Trends in lower-extremity amputations in people with and without diabetes in Spain, 2001-2008

Impact of Diabetic Foot Multidisciplinary Unit on Incidence of Lower-Extremity Amputations by Diabetic Foot

BACKGROUND

One of the most devastating complications of diabetes is diabetes-related foot disease (DFD), which is a priority for public health systems. The 2016-2020 Catalonia Health Plan aimed to reduce the incidence of total and major lower-extremity amputations (LEAs) due to DFD by 10% in the population aged 45-74 years. The aim of the present study was to compare the incidence of LEA-DFD 5 years before and after the creation of the Diabetic Foot Multidisciplinary Unit at our Hospital.

METHODS

We prospectively collected all cases of LEA-DFD performed at Vall d'Hebron University Hospital from 1 January 2016 to 31 December 2020. Cases of LEA-DFD performed from 1 January 2011 to 31 December 2015 were retrospectively reviewed. The incidence of LEA-DFD between these periods was compared.

RESULTS

A total of 457 LEAs due to DFD were performed in 316 patients. We observed a reduction of 27.9% [CI: 23.7-32.1%] in the incidence of total LEA in the 2016-2020 period in comparison with the period 2011-2016 (0.8 ± 0.1 vs. 1.1 ± 0.3 per 10.000 inhabitants/year, p < 0.001), as well as a reduction of 49.3% [CI: 44.6-53.9%] in the incidence of major LEA-DFD (0.15 ± 0.1 vs. 0.30 ± 0.1 per 10.000 inhabitants/year, p < 0.001).

CONCLUSIONS

The implementation of a Diabetic Foot Multidisciplinary Unit resulted in a significant reduction in the rate of amputations due to DFD in the population with diabetes in North Barcelona.

Functional decline in people with diabetes: Bidirectional relationships between body function and activity-participation components in a two-wave longitudinal structural equation modeling

This study examined the impact of diabetes over time. The sample included 68 people with diabetes used a three-year longitudinal design to test a model of functional decline. Indicators of the body function and activity and participation components of the International Classification of Functioning, Disability and Health (ICF) were derived from the Nordic Musculoskeletal Questionnaire, World Health Organization Quality of Life-Brief version (WHOQOL-BREF), and Participation Scale. On the basis of the ICF framework, it is hypothesized and found that there is an interaction between the body function and the activity and participation components, which, in turn, are predictors of future functional capability. The structural equation analyses confirmed that at both T1 and T2 pain measures are associated with physical, psychological, and social functioning; environmental factors mediate the relationship between these two constructs. Moreover, the activity and participation component at T1 predicted the body function component at T2. The main finding suggests that functional consequences of diabetes are complex and multifactorial. The significant functional decline in people with diabetes in just three years is worrying. The theoretical and practical implications of these findings are discussed.

Trends in the incidence rates of lower limb amputation due to nondiabetic peripheral artery disease in a large industrial city in Western Siberia, Russia: A review from 1996 to 2019

BACKGROUND

lower limb amputation (LLA) is a growing problem in the population with and without diabetes mellitus. Monitoring the incidence rates of LLA is important for health care planning and has implications for the future problems of medical and social care.

OBJECTIVE

This study aimed to determine the trends in incidence rates of LLA due to nondiabetic peripheral artery disease in Novokuznetsk, Western Siberia, Russia.

STUDY DESIGN

An observational study.

METHODS

Data on all transtibial and transfemoral amputations performed in inpatient facilities in Novokuznetsk from 1996 to 2019 were derived from the regional Register of patients with limb amputations. The rates were calculated per 100,000 population.

RESULTS

A total of 2448 persons with amputations due to nondiabetic peripheral artery disease were included in this study (3191 amputations). The overall incidence rate of LLA in Novokuznetsk increased from 14.6 in 1996 to 30.4 in 2019. The proportion of persons older than 60 years increased from 15.5% in 1996 to 20.3% in 2019.

CONCLUSION

The expected aging of the population and increasing incidence of LLA are relevant issues in Russia. These findings can contribute to improving healthcare services and the development of prevention programs to reverse the alarming trend.

Time trends (2001-2019) and sex differences in incidence and in-hospital mortality after lower extremity amputations among patients with type 1 diabetes in Spain

Background

We examined trends in incidence (2001–2019), clinical characteristics, and in-hospital outcomes following major and minor lower extremity amputations (LEAs) among type 1 diabetes mellitus (T1DM) patients in Spain and attempted to identify sex differences.

Methods

Retrospective cohort study using data from the Spanish National Hospital Discharge Database. We estimated the incidence of the LEA procedure stratified by type of LEA. Joinpoint regression was used to estimate incidence trends, and logistic regression was used to estimate factors associated with in-hospital mortality (IHM).

Results

LEA was coded in 6011 patients with T1DM (66.4% minor and 33.6% major). The incidence of minor LEA decreased by 9.55% per year from 2001 to 2009 and then increased by 1.50% per year, although not significantly, through 2019. The incidence of major LEA decreased by 13.39% per year from 2001 to 2010 and then remained stable through 2019. However, incidence increased in men (26.53% per year), although not significantly, from 2017 to 2019. The adjusted incidence of minor and major LEA was higher in men than in women (IRR 3.01 [95% CI 2.64–3.36] and IRR 1.85 [95% CI 1.31–2.38], respectively). Over the entire period, for those who underwent a minor LEA, the IHM was 1.58% (2.28% for females and 1.36% for males; p = 0.045) and for a major LEA the IHM was 8.57% (10.52% for females and 7.59% for males; p = 0.025).

IHM after minor and major LEA increased with age and the presence of comorbid conditions such as peripheral arterial disease, ischemic heart disease or chronic kidney disease. Female sex was associated with a higher IHM after major LEA (OR 1.37 [95% CI 1.01–1.84]).

