower extremity amputation incidence before and after the introduction of better organized diabetes foot care: continuous longitudinal monitoring using a standard method

How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia

OBJECTIVE

Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them.

METHODS

All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers.

RESULTS

From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance.

CONCLUSIONS

LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.

A critical literature review highlighting the methodological differences within epidemiological studies: Pedal Amputations in England

INTRODUCTION

There is an absence in the application of standardised epidemiological principles when calculating and reporting on lower extremity amputation (LEA) rates [1]. The rates of minor LEAs in the diabetic population range from 1.2-362.9 per 100,000 and in the population without diabetes 0.9-109.4 per 100,000. The reported rates of major lower limb amputations vary from 5.6-600 per 100,000 in the diabetic population and 3.6-58.7 per 100,000 in the total population [1]. The variation in methodology does not facilitate comparison across populations and time. All studies published using the population from England, UK, describing minor amputations were systematically reviewed and rates and methodologies compared.

METHOD

A systematic search was carried out using (PRISMA) guidelines [2] to reveal primary data of minor lower extremity amputation rates in England between 1988-2018. This was carried out using electronic databases, grey literature and reference list searching. The search yielded eleven studies that were eligible for review.

RESULTS

Significant variation in the reporting of minor lower extremity amputation rates across regional and gender groups in England was found. Rates in the diabetic and non-diabetic population varied from 1.2 to 362.9 per 100,000 and 0.9 to 109.4 per 100,000 respectively. This was predominately a result of poorly describing numerator and denominator populations and defining minor amputations differently. As a result, there was an inability to confidently establish regional, gender and time trends.

CONCLUSION

The inconsistent nature of reporting minor amputations makes drawing conclusions on temporal and population change difficult. Future studies should describe and present basic numerator and denominator population characteristics e.g. number, age and sex and use the standard definition of minor amputation as one that is at or below the ankle.

The natural history of chronic limb-threatening ischemia after technical failure of endovascular intervention

OBJECTIVES

The treatment for chronic limb-threatening ischemia (CLTI) has changed dramatically in the last few decades with a shift toward an endovascular-first approach and aggressive revascularization to achieve limb salvage. As the size of the CLTI population and intervention rates increase, patients will continue to experience technical failure (TF). Here, we describe the natural history of patients after TF of endovascular intervention for CLTI.

METHODS

We conducted a retrospective cohort study of patients with CLTI who attempted endovascular intervention or bypass at our multidisciplinary limb salvage center from 2013 to 2019. Patient characteristics were collected according to the Society for Vascular Surgery's reporting standards. Primary outcomes included survival, limb salvage, wound healing, and revascularization patency. Product-limit Kaplan-Meier estimated survival functions for these outcomes, and between-group comparisons were made using Mantel-Cox log-rank nonparametric tests.

RESULTS

We identified 242 limbs from 220 unique patients who underwent primary bypass (n = 30) or attempted endovascular intervention (n = 212) at our limb salvage center. Endovascular intervention was a TF in 31 (14.6%) limbs. After TF, 13 limbs underwent secondary bypass and 18 limbs were managed medically. Patients who experienced TF tended to be older (P < .001), male (P = .003), current tobacco users (P = .014), have longer lesions (P = .001), and have chronic total occlusions of target arteries (P < .001) as compared with those who experienced technical success. Furthermore, the TF group had worse limb salvage (P = .047) and slower wound healing (P = .028), but their survival was not different. Survival, limb salvage, and wound healing were not different in patients who received secondary bypass or medical management after TF. The secondary bypass group was older (P = .012) and had a lower prevalence of tibial disease (P = .049) than the primary bypass group and trended toward decreased survival, limb salvage, and wound healing (P = .059, P = .083, and P = .051, respectively).

CONCLUSIONS

Increased age, male sex, current tobacco use, longer arterial lesions, and occluded target arteries are associated with TF of endovascular intervention. Limb salvage and wound healing are relatively poor after TF of endovascular intervention, but survival appears comparable with patients who experience technical success. Secondary bypass may not always rescue patients after TF, though our sample size limits statistical power. Interestingly, patients who received a secondary bypass after TF trended toward decreased survival, limb salvage, and wound healing compared with primary bypass.

The Impact of Implementing a Diabetic Limb-Preservation Program on Amputation Outcomes at an Academic Institution in a Majority-Minority State

Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients' morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) (P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) (P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) (P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 (P < .001). The rate of obtaining bone biopsies increased from 32.1% (n = 45) to 72.1% (P < .001). The rate of revascularization increased from 10.7% (n = 15) to 15.2% (n = 30) (P = .299). Average hospital LOS decreased significantly from 11.6 days to 9.8 days (P = .044). Conclusion. After the implementation of a limb-preservation team, there was a precipitous drop in major limb amputations in favor of minor amputations. The average hospital LOS decreased. These findings demonstrated improved clinical care and outcomes in patients with lower extremity osteomyelitis and reinforce the importance of a diabetic foot-preservation service within healthcare institutions.

Life Expectancy and Mortality After Lower Extremity Amputation: Overview and Analysis of Literature

Lower limb amputation (LLA) is a major surgical procedure with a significant impact on quality of life and mortality rates as well. Previous studies have shown that mortality rates following LLA can range from 9-17% within 30 days in the UK. This study systematically evaluates and reviews the published literature on life expectancy, mortality, and survival rates following lower extremity amputation (LEA). We have conducted a comprehensive search on Medline, CINAHL, and Cochrane Central databases resulting in 87 full-text articles. After a thorough review, only 45 (52.9%) articles met the minimum inclusion criteria for the study. Our analysis indicated 30-day mortality rates following LEA ranged from 7.1% to 51.4%, with an average mortality rate of 16.45% (SD 14.35) per study. Furthermore, 30-day mortality rates following below-knee amputation (BKA) and above-knee amputation (AKA) were found to be between 6.2% to 51.4%, X= 17.16% ± 19.46 SD and 12.7 to 21.7%, X= 16.15% ± 4.17 SD, respectively. Our review provides a comprehensive insight into the life expectancy, mortality, and survival rates following LEA. These findings highlight the importance of considering various factors, including patient age, presence of comorbidities such as diabetes, heart failure, and renal failure, and lifestyle factors such as smoking, in determining prognosis following LLA. Further research is necessary to determine strategies for improving outcomes and reducing mortality in this patient population.

Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact

The Global Diabetes Compact is a WHO-driven initiative uniting stakeholders around goals of reducing diabetes risk and ensuring that people with diabetes have equitable access to comprehensive, affordable care and prevention. In this report we describe the development and scientific basis for key health metrics, coverage, and treatment targets accompanying the Compact. We considered metrics across four domains: factors at a structural, system, or policy level; processes of care; behaviours and biomarkers such as glycated haemoglobin (HbA1c); and health events and outcomes; and three risk tiers (diagnosed diabetes, high risk, or whole population), and reviewed and prioritised them according to their health importance, modifiability, data availability, and global inequality. We reviewed the global distribution of each metric to set targets for future attainment. This process led to five core national metrics and target levels for UN member states: (1) of all people with diabetes, at least 80% have been clinically diagnosed; and, for people with diagnosed diabetes, (2) 80% have HbA1c concentrations below 8·0% (63·9 mmol/mol); (3) 80% have blood pressure lower than 140/90 mm Hg; (4) at least 60% of people 40 years or older are receiving therapy with statins; and (5) each person with type 1 diabetes has continuous access to insulin, blood glucose meters, and test strips. We also propose several complementary metrics that currently have limited global coverage, but warrant scale-up in population-based surveillance systems. These include estimation of cause-specific mortality, and incidence of end-stage kidney disease, lower-extremity amputations, and incidence of diabetes. Primary prevention of diabetes and integrated care to prevent long-term complications remain important areas for the development of new metrics and targets. These metrics and targets are intended to drive multisectoral action applied to individuals, health systems, policies, and national health-care access to achieve the goals of the Global Diabetes Compact. Although ambitious, their achievement can result in broad health benefits for people with diabetes.

Development of a coordinated acute diabetic foot pathway for management of acute diabetic foot infection and ulceration

BACKGROUND

Diabetic foot ulceration (DFU) has become an increasingly common emergency presentation. These patients are presenting at a younger age and with increasingly complex co-morbidities. They require frequent hospitalisation for management of DFU which has significant consequences for management of health resources but also for quality of life in the diabetic patient population.

AIM

The aim of this study was to evaluate the impact of the development of a coordinated, streamlined acute diabetic foot pathway for management of in-patients presenting as emergencies with DFU on length of stay, re-admission to hospital and minor and major amputations.

METHODS

A dedicated acute diabetic foot pathway was introduced to St. Vincent's University Hospital (SVUH) in April 2016. Management of patients admitted urgently to the emergency department or out-patient clinics of St. Vincent's University Hospital during the 3-year period before April 2016 was compared to that of patients admitted in the 3 years after April 2016 following introduction of the acute diabetic foot pathway. Demographic data hospital length of stay, need for re-admission, major and minor amputations performed and cost of hospital stay were compared before and after introduction of the pathway.

RESULTS

There were 931 admissions with acute diabetic foot ulceration or infection between January 2012 and December 2019; 419 were admitted between January 2012 and March 2016 and 512 between April 2016 and December 2019. There was no difference in demographic data between the two time periods. Length of stay decreased from 13 +/- 4.24 to 3 +/- 1.41 days between the two time periods (p < 0.001). Re-admission rates within 30 days decreased from 21.7 to 10.1% (p < 0.05). The number of major lower limb amputations decreased over the two time periods from 8.8 to 7.2% with a concomitant increase in minor amputations from 16.7 to 25.3%. Risk of major lower limb amputation was significantly higher in those patients living more than 20 km from the hospital. Costs associated with in-patient stay for management of DFU decreased from €9,247,700 to €8,988,100 despite an 18% increase in the number of patients treated and a 9.9% increase in hospital admissions.

CONCLUSION

Introduction of a dedicated, streamlined pathway involving multi-disciplinary input resulted in a significant improvement in patient management as assessed by length of hospital stay and need for re-admission. While the number of major lower limb amputations has decreased there has been a significant increase in the number of minor amputations.

Global trends in the incidence of hospital admissions for diabetes-related foot disease and amputations: a review of national rates in the 21st century

AIMS/HYPOTHESIS

Diabetic foot disease (DFD) is a leading cause of hospital admissions and amputations. Global trends in diabetes-related amputations have been previously reviewed, but trends in hospital admissions for multiple other DFD conditions have not. This review analysed the published incidence of hospital admissions for DFD conditions (ulceration, infection, peripheral artery disease [PAD], neuropathy) and diabetes-related amputations (minor and major) in nationally representative populations.

METHODS

PubMed and Embase were searched for peer-reviewed publications between 1 January 2001 and 5 May 2022 using the terms 'diabetes', 'DFD', 'amputation', 'incidence' and 'nation'. Search results were screened and publications reporting the incidence of hospital admissions for a DFD condition or a diabetes-related amputation among a population representative of a country were included. Key data were extracted from included publications and initial rates, end rates and relative trends over time summarised using medians (ranges).

RESULTS

Of 2527 publications identified, 71 met the eligibility criteria, reporting admission rates for 27 countries (93% high-income countries). Of the included publications, 14 reported on DFD and 66 reported on amputation (nine reported both). The median (range) incidence of admissions per 1000 person-years with diabetes was 16.3 (8.4-36.6) for DFD conditions (5.1 [1.3-7.6] for ulceration; 5.6 [3.8-9.0] for infection; 2.5 [0.9-3.1] for PAD) and 3.1 (1.4-10.3) for amputations (1.2 [0.2-4.2] for major; 1.6 [0.3-4.3] for minor). The proportions of the reported populations with decreasing, stable and increasing admission trends were 80%, 20% and 0% for DFD conditions (50%, 0% and 50% for ulceration; 50%, 17% and 33% for infection; 67%, 0% and 33% for PAD) and 80%, 7% and 13% for amputations (80%, 17% and 3% for major; 52%, 15% and 33% for minor), respectively.

CONCLUSIONS/INTERPRETATION

These findings suggest that hospital admission rates for all DFD conditions are considerably higher than those for amputations alone and, thus, the more common practice of reporting admission rates only for amputations may substantially underestimate the burden of DFD. While major amputation rates appear to be largely decreasing, this is not the case for hospital admissions for DFD conditions or minor amputation in many populations. However, true global conclusions are limited because of a lack of consistent definitions used to identify admission rates for DFD conditions and amputations, alongside a lack of data from low- and middle-income countries. We recommend that these areas are addressed in future studies.

REGISTRATION

This review was registered in the Open Science Framework database ( https://doi.org/10.17605/OSF.IO/4TZFJ ).

Impact of case-mix adjustment on observed variation in the healing of diabetic foot ulcers at 12 weeks using data from the National Diabetes Foot Care Audit of England and Wales: A cohort study

AIM

This cohort study investigates the extent to which variation in ulcer healing between services can be explained by demographic and clinical characteristics.

METHODS

The National Diabetes Foot Care Audit collated data on people with diabetic foot ulcers presenting to specialist services in England and Wales between July 2014 and March 2018. Logistic regression models were created to describe associations between risk factors and a person being alive and ulcer-free 12 weeks from presentation, and to investigate whether variation between 120 participating services persisted after risk factor adjustment.

RESULTS

Of 27,030 people with valid outcome data, 12,925 (47.8%) were alive and ulcer-free at 12 weeks, 13,745 (50.9%) had an unhealed ulcer and 360 had died (1.3%). Factors associated with worse outcome were male sex, more severe ulcers, history of cardiac or renal disease and a longer time between first presentation to a non-specialist healthcare professional and first expert assessment. After adjustment for these factors, four services (3.3%) were more than 3SD above and seven services (5.8%) were more than 3SD below the national mean for proportions that were alive and ulcer-free at follow-up.

CONCLUSIONS/INTERPRETATIONS

Variation in the healing of diabetic foot ulcers between specialist services in England and Wales persisted after adjusting for demographic characteristics, ulcer severity, smoking, body mass index and co-morbidities. We conclude that other factors contribute to variation in healing of diabetic foot ulcers and include the time to specialist assessment.

Temporal trends in patients with peripheral artery disease influenced by diabetes mellitus in Germany

INTRODUCTION

In patients with peripheral artery disease (PAD) the presence of diabetes mellitus (DM) is associated with higher morbidity and mortality. Because huge efforts are made to improve medical care of patients with DM including chronic disease programs, the aim of the present study was to investigate temporal trends regarding the clinical burden of DM on PAD patients within a 15-year observational period.