Conclusions

Our data show a decrease in incidence rates for minor and major LEA in men and women with T1DM and a slight, albeit insignificant, increase in major LEA in men with T1DM in the last two years of the study. The incidence of minor and major LEA was higher in men than in women. Female sex is a predictor of IHM in patients with T1DM following major LEA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12933-022-01502-y.

Trends of Non-Traumatic Lower-Extremity Amputation and Type 2 Diabetes: Spain, 2001-2019

(1) Background: To examine trends in the incidence (2001–2019), clinical characteristics and in-hospital outcomes following major and minor non-traumatic lower-extremity amputations (LEAs) among people with type 2 diabetes mellitus (T2DM) in Spain, assessing possible sex differences. (2) Methods: Retrospective cohort study using data from the Spanish National Hospital Discharge Database. Joinpoint regression was used to estimate incidence trends, and multivariable logistic regression to estimate factors associated with in-hospital mortality (IHM). (3) Results: LEA was coded in 129,059 patients with T2DM (27.16% in women). Minor LEAs accounted for 59.72% of amputations, and major LEAs comprised 40.28%. The adjusted incidences of minor and major LEAs were higher in men than in women (IRR 3.51; 95%CI 3.46–3.57 and IRR 1.98; 95%CI 1.94–2.01, respectively). In women, joinpoint regression showed that age-adjusted incidence of minor LEAs remained stable over time, and for major LEAs, it decreased from 2006 to 2019. In men, incidences of minor and major LEAs decreased significantly from 2004 to 2019. In-hospital mortality (IHM) increased with age and the presence of comorbidity, such as heart failure (OR 5.11; 95%CI 4.61–5.68, for minor LEAs and OR 2.91; 95%CI 2.71–3.13 for major LEAs). Being a woman was associated with higher IHM after minor and major LEA (OR 1.3; 95%CI 1.17–1.44 and OR 1.18; 95%CI 1.11–1.26, respectively). (4) Conclusions: Our data showed major sex differences indicating decreasing and increasing LEA trends among men and women, respectively; furthermore, women presented significantly higher IHM after minor and major LEA procedures than men.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

The impact of gender on diabetes-related lower extremity amputations: An Italian regional analysis on trends and predictors

BACKGROUND

Diabetes-related lower extremity amputations (LEAs) are a major public health issue. The aim of the study was to evaluate trends by gender and predictors of LEAs in an Italian region.

METHODS

Data were collected from hospital discharge records between 2006 and 2015. Gender- and age-adjusted standardised hospitalisation rates for major and minor amputations were calculated. Poisson regression model was performed to estimate trends in LEAs.

RESULTS

Hospitalisation rates decreased for minor amputations both among males (-30.0%) and females (-5.3%), while the major amputation rates decreased only for males (-44.7%). Males were at higher risk of undergoing major (IRR 1.41, 95%CI 1.19-1.67) and minor (IRR 1.62, 95%CI 1.45-1.82) amputations. Peripheral vascular disease was the leading predictor of major and minor amputations.

CONCLUSION

A significant reduction of LEAs was observed only for males. Identifying their predictable factors may help caregivers to provide higher standards of diabetes care.

Twenty years with diabetes and amputations: a retrospective population-based cohort study

AIM

To investigate the trends in non-traumatic lower limb amputation in people with and without diabetes.

METHODS

From the Danish National Patient Register, all people with either type 1 or type 2 diabetes (n = 462 743) as well as a group of people without diabetes from the general population (n = 1 388 886) were identified and separated into three groups based on diabetes type. Among these, 17 265 amputations were identified between 1997 and 2017 and stratified into trans-femoral amputations, trans-tibial amputations and amputations below the ankle using surgical codes. Annual changes were described using least-squares linear regression.

RESULTS

The yearly mean decrease in incidence rate of amputation per 1000 person-years was -0.032 [95% CI: -0.062, -0.001], -0.022 [-0.032, -0.012] and -0.006 [-0.009, -0.003] for trans-femoral amputation, -0.072 [-0.093, -0.052], -0.090 [-0.102, -0.078] and -0.015 [-0.016, -0.013] for trans-tibial amputation, and -0.055 [-0.080, -0.020], -0.075 [-0.090, -0.060] and -0.011 [-0.014, -0.007] for amputation below the ankle in people with type 1 diabetes, people with type 2 diabetes and people without diabetes, respectively.

CONCLUSIONS

Over recent decades, the incidence of amputation has decreased significantly in people with diabetes and in the general population without diabetes.

Secular trends in rates of hospitalisation for lower extremity amputation and 1 year mortality in people with diabetes in Hong Kong, 2001-2016: a retrospective cohort study

AIMS/HYPOTHESIS

We aimed to describe trends in rates of hospitalisation for lower extremity amputation (LEA) and 1 year mortality rates after LEA in people with diabetes in Hong Kong between 2001 and 2016.

METHODS

The Hong Kong Diabetes Surveillance Database is a territory-wide population-based diabetes cohort (N = 770,078) identified from the Hong Kong Hospital Authority electronic medical system. We identified LEA events using ICD-9 procedure codes and 1 year mortality after LEA from linkage to the Hong Kong Death Registry. Joinpoint regression models were used to describe the trends.

RESULTS

Between 2001 and 2016, 6113 hospitalisations for LEAs in men and 4149 in women were recorded in the Hong Kong Diabetes Surveillance Database. The rates of minor LEAs declined by 48.6% (average annual per cent change [AAPC]: -3.8; 95% CI -5.7, -1.9) in men and by 59.5% (AAPC: -6.3; 95% CI -10.6, -1.8) in women. The rates of major LEAs declined by 77.9% (AAPC: -8.0; 95% CI -9.6, -6.5) in men and by 79.3% (AAPC: -10.4; 95% CI -13.1, -7.6) in women. The cumulative 1 year mortality rates after minor and major LEAs were 18.5% and 41.8% in men, and 21.3% and 42.0% in women, respectively, for the whole period. No change was detected in 1 year mortality rates during the surveillance in both sexes.