METHODS

We analyzed all patients hospitalized because of PAD between 2005 and 2019 in Germany stratified regarding DM.

RESULTS

Overall, 2 654 871 hospitalizations of PAD patients (865 823 with DM) were included. Hospitalizations based on PAD inclined from 142 778 in 2005 to 190 135 in 2019 (β 3956 per year; 95% confidence interval [CI] 3034-4878, p < .001) with simultaneous increase of hospitalizations of PAD patients with DM (2005: 41609 (29.1%) versus 2019: 65 302 (34.3%); β 2019 per year [95% CI 1593-2446], p < .001). Amputation rates (β -0.42 [95% CI -0.44 to -0.40]; p < .001) as well as in-hospital case-fatality rate (2005: 4.7%, 2019: 2.8%; β -0.64 [95% CI -0.69 to -0.59]; p < .001) decreased in diabetic PAD patients during the observational time. In spite of improved morbidity and mortality in the last years of the observational period, patients with DM still suffered from an increased risk for morbidity and mortality during the observational period compared to nondiabetic PAD patients.

CONCLUSIONS

Despite the progress in DM treatments, DM still was associated with an unfavorable clinical patient profile and remained a substantial risk factor for morbidity and mortality in hospitalized patients with PAD and DM in Germany between 2005 and 2019.

Plasma Adrenomedullin, Allelic Variations in the ADM Gene, and Risk for Lower-Limb Amputation in People With Type 2 Diabetes

OBJECTIVE

Patients with diabetes have an increased risk for lower-limb amputation (LLA), but biomarkers to assess risk of LLA are lacking. Adrenomedullin (ADM) is a vasodilator peptide that also plays a role in fluid and electrolyte homeostasis in the kidney, increasing natriuresis and diuresis. ADM was shown to be associated with cardiovascular and renal events in diabetes, but it was not investigated in terms of LLA risk. We investigated the hypothesis that ADM is associated with LLA in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We studied 4,375 participants in the DIABHYCAR and SURDIAGENE cohorts (men, 68%; mean 66 years of age; mean duration of diabetes 12 years; and median follow-up 5.3 years). Plasma midregional proadrenomedullin (MR-proADM; a surrogate for ADM) was measured by immunofluorescence. Five single nucleotide polymorphisms (SNPs) in the ADM gene region were genotyped.

RESULTS

LLA requirement during follow-up by increasing tertiles of plasma MR-proADM distribution was 1.0% (tertile 1 [T1]), 2.3% (T2), and 4.4% (T3) (P < 0.0001). In Cox multivariate analysis, the adjusted hazard ratio (95% CI) for LLA was 4.40 (2.30-8.88) (P < 0.0001) for T3 versus T1. Moreover, MR-proADM significantly improved indices for risk stratification of LLA. Four SNPs were associated with plasma MR-proADM concentration at baseline and with LLA during follow-up. Alleles associated with higher MR-proADM were associated with increased LLA risk.

CONCLUSIONS

We observed associations of plasma MR-proADM with LLA and of ADM SNPs with plasma MR-proADM and with LLA in people with type 2 diabetes. This pattern of Mendelian randomization supports the causality of the association of ADM with LLA.

Contribution of diabetes to amputations in sub-Sahara Africa: A systematic review and meta-analysis

Diabetes related amputations remain a major global problem, with devastating complications. We critically appraised relevant literature to quantify the prevalence of diabetes related amputations in sub-Saharan Africa (SSA). An electronic search was performed using the EMBASE and PubMed databases until 2020. Twenty-four out of 834 studies retrieved were included. The pooled prevalence of diabetic-related amputations was 36.9% (95%CI: 32.9%-40.8%). Complications of diabetes related amputations included infection, anaemia, foot deformity and mortality. The study revealed a substantial contribution of diabetes to the burden of amputations in SSA and suggests the need for further studies to assess how to reduce the incidence of diabetes, reduce the incidence of and or delay the progression of macro and microvascular complications of diabetes in SSA.

The barriers and facilitators of foot care practices in diabetic patients in Indonesia: A qualitative study

AIM

To investigate the barriers and facilitators of foot care practice in diabetic patients in Indonesia.

DESIGN

A qualitative content analysis with an inductive approach.

METHOD

Semi-structured interviews were conducted on 34 type 2 diabetes mellitus (T2DM) patients, health providers and family members in Purwokerto, Indonesia, between July 2020 and December 2020. The interview transcripts were coded using NVivo 12.

RESULTS

Four themes emerged from data analysis, including personal barriers (low susceptibility of developing foot ulcer, limited knowledge about foot care, fatalistic practices, financial problems, glucose control taking priority over foot care, lack of motivation, lack of confidence, fear of being labelled), environmental barriers (lack of knowledge and time of health providers, lack of family support and climate conditions), perceived foot health benefits (intention to feel better and desire to stay socially active) and religious practices (foot washing as part of religious practice and intention to feel clean before praying).

ECONOMIC VALUE OF PODIATRY SERVICE IN LIMB SALVAGE ALLIANCE

INTRODUCTION

Over the last decade, multidisciplinary "toe and flow" programs have gained great popularity with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States.

METHODS

An administrative database that captured monthly OR cases, clinic encounters, in-patient volume, and total work relative value units (wRVU) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of three years, there was a significant change in the number of podiatrists (n=1 to 4) within the program where the clinical full-time employees for vascular surgeons remained relatively stable.

RESULTS

The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of four years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P<0.01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40% respectively (P<0.01) in the last three years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs.

CONCLUSION

This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrist in a vascular surgery practice is clearly demonstrated.

Major amputation rates and outcomes for Aboriginal and Torres Strait Islander and non-Indigenous people in North Queensland Australia between 2000 and 2015

BACKGROUND

This study estimated the incidence of major amputation for people in North Queensland, Australia, examined changes in amputation rates over time and investigated survival after major amputation.

METHODS

This was a retrospective study of patients who underwent a major amputation above the ankle between 2000 and 2015. Major amputation rates and incidence rate ratios (IRR) were calculated using census data to define the at-risk population. Associations between risk factors and calendar year with major amputation were assessed using quasipoisson regression. Kaplan-Meier survival and Cox-proportional hazard analyses estimated the incidence of and risk factors for all-cause mortality.

RESULTS

The annual incidence of major amputation was estimated to be greater in Aboriginal and Torres Strait Islanders than non-Indigenous people (IRR 2.75, 95 % CI 1.92 to 3.84). After adjusting for population growth, the annual incidence of major amputations did not change significantly over time for either groups. Aboriginal and Torres Strait Islander people were at greater risk of all-cause mortality after major amputation compared to non-Indigenous people, although this association was not significant after adjusting for other risk factors (hazard ratio 1.24, 95 % CI 0.82 to 1.90).

CONCLUSIONS

The incidence of major amputation in North Queensland has not reduced over time, indicating the need for better preventative treatments, particularly in Aboriginal and Torres Strait Islander people.

What happens to our amputees? The Darling Downs experience

BACKGROUND

Major lower limb amputation is occasionally required in the management of end-stage pathology where other treatment options have failed. The primary aim of this study was to determine the 30-day and 1-year mortality rates of patients undergoing nontraumatic major lower limb amputation. Secondary aims were to investigate risk factors for poor outcomes, incidence of previous minor amputation, and the rate of subsequent major amputation.