CONCLUSIONS/INTERPRETATION

Although hospitalisation rates for LEAs have declined overall in people with diabetes, there were no improvements in 1 year mortality rates after LEA. Continuous efforts are needed to further prevent LEAs and improve the survival rate of people undergoing LEAs. Graphical abstract.

Age- and sex-specific incidence of non-traumatic lower limb amputation in patients with type 2 diabetes mellitus in a U.S. claims database

AIM

To estimate age- and sex-specific incidence rates (IRs) of non-traumatic lower limb amputations (LLA) in patients with type 2 diabetes mellitus (T2DM) using a claims database from the United States (US).

METHODS

Patients with T2DM 18 years and older were identified using the Truven Health MarketScan database from January 1, 2007 to September 30, 2018. The overall and age- and sex-specific IRs of all non-traumatic LLA, minor LLA (amputation at or below the ankle), and major LLA (amputation above ankle) were calculated.

RESULTS

Among the 6,117,981 patients with T2DM, 14,627 LLA events occurred (minor LLA; 72.8%; major LLA: 27.2%). The IRs (95% CI) of all LLA, minor LLA, and major LLA per 1000 person-years or PY were 0.86 (0.85, 0.88), 0.63 (0.62, 0.64), and 0.23 (0.23, 0.24), respectively. The IR (95% CI) of all LLA per 1000 PY in males was higher compared to females [1.24 (1.22, 1.26) vs. 0.46 (0.45, 0.48)]. The incidence of all LLA increased with an increasing age (highest IR in age-group of ≥80 years).

CONCLUSIONS

This study identified males and older patients with T2DM at higher risk of developing LLA in the US, warranting further exploration of risk factors of LLA in these subgroups.

Cost-effectiveness of Platelet-Rich Plasma for Diabetic Foot Ulcer in Spain

This study evaluated the cost-effectiveness of platelet-rich plasma (PRP) added to usual care versus usual care alone in elderly patients with chronic diabetic foot ulcer (DFU) from the Spanish health care system perpective. A 6-state Markov model with 3-month cycles was used to estimate costs and outcomes of wound healing and risk of recurrences, infections, and amputations over 5 years. Three treatment strategies were compared: (a) usual care plus PRP obtained with a commercial kit, (b) usual care plus PRP obtained manually, and (c) usual care. Data on effectiveness were taken from a recent meta-analysis. Outcomes and costs were discounted at 3% and resources were valued in 2018 euro. Compared with usual care, the PRP treatment with the manual method was more effective and less costly (dominant option), whereas the PRP treatment with the commercial kit was more effective but also more costly, with the incremental ratio being above the cost-effectiveness threshold (€57 916 per quality-adjusted life year). These results are sensitive to the price of PRP kits (a 20% discount would make the PRP treatment a cost-effective option) and effectiveness data, due to the heterogeneity of primary studies. In conclusion, PRP treatment for DFUs could be considered a cost-effective or even cost-saving alternative in Spain, depending on the method of obtaining the PRP. Despite the dominance of the manual method, its general use is limited to hospitals and specialized centers, whereas PRP kits could be used in primary care settings, but their prices should be negotiated by health authorities.

Time Trends in the Incidence of Long-Term Mortality in T2DM Patients Who Have Undergone a Lower Extremity Amputation. Results of a Descriptive and Retrospective Cohort Study

(1) Background: The aims of this study were to examine the incidence of lower extremity amputations (LEAs) among patients with type 2 diabetes mellitus (T2DM) and to compare the mortality risk of diabetic individuals who underwent LEA with age and sex-matched diabetic individuals without LEA. (2) Methods: We performed a descriptive observational study to assess the trend in the incidence of LEA and a retrospective cohort study to evaluate whether undergoing LEA is a risk factor for long-term mortality among T2DM patients. Data were obtained from the Hospital Discharge Database for the Autonomous Community of Madrid, Spain (2006–2015). (3) Results: The incidence rates of major below-knee and above-knee amputations decreased significantly from 24.9 to 17.1 and from 63.9 to 48.2 per 100000 T2DM individuals from 2006 to 2015, respectively. However, the incidence of minor LEAs increased over time. Mortality was significantly higher among T2DM patients who underwent LEA compared with those who did not undergo this procedure (HR 1.75; 95% CI 1.65–1.87). Male sex, older age, and comorbidity were independently associated with higher mortality after LEA. (4) Conclusions: Undergoing a LEA is a significant risk factor for long term mortality among T2DM patients, and those who underwent a major above-knee LEAs have the highest risk.

Trends in Diabetes-Related Potentially Preventable Hospitalizations in Adult Population in Spain, 1997⁻2015: A Nation-Wide Population-Based Study

We aimed to assess national trends in the rates of diabetes-related potentially preventable hospitalizations (overall and by preventable condition) in the total adult population of Spain. We performed a population-based study of all adult patients with diabetes who were hospitalized from 1997 to 2015. Overall potentially preventable hospitalizations and hospitalizations by diabetes-related preventable conditions (short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputations) were examined. Annual rates adjusted for age and sex were analyzed and trends were calculated. Over 19-years-period, 424,874 diabetes-related potentially preventable hospitalizations were recorded. Overall diabetes-related potentially preventable hospitalizations decreased significantly, with an average annual percentage change of 5.1 (95%CI: −5.6–(−4.7%); p_trend < 0.001). Among preventable conditions, the greatest decrease was observed in uncontrolled diabetes (−5.6%; 95%CI: −6.7–(−4.7%); p_trend < 0.001), followed by short-term complications (−5.4%; 95%CI: −6.1–(−4.9%); p_trend < 0.001), long-term complications (−4.6%; 95%CI: −5.1–(−3.9%); p_trend < 0.001), and lower-extremity amputations (−1.9%; 95%CI: −3.0–(−1.3%); p_trend < 0.001). These reductions were observed in all age strata for overall DM-related PPH and by preventable condition but lower-extremity amputations for those <65 years old. There was a greater reduction in overall DM-related PPH, uncontrolled DM, long-term-complications, and lower extremity amputations in females than in males (all p < 0.01). No significant difference was shown for short-term complications (p = 0.101). Our study shows a significant reduction in national trends for diabetes-related potentially preventable hospitalizations in Spain. These findings could suggest a sustained improvement in diabetes care in Spain, despite the burden of these diabetes-related complications and the increase in the diabetes mellitus prevalence.