METHODS

All nontraumatic, major lower limb amputations performed at Toowoomba Hospital during an 18-year period were retrospectively reviewed. Mortality data were obtained from the Queensland Registry of Births, Deaths and Marriages. Kaplan-Meier analysis was performed to determine survival after amputation.

RESULTS

A total of 147 patients were included in the study, with 104 undergoing below knee and 43 undergoing above knee amputations. Ten patients identified as having an Aboriginal and Torres Strait Islander background. For all patients, the 30-day mortality was 4.1% and 1-year mortality was 21.1%. For Indigenous patients, 30-day mortality was 10%. Previous minor amputation had occurred in 40 patients. Twenty-nine patients underwent further minor surgery after their initial major amputation, with thirteen requiring subsequent major amputation. Factors that increased mortality risk were the presence of peripheral vascular disease, an American Society of Anesthesiologists score of four and age greater than 65 years.

CONCLUSION

The morbidity and mortality following major lower limb amputation is significant. The findings of this study highlight the importance of preventative measures to minimize the incidence of lower limb amputations in the future.

Risk of amputation with canagliflozin across categories of age and cardiovascular risk in three US nationwide databases: cohort study

OBJECTIVE

To estimate the rate of lower limb amputation among adults newly prescribed canagliflozin according to age and cardiovascular disease.

DESIGN

Population based, new user, cohort study.

DATA SOURCES

Two commercial and Medicare claims databases, 2013-17.

PARTICIPANTS

Patients newly prescribed canagliflozin were propensity score matched 1:1 with patients newly prescribed a glucagon-like peptide-1 (GLP-1) receptor agonist. Hazard ratios and rate differences per 1000 person years were computed for the rate of lower limb amputation in the following four groups: group 1, patients aged less than 65 years without baseline cardiovascular disease; group 2, patients aged less than 65 with baseline cardiovascular disease; group 3, patients aged 65 or older without baseline cardiovascular disease; group 4, patients aged 65 or older with baseline cardiovascular disease. Within each group, pooled hazard ratio and rate difference per 1000 person years were calculated by meta-analysis.

INTERVENTION

Canagliflozin versus a GLP-1 agonist.

MAIN OUTCOME MEASURES

Lower limb amputation requiring surgery.

RESULTS

Across the three databases, 310 840 propensity score matched adults who started canagliflozin or a GLP-1 agonist were identified. The hazard ratio and rate difference per 1000 person years for amputation in adults receiving canagliflozin compared with a GLP-1 agonist for each group was: group 1, hazard ratio 1.09 (95% confidence interval 0.83 to 1.43), rate difference 0.12 (-0.31 to 0.55); group 2, hazard ratio 1.18 (0.86 to 1.62), rate difference 1.06 (-1.77 to 3.89); group 3, hazard ratio 1.30 (0.52 to 3.26), rate difference 0.47 (-0.73 to 1.67); and group 4, hazard ratio 1.73 (1.30 to 2.29), rate difference 3.66 (1.74 to 5.59).

CONCLUSIONS

The increase in rate of amputation with canagliflozin was small and most apparent on an absolute scale for adults aged 65 or older with baseline cardiovascular disease, resulting in a number needed to treat for an additional harmful outcome of 556 patients at six months (that is, 18 more amputations per 10 000 people who received canagliflozin). These results help to contextualize the risk of amputation with canagliflozin in routine care.

Trends and outcomes of non-traumatic major lower extremity amputations in an Irish tertiary referral hospital

OBJECTIVES

Data on vascular patients following amputation in Ireland is lacking, limiting capability to plan services. This paper seeks to benchmark survival and rehabilitation outcomes among vascular patients in Ireland following lower extremity amputation (LEA), and compare subgroups of those undergoing transfemoral (TFA) or transtibial amputation (TTA).

METHODS

A review was conducted of all patients who underwent non-traumatic TFA or TTA from 2000 to 2009 in a tertiary vascular surgery centre. Demographics, surgical data, perioperative outcomes, medium-term functional outcomes, and survival were assessed.

RESULTS

One hundred and seventy-two patients (2:1 male: female) underwent 192 non-traumatic LEAs. Median age for TFA was 75 years and TTA 67 (p = 0.002). A percentage of 36.5% had undergone prior attempts at surgical revascularization, 25% had undergone prior distal amputation or debridement. Thirty-three (17%) required stump revision. Twenty-three (13.2%) died in hospital. Median survival for those who died in hospital was 17 days (0-367), versus 17 months (2-106) for those who survived to discharge.

CONCLUSION

LEA for vascular pathology has significant morbidity and mortality, with long in-patient stays and short median survival; there is need to focus on improving quality of life in postoperative pathways.

Foot self-care behavior and its predictors in diabetic patients in Indonesia

OBJECTIVES

Previous studies have shown that diabetic foot ulcers are principally associated with improper foot self-care. Since appropriate foot self-care is essential to prevent diabetic foot-ulcers, any factors which can predict foot self-care behavior should be identified. However, until now, foot self-care behavior data and predictors of foot-care behavior in Indonesia remain unclear since such studies on Indonesian diabetic patients is very limited. Therefore, the purpose of this study was to investigate foot self-care behavior and to identify its predictors in Indonesia. The design of this study was cross-sectional. Cluster sampling was used, involving 546 type 2 diabetes mellitus patients registered in 22 primary healthcare centers. The questionnaires used in this study included the Diabetes Distress Scale, Beck Depression Inventory II, Family APGAR, Foot-Care Knowledge and Modified Diabetic Foot Care Behaviors.

RESULTS

Foot self-care behavior and knowledge about foot care were poor. The predictors of foot self-care behavior were age, educational level, diabetes distress, family support, and knowledge. It needs the program to improve foot self-care knowledge and the program to reduce the diabetes distress in Indonesian diabetic patients. In performing of these programs, families should be involved to improve the support toward foot self-care behavior in patients.

The cost of diabetic foot ulcers and amputations to the National Health Service in England

AIM

To estimate the healthcare costs of diabetic foot disease in England.

METHODS

Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015.

RESULTS

The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration.

CONCLUSIONS

Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

Global Vascular Guidelines on the Management of Chronic Limb-Threatening Ischemia

GUIDELINE SUMMARY

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Global vascular guidelines on the management of chronic limb-threatening ischemia

Chronic limb-threatening ischemia (CLTI) is associated with mortality, amputation, and impaired quality of life. These Global Vascular Guidelines (GVG) are focused on definition, evaluation, and management of CLTI with the goals of improving evidence-based care and highlighting critical research needs. The term CLTI is preferred over critical limb ischemia, as the latter implies threshold values of impaired perfusion rather than a continuum. CLTI is a clinical syndrome defined by the presence of peripheral artery disease (PAD) in combination with rest pain, gangrene, or a lower limb ulceration >2 weeks duration. Venous, traumatic, embolic, and nonatherosclerotic etiologies are excluded. All patients with suspected CLTI should be referred urgently to a vascular specialist. Accurately staging the severity of limb threat is fundamental, and the Society for Vascular Surgery Threatened Limb Classification system, based on grading of Wounds, Ischemia, and foot Infection (WIfI) is endorsed. Objective hemodynamic testing, including toe pressures as the preferred measure, is required to assess CLTI. Evidence-based revascularization (EBR) hinges on three independent axes: Patient risk, Limb severity, and ANatomic complexity (PLAN). Average-risk and high-risk patients are defined by estimated procedural and 2-year all-cause mortality. The GVG proposes a new Global Anatomic Staging System (GLASS), which involves defining a preferred target artery path (TAP) and then estimating limb-based patency (LBP), resulting in three stages of complexity for intervention. The optimal revascularization strategy is also influenced by the availability of autogenous vein for open bypass surgery. Recommendations for EBR are based on best available data, pending level 1 evidence from ongoing trials. Vein bypass may be preferred for average-risk patients with advanced limb threat and high complexity disease, while those with less complex anatomy, intermediate severity limb threat, or high patient risk may be favored for endovascular intervention. All patients with CLTI should be afforded best medical therapy including the use of antithrombotic, lipid-lowering, antihypertensive, and glycemic control agents, as well as counseling on smoking cessation, diet, exercise, and preventive foot care. Following EBR, long-term limb surveillance is advised. The effectiveness of nonrevascularization therapies (eg, spinal stimulation, pneumatic compression, prostanoids, and hyperbaric oxygen) has not been established. Regenerative medicine approaches (eg, cell, gene therapies) for CLTI should be restricted to rigorously conducted randomizsed clinical trials. The GVG promotes standardization of study designs and end points for clinical trials in CLTI. The importance of multidisciplinary teams and centers of excellence for amputation prevention is stressed as a key health system initiative.

Incidence and determinants of diabetes-related lower limb amputations in Ghana, 2010-2015- a retrospective cohort study

BACKGROUND

Diabetes-related lower limb amputations (LLA) are associated with significant morbidity and mortality. Although the incidence has decreased over the past two decades in most High-Income Countries, the situation in Low-Middle Income Countries (LMIC), especially those in sub-Saharan Africa (SSA) is not clear. We have determined the incidence and determinants of diabetes-related LLA in Ghana.

METHODS

This was a tertiary-care-based retrospective cohort study involving patients enrolled in the diabetes clinic of Komfo Anokye Teaching Hospital, Ghana from 1st January 2010 to 31st December 2015 after a median follow-up of 4.2 years. Demographic characteristics and clinical variables at baseline were recorded. The primary outcome was new diabetes-related LLA in each year under study. Cox proportional hazard regression models were used to describe the associations of diabetes-related LLA.

RESULTS

The mean age at enrolment for the cohort was 55.9 ± 14.6 years, with a female preponderance (62.1%). The average incidence rate of diabetes-related LLA was 2.4 (95% CI:1.84-5.61) per 1000 follow-up years: increasing from 0.6% (95% CI:0.21-2.21) per 1000 follow up years in 2010 to 10.9% (95% CI:6.22-12.44) per 1000 follow-up years in 2015. Diabetes-related LLA was associated with increased age at enrollment (for every 10 year increase in age: HR: 1.11, CI: 1.06-1.22, p < 0.001), male gender (HR: 3.50, CI:2.88-5.23, p < 0.01), type 2 diabetes (HR 3.21, CI: 2.58-10.6, p < 0.001), high Body Mass Index (HR: 3.2, CI: 2.51-7.25 p < 0.001), poor glycemic control (for a percent increase in HbA1c, HR:1.11, CI:1.05-1.25, p = 0.03), hypertension (HR:1.14, CI:1.12-3.21 p < 0.001), peripheral sensory neuropathy (HR:6.56 CI:6.21-8.52 p < 0.001) and peripheral vascular disease (HR: 7.73 CI: 4.39-9.53, p < 0.001).

CONCLUSION

The study confirms a high incidence of diabetes related-LLA in Ghana. Interventions aimed at addressing systemic and patient-level barriers to good vascular risk factor control and proper foot care for diabetics should be introduced in LMICs to stem the tide of the increasing incidence of LLA.

Incidence rates of dysvascular lower extremity amputation changes in Northern Netherlands: A comparison of three cohorts of 1991-1992, 2003-2004 and 2012-2013

Objective

To analyze the incidence rates of dysvascular major lower extremity amputations (LEA) in Northern Netherlands in 2012–2013 compared to previous cohorts in 1991–1992 and 2003–2004.

Design

Retrospective cohort study.

Participants

Adults (N = 343) with first ever dysvascular LEA at ankle disarticulation or more proximal levels. The median age (interquartile range) was 74.2 years (64.5–81.9), 64% were male and 55% had been diagnosed with diabetes mellitus (DM).

Main outcome measures

Crude and age-standardized incidence rates of major LEA per 100.000 person-years.

Results

Crude incidence rate (IR) of first ever major LEA in 2012–2013 was 9.9 per 100.000 person-years, while the age-standardized IR was 7.7 per 100.000 person-years. A Poisson regression analysis showed that amputation rates among men were 2.3 times higher compared to women (95%CI 1.9–2.6), while in 2012–2013 the population aged >63 years had decreased amputation rates compared to 1991–1992. In the DM population the crude IR decreased from 142.6 per 100.000 person-years in 2003–2004 to 89.2 per 100.000 person-years in 2012–2013 (p<0.001).

Conclusions

In 2012–2013 a decrease in age-standardized IR for the general population and a decrease in crude IR for the DM population were observed compared to cohorts from the previous two decades, despite considerable shifts in the age distribution of the Dutch population towards more elderly people and increased prevalence of DM. These findings might suggest that improved treatment of patients at risk of dysvascular amputations is associated with reduced incidence rates of major LEA at the population level.

Barriers to foot care in patients with diabetes as identified by healthcare professionals

AIMS

To seek the views of healthcare professionals as to the barriers to foot care that they perceive as having an impact on clinical outcomes and contributing to the number of amputations.

METHODS

The study involved healthcare professionals from the UK attending our 2015 and 2016 Masterclass diabetic foot conferences. Admission to these conferences was open to all members of the multidisciplinary spectrum who provide care of people with diabetes and foot problems. Attendees were asked to write down concerns that they considered to constitute barriers to foot care for people with diabetes.

RESULTS

A total of 425 responses were received (90.8% of the total attendance at the 2015/2016 conferences). Analysis of the responses produced eight key subject areas in which barriers to care were identified: patient referrals, communication between disciplines, access to specialist services, patient care, funding, organization of care, education and infection. Within these key areas, respondents reported poor recognition and diagnosis of foot problems, lack of awareness of the need for referral both by the person with diabetes and healthcare professionals, difficulties in the referral pathway, lack of access to multidisciplinary care, shortage of resources and lack of education of both people with diabetes and healthcare professionals. The respondents identified these barriers as contributing to delay in people with diabetes receiving specialist help. Such a delay can lead to amputation.

CONCLUSIONS

The crucial barrier to diabetic foot care is delay in accessing specialist care. Until this is addressed, care will be less than optimum and amputations will continue.

Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers

Diabetic foot ulcers remain a major health care problem. They are common, result in considerable suffering, frequently recur, and are associated with high mortality, as well as considerable health care costs. While national and international guidance exists, the evidence base for much of routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individuals. It is probable that this contributes to the geographic variation in outcome that has been documented in a number of countries. This article considers these issues in depth and emphasizes the urgent need to improve the design and conduct of clinical trials in this field, as well as to undertake systematic comparison of the results of routine care in different health economies. There is strong suggestive evidence to indicate that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes.