Propolis as an Adjuvant in the Healing of Human Diabetic Foot Wounds Receiving Care in the Diagnostic and Treatment Centre from the Regional Hospital of Talca

OBJECTIVE

Diabetic foot wounds are a relevant diabetes complication and a major health problem. It has been described that propolis has health benefits due to its anti-inflammatory, antioxidant, and support in the healing process. The current study assessed the effect of propolis as an adjuvant in the healing of human diabetic foot ulcers. This was evaluated in a randomized placebo-controlled study of subjects receiving care in the Diagnostic and Treatment Centre from the Regional Hospital of Talca, Chile.

RESEARCH DESIGN AND METHODS

Randomized subjects received ambulatory healing treatment for diabetes foot wounds with propolis spray (3%), which was applied to cover the entire wound surface each time it was dressed from week 0 until cicatrization or 8 weeks as a maximum. Two serum samples were taken (day 0 and end of the study) for cytokine and oxidative stress analyses. Also, macro- and microscopy were analyzed in the process of wound healing.

RESULTS

The study comprised 31 subjects with type 2 diabetes in treatment for diabetic foot wounds in the Diagnostic and Treatment Centre from the Regional Hospital of Talca. Propolis promotes a reduction of the wound's area by an average of 4 cm², related to an increase in the connective tissue deposit compared to the control. Also, propolis increased the glutathione (GSH) and GSH/glutathione disulfide (GSSG) ratio (p < 0.02), depleted tumor necrosis factor- (TNF-) α, and increased interleukin- (IL-) 10 levels. Topical propolis did not modify the biochemical parameters in the serum of the studied subjects.

CONCLUSIONS

The topical use of propolis turned out to be an interesting therapeutic strategy as an adjuvant in the care of diabetes foot wounds due to its ability to improve and promote healing based on its anti-inflammatory and antioxidant profile. This trial is registered with NCT03649243.

Global trends in diabetes complications: a review of current evidence

In recent decades, large increases in diabetes prevalence have been demonstrated in virtually all regions of the world. The increase in the number of people with diabetes or with a longer duration of diabetes is likely to alter the disease profile in many populations around the globe, particularly due to a higher incidence of diabetes-specific complications, such as kidney failure and peripheral arterial disease. The epidemiology of other conditions frequently associated with diabetes, including infections and cardiovascular disease, may also change, with direct effects on quality of life, demands on health services and economic costs. The current understanding of the international burden of and variation in diabetes-related complications is poor. The available data suggest that rates of myocardial infarction, stroke and amputation are decreasing among people with diabetes, in parallel with declining mortality. However, these data predominantly come from studies in only a few high-income countries. Trends in other complications of diabetes, such as end-stage renal disease, retinopathy and cancer, are less well explored. In this review, we synthesise data from population-based studies on trends in diabetes complications, with the objectives of: (1) characterising recent and long-term trends in diabetes-related complications; (2) describing regional variation in the excess risk of complications, where possible; and (3) identifying and prioritising gaps for future surveillance and study.

Prediabetes: lifestyle, pharmacotherapy or regulation?

The rapidly rising number of people with diabetes worldwide has led to multiple attempts to identify effective means of preventing type 2 diabetes. Lifestyle interventions have shown impressive efficacy in multiple clinical trials of people with impaired glucose tolerance, but, as currently formulated, appear to have very little impact on impaired fasting glucose. Attempts to roll out lifestyle interventions beyond clinical trials have generally recruited too few people to have a chance of influencing the population prevalence of diabetes. Several drugs have also been shown to reduce the incidence of diabetes, but until such drugs can be shown to prevent the clinical consequences of diabetes, it is unlikely that guidelines will recommend their widespread use for diabetes prevention. Population-level interventions, including education and regulation, are attractive, as they have the potential to influence a high proportion of the population. Favourable effects of a sugar sweetened beverage tax on consumption are encouraging, but data on its influence on diabetes are not yet available.

In-hospital outcomes for solid organ transplants according to type 2 diabetes status: An observational, 15-year study in Spain

AIMS

To describe trends and outcomes during admission for solid organ transplant in people with or without type 2 diabetes in Spain, 2001-2015.

METHODS

We used national hospital discharge data to select all hospital admissions for kidney, lung, heart, and liver transplant. We estimated admission rates stratified by type 2 diabetes status. We built Poisson regression models to compare the adjusted time trends in admission rates. We tested in-hospital mortality (IHM) in logistic regression analyses.

RESULTS

We identified 50 964 transplants (16.7% in people with type 2 diabetes): kidney, 30 919; lung, 2810; heart, 3649; liver, 13 586. The overall adjusted incidence rate ratios (95% confidence intervals) of admission in people with type 2 diabetes vs no diabetes were 2.4 (2.32-2.48) for kidney, 1.51 (1.33-1.70) for lung, 2.87 (2.63-3.13) for heart, and 4.16 (3.99-4.33) for liver transplant. In the multivariate analysis, IHM decreased significantly over time for all types of transplant. Type 2 diabetes independently predicted lower IHM during admission only for heart (Odds ratio, OR [95% CI] = 0.62 [0.47-0.81]) and liver transplant (OR [95% CI] = 0.69 [0.58-0.82]).