Improved limb salvage for patients with vascular disease and tissue loss associated with new model of provision targeted at the diabetic foot

AIMS

The establishment of a vascular surgeon-led emergency diabetic foot service in 2006 has evolved to provide lower limb wound care for patients with and without diabetes. We aimed to determine whether the service was associated with sustained, improved limb salvage rates for the whole population, analyse key aspects of service provision and compare outcomes against published studies.

METHODS

The vascular unit serves a largely rural population of approximately 240,000. Data was collected prospectively on lower limb amputations, arterial and minor surgical interventions from 2006 to 2015, and retrospectively retrieved for 2004-2005, prior to service commencement. Data was also collected on referral patterns, volume of patient admissions and attendances, and delays. Lower limb amputation rates were compared against published data and analysis of admission trends and delays employed non-parametric tests.

RESULTS

Age/gender adjusted major lower limb amputations for the populations with and without diabetes were 412/100,000 in 2004 and 15/100,000 in 2005 respectively. Following service introduction, major amputations reduced and since 2012 have been sustained at between 15-44/100,000 and 1-3/100,000 for patients with and without diabetes respectively, comparing favourably with published data. Vascular interventions have remained static, but referrals of patients directly to the service and numbers of minor procedures have increased.

CONCLUSIONS

The sustained decreases in all major lower limb amputations that have coincided with the development of a core team approach to providing rapid access and comprehensive care for patients with emergency diabetic foot problems may indicate that this service design benefits patients with and without diabetes.

Fighting diabetic foot ulcers-The diabetologist: A king maker of the fight

Diabetic foot ulcer is a costly and serious complication of diabetes mellitus and is the major cause of non-traumatic limb amputations worldwide. Its development is primarily the result of diabetic neuropathy and/or peripheral arterial disease with accompanied bone abnormalities and is complicated by invasive infection. The management of this clinical condition focuses on identification of the "at-risk" foot, treatment of the ulcerated foot, and prevention of further complications. As diabetic foot ulcer represents the sum of multiple etiologies, its treatment requires a multidisciplinary team, which can result in a significant reduction in the incidence of ulcers, infections and amputations. The team should include a diabetologist, a podiatrist, an orthoptist, an educator and a plaster technician, in close collaboration with a vascular surgeon, an orthopedic/podiatric surgeon and a dermatologist. It is recommended that a diabetologist be the multidisciplinary team leader, as diabetic foot ulcer is a complication of diabetes and chronic hyperglycemia represents the main cause for its development. The appropriate composition of professionals involved in the team is institution-dependent and may vary worldwide, depending on the diabetic population. The concept of establishing a diabetic foot care team is recommended by all National and International Diabetes Scientific Societies and Associations.

Diabetes-related amputations create considerable public health burden in the UK

AIMS

The main aim of this study was to assess the cost of diabetic amputation (both direct and indirect) to the National Health Service from the point of amputation onwards.

METHODS

This systematic review involved searches of published literature between January 2007 and March 2017 mainly using the bibliographic databases, the Cochrane Library, EMBASE via Ovid®, MEDLINE via Ovid®, as well as grey literature, both in print and in electronic formats published through non-commercial publications, which reported the cost of amputation due to diabetic foot ulcers.

RESULTS

The studies included in this review varied considerably in estimating the cost including cost elements and how those costs were categorised. The cost estimates for inpatient care associated with amputation involving admissions or procedures on amputation stumps in people with diabetes was £43.8 million. The annual expenditure for post-amputation care involving prosthetic care, physiotherapy, transport and wheelchair use was £20.8 million.

CONCLUSIONS

There is a considerable public health and economic burden caused by diabetes-related amputations in England. More focussed research is needed with improved methods of estimating costs that would account for direct and indirect costs associated with diabetic amputation.

A systematic review describing incidence rate and prevalence of dysvascular partial foot amputation; how both have changed over time and compare to transtibial amputation

BACKGROUND

Partial foot amputation (PFA) is a common consequence of advanced peripheral vascular disease. Given the different ways incidence rate and prevalence data have been measured and reported, it is difficult to synthesize data and reconcile variation between studies. As such, there is uncertainty in whether the incidence rates and prevalence of PFA have increased over time compared to the decline in transtibial amputation (TTA). The aims of this systematic review were to describe the incidence rate and prevalence of dysvascular PFA over time, and how these compare to TTA.

METHOD

Databases (i.e., MEDLINE, EMBASE, psychINFO, AMED, CINAHL, ProQuest Nursing and Allied Health) were searched using MeSH terms and keywords related to amputation level and incidence rate or prevalence. Original research published in English from 1 January 2000 to 31 December 2015 were independently appraised, and data extracted, by two reviewers. The McMaster Critical Review Forms were used to assess methodological quality and bias. Results were reported as narrative summaries given heterogeneity of the literature and included the weighted mean annual incidence rate and 95% confidence interval.

RESULTS

Twenty two cohort studies met the inclusion criteria. Twenty one reported incidence rate data for some level of PFA; four also included a TTA cohort. One study reported prevalence data for a cohort with toe(s) amputation. Samples were typically older, male and included people with diabetes among other comorbidities. Incidence rates were reported using a myriad of denominators and strata such as diabetes type or initial/recurrent amputation.

CONCLUSION

When appropriately grouped by denominator and strata, incidence rates were more homogenous than might be expected. Variation between studies did not necessarily reduce confidence in the conclusion; for example, incidence rate of PFA were many times larger in cohorts with diabetes (94.24 per 100,000 people with diabetes; 95% CI 55.50 to 133.00) compared to those without (3.80 per 100,000 people without diabetes; 95% CI 1.43 to 6.16). It is unclear whether the incidence rates of PFA have changed over time or how they have changed relative to TTA. Further research requires datasets that include a large number of amputations each year and lengthy time periods to determine whether small annual changes in incidence rates have a cumulative and statistically significant effect over time.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015029186 .

Incidence of lower extremity amputations in the diabetic compared with the non-diabetic population: A systematic review

Lower extremity amputation (LEA) in patients with diabetes results in high mortality, reduced quality of life, and increased medical costs. Exact data on incidences of LEA in diabetic and non-diabetic patients are important for improvements in preventative diabetic foot care, avoidance of fatal outcomes, as well as a solid basis for health policy and the economy. However, published data are conflicting, underlining the necessity for the present systematic review of population-based studies on incidence, relative risks and changes of amputation rates over time. It was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Nineteen out of 1582 studies retrieved were included in the analysis. The incidence of LEA in the diabetic population ranged from 78 to 704 per 100,000 person-years and the relative risks between diabetic and non-diabetic patients varied between 7.4 and 41.3. Study designs, statistical methods, definitions of major and minor amputations, as well as the methods to identify patients with diabetes differed greatly, explaining in part these considerable differences. Some studies found a decrease in incidence of LEA as well as relative risks over time. This obvious lack of evidence should be overcome by new studies using a standardized design with comparable methods and definitions.

The hospitalization profiles of patients with or without diabetes treated for nontraumatic lower extremity amputation in Ribeirão Preto, São Paulo State, Brazil, 2001-2008

The aim of this retrospective study was to assess the hospitalizations of patients with or without diabetes mellitus (DM) who underwent nontraumatic lower extremity amputation (NLEA) with regard to demographic and hospitalization-related variables. It is a high proportion of hospital beds in developing countries, for patients with diabetes mellitus with lower extremity complications. Nontraumatic amputations of lower extremities rates is an important indicator to assess the effectiveness of efforts to reduce chronic complications related to diabetic foot.A total of 2,296 hospital admissions were analyzed with regard to gender, age, length of stay, type of financing, origin, diagnosis, number of hospital admissions and readmissions, and hospitalization outcome from 2001 to 2008 in a municipality of Southeast Brazil. The association between the independent variables and the number of hospitalizations of patients with or without diabetes was assessed using chi-square tests for gender, type of financing, and hospitalization outcome and using the Mann-Whitney U test for age and length of stay. A total of 58% were patients without diabetes, 62.6% were male, 74.5% were treated at a public health care service, and 7.6% died. The mean age was 62.7 years, the mean length of stay was of 9.5 days, and the mean number of readmissions was 2.29 times. The length of stay was higher (P < .001), and the number of men was lower (P = .001) among the patients with diabetes who were hospitalized compared with patients without diabetes.The number of hospitalizations related to NLEA increased among patients with diabetes but reduced among those without diabetes between 2001 and 2008.

Podiatry impact on high-low amputation ratio characteristics: A 16-year retrospective study

PURPOSE

Complications from diabetes mellitus including major lower extremity amputation may have significant impact on a patient's mortality. This study determined what impact the addition of a limb salvage and diabetic foot program involving podiatry had at an academic institution over 16years by analyzing high-low amputation ratio data.

METHODS

The high-low amputation ratio in the diabetic population who underwent non-traumatic amputation of the lower extremity was retrospectively evaluated at an academic institution via cohort discovery of the electronic medical record and analysis of billing over 16years.

RESULTS

We directly compared two eras, one without podiatry and one with a podiatry presence. It was found that with the addition of a podiatry program, limb salvage rates significantly increased (R² (without podiatry)=0.45, R² (with podiatry)=0.26), with a significant change in both the rate of limb salvage per year (-0.11% per year versus -0.36% per year; p<0.01) and an overall decrease in high-low amputation ratio (0.89 without podiatry to 0.60 with podiatry). Of note, approximately 40 major lower extremity amputations were avoided per year with the addition of a podiatry program (p<0.05).

CONCLUSIONS

Our findings signify the importance of podiatric care in the diabetic population. With an established podiatry program present at an academic institution, major lower extremity amputations can be avoided and more limbs can be salvaged, thus preventing some of the moribund complications from this condition.

Comparison of Transtibial Amputations in Diabetic Patients With and Without End-Stage Renal Disease

BACKGROUND

The primary purpose of this retrospective study was to report on a consecutive series of 102 patients with diabetes mellitus (DM) who underwent transtibial amputation (TTA) for chronic infections and nonreconstructable lower extremity deformities. A secondary aim was to compare the outcomes of TTA patients with end-stage renal disease on dialysis (ESRD) to patients without ESRD, and to identify risk factors for mortality after TTA.

METHODS

This cohort involved a consecutive series of patients who were treated by a single surgeon. The TTA patients were divided into 2 groups for analysis. The study group included those patients with ESRD who underwent TTA, and the control group included those patients who did not have ESRD.

RESULTS

At the time of final follow-up, 64 of 102 patients were ambulatory with a prosthesis. There was a significant improvement in ambulatory status after amputation (preoperatively 45.1%, postoperatively 62.7%, P = .02). Wound healing complications (infection and/or dehiscence) occurred in 31 of 102 patients and led to a transfemoral amputation in 4 patients. After TTA patients with ESRD were significantly more likely to die (52.4% vs. 23.5%, p <0.05) and significantly less like to ambulate (42.9% vs. 67.9%, p <0.05) than patients without ESRD. Contralateral foot problems after the TTA occurred in 33 of 97 patients and resulted in 10 patients undergoing a contralateral transtibial amputation. Excluding patients with bilateral amputations (5 prior to and 10 after the index amputation), 64 of 87 patients with successful unilateral transtibial amputations were able to ambulate with a prosthesis. Thirty of 102 patients (29.4%) died during the follow-up period, and 6 of these deaths occurred during the perioperative period (within 30 days of surgery). There were no significant differences between the 2 groups with regard to the use of staged TTA, need for transfemoral amputation, or wound healing problems at the amputation site. Patients who were unable to walk postoperatively had a calculated 5-year survival rate of 30.1%, whereas those who were ambulatory had a 5-year survival rate of 68.8%. Cox proportional hazards model demonstrated a 62% reduced risk of mortality in patients who were able to ambulate after LEA compared with those patients who were not able to ambulate.

CONCLUSION

TTA in patients with diabetes was associated with substantial morbidity and mortality. Risk factors that were significantly associated with an increased rate of mortality were the presence of ESRD, age ≥56 years, and inability to ambulate postoperatively.

LEVEL OF EVIDENCE

Level III, retrospective case controlled study.

Trends in the incidence of lower limb amputation after implementation of a Multidisciplinary Diabetic Foot Unit

BACKGROUNDS AND OBJECTIVE

Incidence of lower extremity amputations (LEA) in the population with and without diabetes mellitus (DM) was assessed after implementation of a Multidisciplinary Diabetic Foot Unit (MDFU) during 2008.

MATERIAL AND METHODS

Non-traumatic LEA were analyzed, and those performed before (2001-2007) and after (2008-2014) introduction of the MDFU were compared. LEA were grouped by age and sex. Their incidence was expressed as a rate per 100,000 population per year, adjusted to the standard European population.

RESULTS

A total of 664 LEA were performed during the 2001-2014 period, 486 (73%) of them in patients with DM. Total LEA incidence was 11.2/10⁵ population in DM versus 3.9/10⁵ in the population without DM. Incidence of major LEA in patients with DM significantly decreased from 6.1/10⁵ population in the 2001-2007 period to 4.5/10⁵ in the 2008-2014 period (p=.03). Joinpoint regression analysis also showed a reduction in the trend of incidence of major LEA in patients with DM, with an annual percentage change of -3.3% [95% CI, -6.2-0.3] (p=.025). No significant differences were found for all other incidences and trends in the diabetic and non-diabetic populations.

CONCLUSIONS

Implementation of a MDFU has been shown to be associated with a significant reduction in major amputation rate in the diabetic population, although the results are not optimal yet. Both results and work at the MDFU should be improved.

Retrospective study of the evolution of the incidence of non-traumatic lower-extremity amputations (2007-2013) and risk factors of reamputation

AIM

Describe the incidence of non-traumatic amputation in a Spain region and identify the risk factors associated with the level of amputation and reamputation.

METHODS

Retrospective study on non-traumatic lower-extremity amputees in a Spanish region between 2007 and 2013. A descriptive, bivariate and multivariate analysis was performed using bivariate logistic regression. Statistical significance p≤0.05, SPSS V.21.