CONCLUSIONS

Admission rates for solid organ transplant were higher in people with type 2 diabetes than in people without diabetes. Type 2 diabetes was associated with lower in-hospital mortality during admission for heart and liver transplant.

Perioperative and long-term all-cause mortality in patients with diabetes who underwent a lower extremity amputation

INTRODUCTION

Long-term mortality of patients with diabetes who undergo lower extremity amputation (LEA) has not been reported in Spain.

METHODS

The retrospective cohort included all subjects who underwent LEAs from January 1, 2005 to December 31, 2015 in San Jorge Hospital, Huesca, Spain. Live status of every patient up to September 2017 and the date of death were retrieved using the national death index.

RESULTS

The series included 203 patients: 116 patients (57.1%) underwent a minor amputation and 87 patients (42.9%) underwent a major amputation. Twenty-five patients (12.3%) died in the perioperative period. Significant risk factors of perioperative mortality were undergoing an above-the-knee amputation, postoperative cardiac complications, age >74 years and acute renal failure. Survival rates at 1, 3, and 5 years were 90.6, 72.8, and 55.5% in patients who underwent a minor amputation compared with 70.8, 41.3, and 34.4% in patients who underwent a major amputation, respectively. Log-rank test between the two groups was χ² = 12.7 (p < 0.01).

CONCLUSIONS

Long-term survival was worse in patients who underwent a major amputation with a 5-year mortality of 65.6%. This mortality is worse than what has been reported for some types of common malignancies.

Hospital Admissions in People With Alzheimer's Disease or Senile Dementia According to Type 2 Diabetes Status: An Observational 10-Year Study

We aimed to describe admission rates and outcomes of hospitalized people with Alzheimer's disease (AD) or senile dementia stratified by type 2 diabetes (T2D) in Spain, 2004 to 2013 (N = 541 858, 143 501 [26.5%] of whom had T2D). We excluded alternative causes of dementia. Hospitalization rates were higher in people with T2D (130.5 vs 91.5 cases/105 people). People older than 84 years and comorbidity increased over time. Crude inhospital mortality (IHM) decreased over time both in people with and without T2D (all P values <.001). Time trend analyses, 2004 to 2013, showed an overall adjusted incidence rate ratio (95% confidence interval [95% CI]) of hospitalization of 1.41 (1.40-1.42) for T2D (men, 1.32 [1.30-1.33]; women, 1.46 [1.45-1.48]). In logistic regression analyses, IHM decreased over time (odds ratio, OR [95% CI] = 0.97 [0.96-0.98]) and T2D was not associated with a higher IHM (OR [95% CI] = 0.99 [0.98-1.01]). In conclusion, admission rates were higher in patients with T2D. Inhospital mortality decreased over time. Diabetes did not predict IHM in patients with AD or senile dementia.

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 .

Transcatheter aortic valve implantation and surgical aortic valve replacement among hospitalized patients with and without type 2 diabetes mellitus in Spain (2014-2015)

Background

Type 2 diabetes mellitus (T2DM) is strongly related to the in-hospital and short-term prognosis in patients with cardiovascular diseases needing surgical or invasive interventions. How T2DM might influence the treatment of aortic stenosis (AS) has not been completely elucidated for surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI). The aims of this study were: (1) to describe the use of aortic valve replacement procedures (TAVI and SAVR) among hospitalized patients with and without T2DM; and (2) to identify factors associated with in hospital mortality (IHM) among patients undergoing these procedures.

Methods

We analyzed data from the Spanish National Hospital Discharge Database between January 1, 2014 and December 31, 2015 for patients aged ≥ 40 years. We selected patients whose medical procedures included TAVI (ICD-9-CM codes 35.05, 35.06) and SAVR (ICD-9-CM codes 35.21, 35.22). We stratified each cohort by diabetes status: T2DM (ICD-9-CM codes 250.x0, 250.x2) and no diabetes. We retrieved data about specific comorbidities, risk factors, procedures, and specific in-hospital postoperative complications. Hospital outcome variables included IHM, and length of hospital stay (LOHS).

Results

We identified a total of 2141 and 16,013 patients who underwent TAVI (n = 715; 33.39% with T2DM) and SAVR (n = 4057; 25.33% with T2DM). In patients who underwent TAVI we found no differences in IHM (3.64% in T2DM vs. 5.12% in non-T2DM, p = 0.603). In the cohort of SAVR, mean LOHS was significantly lower in patients with T2DM than in non-diabetic patients (13.77 vs. 17.27 days). IHM was lower in patients with T2DM (4.36% vs. 6.31%, p < 0.01). After multivariable adjustment for both procedures, patients with T2DM had significantly lower IHM than patients without diabetes (adjusted OR 0.60; IC 95% 0.37–0.99 for TAVI and adjusted OR 0.80; IC 95% 0.66-0-96 for SAVR).

Conclusions

T2DM diabetic patients with AS undergoing a valvular replacement procedure through SAVR or TAVI did not have a worse prognosis compared to non-diabetic patients during hospitalization, showing lower IHM after multivariable adjustment. However, given the limitations of administrative data more prospective studies and clinical trials aimed at evaluating the influence of these procedures in diabetic patients with AS are needed.

Electronic supplementary material

The online version of this article (10.1186/s12933-017-0631-6) contains supplementary material, which is available to authorized users.