RESULTS

495 amputations were carried out in 353 patients. 81.0% (n=286) were men, mean age 68.7±10.8 years. The most frequent levels of amputation were digital (45.9%) and above-knee (40.5%). About 30% of the patients were reamputated. The multivariate analysis revealed that the factors independently related to the need for a minor lower-extremity amputation were DM [OR 3.79 (CI 95% 2.0-7.27)], foot ulcer [OR 5.82 (CI 95% 2.24-15.11)] and previous ipsilateral amputation [OR 3.19 (CI 95% 1.21-8.42)]. The risk factors independently related to the need for reamputation were DM [OR 2.21 (CI95% 1.09-4.49)], smoking [OR 2.45 (CI95% 1.33-4.50)] and previous revascularization [OR 2.75 (CI95% 1.57-4.83)].

CONCLUSIONS

Determining the incidence of amputations in diabetic patients as an indicator of quality makes it possible for health services to be evaluated. In patients with DM the most common reamputations are minor and ipsilateral.

Treatment Failure and Leg Amputation Among Patients With Foot Osteomyelitis

We sought to identify factors associated with treatment failure and leg amputations among those patients who presented with foot osteomyelitis. Characteristics, treatments, and outcomes for all patients treated for probable or definite foot osteomyelitis (per consensus definition) between January 2011 and March 2015 were reviewed. Multivariate Cox regression models were used to identify risk factors for treatment failure (unanticipated resection of additional bone or leg amputation) and of leg amputation alone. A total of 184 episodes of foot osteomyelitis met inclusion criteria. Treatment failure occurred in 53 (28.8%) and leg amputation in 21 (11.4%). Risk factors for treatment failure included severe/unaddressed peripheral artery disease, homelessness, Pseudomonas aeruginosa or Escherichia coli bone isolates, serum albumin <2.8 mg/dL, hallux involvement, insulin therapy, 60 or more pack-years smoking, and <7 days of directed antibiotic therapy for a positive bone margin. Delayed primary wound closure (ie, staged operations) had significantly lower treatment failure risk. Unanticipated resection of bone was not associated with leg amputation. Foot osteomyelitis treatment failure is common. Various factors can help identify those at risk for treatment failure and/or leg amputation, and further studies should focused whether initial management or follow-up should change when these factors are present.

The prevalence of major lower limb amputation in the diabetic and non-diabetic population of England 2003-2013

AIMS

To determine the prevalence of amputation and revascularisation among diabetics and non-diabetics between 2003 and 2013.

METHODS

Retrospective analysis of English hospital data with census estimates for population aged 50-84 years.

RESULTS

There were 42,294 major and 52,525 minor amputations and 355,545 revascularisations. Major amputation rates fell by 20% (27.7-22.9), with minor amputations (22.9-35.2) and revascularisations (199.8-245.4) rising. The major amputation rate reduced in diabetics (men, 180.5-111.8; women, 92.8-52.7) faster than non-diabetics (men, 24.6-18.7; women, 11.0-8.9). In total, 48.2% of men and 58.0% of women amputees were not diabetic.

CONCLUSION

Diabetics continue to experience six times the rate of amputation than non-diabetics. However, half of major amputees were not diabetic and experienced slower rates of decrease. Non-diabetics, particularly those with peripheral arterial disease, should have access to appropriate services, particularly foot care.

Care of Patients with Diabetic Foot Disease in Oman

Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002-2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman.

A cost-effectiveness analysis of optimal care for diabetic foot ulcers in Australia

In addition to affecting quality of life, diabetic foot ulcers (DFUs) impose an economic burden on both patients and the health system. This study developed a Markov model to analyse the cost-effectiveness of implementing optimal care in comparison with the continuation of usual care for diabetic patients at high risk of DFUs in the Australian setting. The model results demonstrated overall 5-year cost savings (AUD 9100·11 for those aged 35-54, $9391·60 for those aged 55-74 and $12 394·97 for those aged 75 or older) and improved health benefits measured in quality-adjusted life years (QALYs) (0·13 QALYs, 0·13 QALYs and 0·16 QALYs, respectively) for high-risk patients receiving optimal care for DFUs compared with usual care. Total cost savings for Australia were estimated at AUD 2·7 billion over 5 years. Probabilistic sensitivity analysis showed that optimal care always had a higher probability of costing less and generating more health benefits. This study provides important evidence to inform Australian policy decisions on the efficient use of health resources and supports the implementation of evidence-based optimal care in Australia. Furthermore, this information is of great importance for comparable developed countries that could reap similar benefits from investing in these well-known evidence-based strategies.

Color-coded etiological keys: A simple survey tool towards amputation-free limb survival in diabetic foot lesions

Aims/Introduction

We devised a simple implementable color‐coded etiological key survey based on six significant categories to screen and manage all diabetic foot patients. The study results were analyzed to verify the impact of this survey.

Materials and Methods

First we carried out a retrospective internal survey of all diabetic patients that presented to us during the period from January 2004 to January 2007. We used this analysis to develop the color‐coded etiological survey, and applied it to analyze patients prospectively for 5 years from May 2007 to May 2012. Out of 4,102 diabetic foot patients, 739 patients were referred by other medical facilities for major amputation as a result of the severity of their foot lesions. This group was then subjected to further analysis to study the value and impact of the survey on amputation‐free limb survival.

Results

Blood quality abnormalities were most prevalent followed by peripheral occlusive diseases, whereas tissue loss was the least. After the completion of the assessment process, management was implemented according to the defined protocol based on the lesions’ characteristics. The primary end‐point of major amputation‐free limb survival was achieved in 72.5% of patients, with an average hospital stay of 13.3 days. Statistical analysis of the etiological keys showed a significant impact of tissue loss, and previous foot surgery as a poor predictor of limb loss.

Conclusion

We conclude that the implementation of the color‐coded etiological key survey can provide efficient and effective service to diabetic foot victims with comparable outcomes to dedicated diabetic foot clinics.

Variation and Trends in Lower Extremity Amputation Rates in Los Angeles County Hospitals 2000-2010

Lower extremity amputation (LEA) is a preventable complication of diabetes and peripheral vascular disease. Hospital-related factors associated with higher LEA are low hospital LEA revascularization volume, rural setting, and nonteaching status. In this study, we describe LEA rates in health care systems and hospitals in Los Angeles County from 2000 to 2010. Data on hospital discharges in Los Angeles County from 2000 to 2010 were obtained from the California Office of Statewide Health Planning and Development. LEA rates were adjusted for clinical and demographic variables including age, sex, race, source of health care payment, diabetes, and peripheral vascular disease. Adjusted LEA rates over the study period were analyzed by category of hospital (municipal, nonprofit/non-Kaiser, Kaiser, and private), and for changes in rates in each hospital over the study period. Over the 11-year study period the LEA rates increased for municipal hospitals, while decreasing for the other 3 categories of hospitals. Among the 84 hospitals included in the final analysis, 41 hospitals had higher than average relative risk for LEA in 2007-2010. Among these hospitals 12 had higher than average decline in LEA rate between 2000-2003 and 2007-2010. The other 29 hospitals had not lowered the LEA rate as much as the whole County over the study period. After adjusting for demographic and clinical variables, the relative risk for LEA among hospitals varied by 7.5-fold. Significant variability was found both within each of the 4 types of hospitals, and between the 4 types. Hospitals also varied in the degree that they lowered their LEA rates. This study demonstrated that health care systems and hospitals are associated with significant disparity in LEA rates among socioeconomic groups and geographical regions.