Macrovascular Complications in Patients with Diabetes and Prediabetes

Diabetes is a significant health problem worldwide, and its association with cardiovascular disease (CVD) was reported in several studies. Hyperglycemia and insulin resistance seen in diabetes and prediabetes lead to an increase in reactive oxygen species, which triggers intracellular molecular signaling. The resulting prothrombotic state and increase in inflammatory mediators expedite atherosclerotic changes and the development of macrovascular complications. Individuals with diabetes or prediabetes have a higher risk of developing myocardial infarction, stroke, and peripheral artery disease. However, no significant difference in cardiovascular morbidity has been observed with tight glycemic control despite a reduction in some CVD outcomes, and the risk of adverse outcomes such as hypoglycemia was increased. Recently, some GLP-1 receptor agonists and SGLT-2 inhibitors have been shown to reduce cardiovascular events and mortality. In this review we give an overview of the risk and pathogenesis of cardiovascular disease among diabetic and prediabetic patients, as well as the implication of recent changes in diabetes management.

Impact of type 2 diabetes mellitus on in-hospital-mortality after major cardiovascular events in Spain (2002-2014)

BACKGROUND

Diabetes mellitus has long been associated with cardiovascular events. Nevertheless, the higher burden of traditional cardiovascular risk factors reported in high-income countries is offset by a more widespread use of preventive measures and revascularization or other invasive procedures. The aim of this investigation is to describe trends in number of cases and outcomes, in-hospital mortality (IHM) and length of hospital stay (LHS), of hospital admissions for major cardiovascular events between type 2 diabetes (T2DM) and matched non-diabetes patients.

METHODS

Retrospective study using National Hospital Discharge Database, analyzed in 4 years 2002, 2006, 2010, 2014, in Spain. We included patients (≥ 40 years old) with a primary diagnosis of myocardial infarction, ischemic and hemorrhagic stroke, aortic aneurysm and dissection and acute lower limb ischemia in people with T2DM. Cases were matched with controls (without T2DM) by ICD-9-CM codes, sex, age, province of residence and year.

RESULTS

We selected 130,011 matched couples (50,427 with myocardial infarction, 60,236 with stroke, 2599 with aortic aneurysm and dissection and 16,749 with acute lower limb ischemia. Among T2DM patients we found increasing numbers of admissions overtime for stroke (10,794 in 2002 vs 17,559 in 2014), aortic aneurysm and dissection (390 vs 841) and acute lower limb ischemia (3854 vs. 4548). People were progressively older (except for myocardial infarction), had more comorbidities (especially T2DM patients), and were more frequently coded overtime for cardiovascular risk factors (smoking, obesity, hypertension, lipid disorders) and renal diseases. LHS and IHM declined overtime, though IHM only did it significantly in T2DM patients. Multivariable adjustment showed that T2DM patients had a significantly 15% higher mortality rate during admission for myocardial infarction, a 6% higher mortality for stroke, and a 6% higher mortality rate for "all cardiovascular events combined", than non-diabetic matched controls.

CONCLUSIONS

The number of hospital admissions for stroke, aortic aneurysm and dissection and acute lower limb ischemia increased overtime, but remained stable for myocardial infarction. T2DM is associated to higher IHM after major cardiovascular events. Further research is needed to help us understand the reasons for an apparently increased mortality in T2DM patients when admitted to hospital for some major cardiovascular events.

Evaluation of skin perfusion pressure to assess refractory foot ulcers

OBJECTIVE

The number of patients with foot gangrene caused by critical ischaemia and severe infection is increasing significantly in developed countries. The measurement of perilesional skin blood flow by skin perfusion pressure (SPP) is useful to select the appropriate treatment of gangrenous lesions, in that it is not affected by calcifications of blood vessels. However, the prognosis of a foot ulcer may also be affected by the level of blood sugar and infections. This study aimed to validate the use of SPP in cases of foot gangrene and ulcers in patients with and without diabetes mellitus (DM) and infection.

METHOD

Clinical symptoms, ankle-brachial pressure index (ABPI) and SPP were assessed to evaluate the condition of each foot ulcer. Every foot ulcer was treated as independent, even if a participant had multiple ulcers. All ulcers for which we measured SPP were subject to the analysis. All ulcers were purely ischaemic in nature and were exclusively located on the foot or toes.

RESULTS

Data were collected from 117 foot ulcers on 91 toes and feet from 65 patients. Almost all SPP values in healed cases were > 27 mmHg. There were three patients whose ulcers failed to heal by conservative treatments were complicated with severe infection. However, no effect of DM on the relationship between SPP values and prognosis was observed. Logistic regression analysis of all ulcers except for the 5 cases complicated with infection revealed that those with 30 mmHg or lower SPP values are likely to heal by conservative treatment with 23% or lower probability, whereas any ulcer with more than 50 mmHg SPP value and without severe infection may heal without the need for further operations with 80% or higher probability.

CONCLUSION

The combination of SPP and careful evaluation of infection may be a good parameter to decide the appropriate treatment for ischaemic skin ulcers, regardless of the complication of DM.

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.

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.

Outcomes of dysvascular partial foot amputation and how these compare to transtibial amputation: a systematic review for the development of shared decision-making resources

BACKGROUND

Dysvascular partial foot amputation (PFA) is a common sequel to advanced peripheral vascular disease. Helping inform difficult discussions between patients and practitioners about the level of PFA, or the decision to have a transtibial amputation (TTA) as an alternative, requires an understanding of the current research evidence on a wide range of topics including wound healing, reamputation, quality of life, mobility, functional ability, participation, pain and psychosocial outcomes, and mortality. The aim of this review was to describe a comprehensive range of outcomes of dysvascular PFA and compare these between levels of PFA and TTA.

METHODS

The review protocol was registered in PROSPERO (CRD42015029186). A systematic search of the literature was conducted using MEDLINE, EMBASE, psychINFO, AMED, CINAHL, ProQuest Nursing and Allied Health, and Web of Science. These databases were searched using MeSH terms and keywords relating to different amputation levels and outcomes of interest. Peer reviewed studies of original research-irrespective of the study design-were included if published in English between 1 January 2000, and 31 December 2015, and included discrete cohort(s) with dysvascular PFA or PFA and TTA. Outcomes of interest were rate of wound healing and complications, rate of ipsilateral reamputation, quality of life, functional ability, mobility, pain (i.e., residual limb or phantom pain), psychosocial outcomes (i.e., depression, anxiety, body image and self-esteem), participation, and mortality rate. Included studies were independently appraised by two reviewers. The McMaster Critical Review Forms were used to assess methodological quality and identify sources of bias. Data were extracted based on the Cochrane Consumers and Communication Review Group's data extraction template by a primary reviewer and checked for accuracy and clarity by a second reviewer. Findings are reported as narrative summaries given the heterogeneity of the literature, except for mortality and ipsilateral reamputation where data allowed for proportional meta-analyses.

RESULTS

Twenty-nine unique articles were included in the review, acknowledging that some studies reported multiple outcomes. Eighteen studies reported all-cause proportionate mortality. A smaller number of studies reported outcomes related to functional ability (two), mobility (four), quality of life (three), ipsilateral reamputation (six) as well as wound healing and complications (four). No studies related to pain, participation or psychosocial outcomes met the inclusion criteria. Subjects were typically older and male and had diabetes among other comorbidities. More detailed information about the cohorts such as race or sociodemographic factors were reported in an ad hoc manner. Common sources of bias included contamination, co-intervention, or lack of operational definition for some outcomes (e.g., wound healing) as illustrative examples.

CONCLUSIONS

Aside from mortality, there was limited evidence regarding outcomes of dysvascular PFA, particularly how outcomes differ between levels of PFA and TTA. Acknowledging that there is considerable uncertainty given the small body of literature on many topics where the risk of bias is high, the available evidence suggests that a large proportion of people with PFA experience delayed wound healing and ipsilateral reamputation. People with TTA have increased risk of mortality compared to those with PFA, which may reflect that those considered suitable candidates for TTA have more advanced systemic disease that also increases the risk of dying. Mobility and quality of life may be similar in people with PFA and TTA.

SYSTEMATIC REVIEW REGISTRATION

CRD42015029186.

Renal transplant among type 1 and type 2 diabetes patients in Spain: A population-based study from 2002 to 2013

BACKGROUND

To describe trends in the rates and short-term outcomes of renal transplants (RTx) among patients with or without diabetes in Spain (2002-2013).

METHODS

We used national hospital discharge data to select all hospital admissions for RTx. We divided the study period into four three-year periods. Rates were calculated stratified by diabetes status: type 1 diabetes (T1DM), type 2 diabetes (T2DM) and no-diabetes. We analyzed Charlson comorbidity index (CCI), post-transplant infections, in-hospital complications of RTx, rejection, in-hospital mortality and length of hospital stay.

FINDINGS

We identified 25,542 RTx. Rates of RTx increased significantly in T2DM patients over time (from 9.3 cases/100,000 in 2002/2004 to 13.3 cases/100,000 in 2011/2013), with higher rates among people with T2DM for all time periods. T2DM patients were older and had higher CCI values than T1DM and non-diabetic patients (CCI≥1, 31.4%, 20.4% and 21.5%, respectively; P<0.05). Time trend analyses showed significant increases in infections, RTx-associated complications and rejection for all groups (all P values<0.05). Infection rates were greater in people with T2DM (20.8%) and T1DM (23.5%) than in non-diabetic people (18.7%; P<0.05). Time trend analyses (2002-2013) showed significant decreases in mortality during admission for RTx (OR 0.75, 95% CI 0.68-0.83). Diabetes was not associated with a higher in-hospital mortality (OR: 1.20, 95% CI 0.92-1.55).

INTERPRETATION

RTx rates were higher and increased over time at a higher rate among T2DM patients. Mortality decreased over time in all groups. Diabetes does not predict mortality during admission for RTx.

FUNDING

Instituto Salud Carlos III and URJC-Banco Santander.

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.

Predictors of in-hospital mortality following major lower extremity amputations in type 2 diabetic patients using artificial neural networks

BACKGROUND

Outcome prediction is important in the clinical decision-making process. Artificial neural networks (ANN) have been used to predict the risk of post-operative events, including survival, and are increasingly being used in complex medical decision making. We aimed to use ANN analysis to estimate predictive factors of in-hospital mortality (IHM) in patients with type 2 diabetes (T2DM) after major lower extremity amputation (LEA) in Spain.

METHODS

We design a retrospective, observational study using ANN models. We used the Spanish National Hospital Discharge Database to select all hospital admissions of major LEA procedure in T2DM patients.

MAIN OUTCOME MEASURES

Predictors of IHM using 4 ANN models: i) with all discharge diagnosis included in the database; ii) with all discharge diagnosis included in the database, excluding infectious diseases; iii) comorbidities included in the Charlson Comorbidities Index; iv) comorbidities included in the Elixhauser Comorbidity Index.

RESULTS

From 2003 to 2013, 40,857 major LEAs in patients with T2DM were identified with a 10.0% IHM. We found that Elixhauser Comorbidity Index model performed better in terms of sensitivity, specificity and precision than Charlson Comorbidity Index model (0.7634 vs 0.7444; 0.9602 vs 0.9121; 0.9511 vs 0.888, respectively). The area under the ROC curve for Elixhauser comorbidity model was 91.7% (95% CI 90.3-93.0) and for Charlson comorbidity model was 88.9% (95% CI; 87.590.2) p = 0.043. Models including all discharge diagnosis with and without infectious diseases showed worse results. In the Elixhauser Comorbidity Index model the most sensitive parameter was age (variable sensitive ratio [VSR] 1.451) followed by female sex (VSR 1.433), congestive heart failure (VSR 1.341), renal failure (VSR 1.274) and chronic pulmonary disease (VSR 1.266).

CONCLUSIONS

Elixhauser Comorbidity Index is a superior comorbidity risk-adjustment model for major LEA survival prediction in patients with T2DM than Charlson Comorbidity Index model using ANN models. Female sex, congestive heart failure, and renal failure are strong predictors of mortality in these patients.

The prevention of diabetic foot ulceration: how biomechanical research informs clinical practice

Background

Implementation of interprofessional clinical guidelines for the prevention of neuropathic diabetic foot ulceration has demonstrated positive effects regarding ulceration and amputation rates. Current foot care recommendations are primarily based on research regarding the prevention of ulcer recurrence and focused on reducing the magnitude of plantar stress (pressure overload). Yet, foot ulceration remains to be a prevalent and debilitating consequence of Diabetes Mellitus. There is limited evidence targeting the prevention of first-time ulceration, and there is a need to consider additional factors of plantar stress to supplement current guidelines.

Objectives

The first purpose of this article is to discuss the biomechanical theory underpinning diabetic foot ulcerations and illustrate how plantar tissue underloading may precede overloading and breakdown. The second purpose of this commentary is to discuss how advances in biomechanical foot modeling can inform clinical practice in the prevention of first-time ulceration.

Discussion

Research demonstrates that progressive weight-bearing activity programs to address the frequency of plantar stress and avoid underloading do not increase ulceration risk. Multi-segment foot modeling studies indicate that dynamic foot function of the midfoot and forefoot is compromised in people with diabetes. Emerging research demonstrates that implementation of foot-specific exercises may positively influence dynamic foot function and improve plantar stress in people with diabetes.

Conclusion

Continued work is needed to determine how to best design and integrate activity recommendations and foot-specific exercise programs into the current interprofessional paradigm for the prevention of first-time ulceration in people with Diabetes Mellitus.

Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD)

AIMS

Critical appraisal of secondary data made available by the OECD for the time frame 2000-2011.

METHODS

Comparison of trends and variation of amputations in people with diabetes across OECD countries. Generalized estimating equations to test the statistical significance of the annual change adjusting for major potential confounders.

RESULTS

A total of 26 OECD countries contributed to the OECD data collection for at least 1 year in the reference time frame, showing a decline in rates of over 40 %, from a mean of 13.2 (median 9.4, range 5.1-28.1) to 7.8 amputations per 100,000 in the general population (9.9, 1.0-18.4). The multivariate model showed an average decrease equal to -0.27 per 100,000 per year (p = 0.015), adjusted by structural characteristics of health systems, showing lower amputation rates for health systems financed by public taxation (-4.55 per 100,000 compared to insurance based, p = 0.002) and non-ICD coding mechanisms (-7.04 per 100,000 compared to ICD-derived, p = 0.001). Twelve-year decrease was stronger among insurance-based financing systems (tax based: -0.16 per 100,000, p = 0.064; insurance based: -0.36 per 100,000; p = 0.046).

CONCLUSIONS

In OECD countries, amputation rates in diabetes continuously decreased over 12 years. Still, in 2011, one amputation every 7 min could be directly attributed to diabetes. Although interesting, these results should be taken with extreme caution, until common definitions are improved and data quality issues, e.g., a different ability in capturing diabetes diagnoses, are fully resolved.

The changing face of diabetes complications

The global increase in type 2 diabetes prevalence is well documented, but international trends in complications of type 2 diabetes are less clear. The available data suggest large reductions in classic complications of type 2 diabetes in high-income countries over the past 20 years, predominantly reductions in myocardial infarction, stroke, amputations, and mortality. These trends might be accompanied by less obvious, but still important, changes in the character of morbidity in people with diabetes. In the USA, for example, substantial reductions in macrovascular complications in adults aged 65 years or older mean that a large proportion of total complications now occur among adults aged 45-64 years instead, rates of renal disease could persist more than other complications, and obesity-related type 2 diabetes could have increasing effect in youth and adults under 45 years of age. Additionally, the combination of decreasing mortality and increasing diabetes prevalence has increased the overall mean years lived with diabetes and could lead to a diversification of diabetes morbidity, including continued high rates of renal disease, ageing-related disability, and cancers. Unfortunately, data on trends in diabetes-related complications are limited to only about a dozen countries, most of which are high income, leaving the changing character for countries of low and middle income ambiguous.

Cardiovascular Autonomic Dysfunction Predicts Diabetic Foot Ulcers in Patients With Type 2 Diabetes Without Diabetic Polyneuropathy

We investigated the factors that might influence the development of diabetic foot ulcers (DFUs) in type 2 diabetes patients without diabetic polyneuropathy (DPN).From January 2000 to December 2005, a total of 595 patients who had type 2 diabetes without DPN between the ages of 25 and 75 years, and had no prior history of DFUs were consecutively enrolled in the study. A cardiovascular autonomic function test was performed to diagnose cardiovascular autonomic neuropathy (CAN) using heart rate variability parameters.The median follow-up time was 13.3 years. Among the 449 (75.4%) patients who completed the follow-up evaluation, 22 (4.9%) patients developed new ulcers, and 6 (1.3%) patients underwent the procedure for lower extremity amputations. The patients in the DFUs group had a longer duration of diabetes, higher baseline HbA1c levels, higher rates of nephropathy, and CAN. A Cox hazard regression analysis results revealed that the development of DFUs was significantly associated with the presence of CAN (normal vs definite CAN; HR, 4.45; 95% confidence interval, 1.29-15.33) after adjusting for possible confounding factors.The development of DFUs was independently associated with CAN in patients with type 2 diabetes without DPN. We suggested the importance of CAN as a predictor of DFUs even in the patients without DPN, and the need to pay attention to patients with definite CAN and type 2 diabetes.

Lower-extremity amputation as a marker for renal and cardiovascular events and mortality in patients with long standing type 1 diabetes

Background

We evaluated the risks of renal and cardiovascular complications, and mortality associated with lower extremity amputation (LEA) in patients with type 1 diabetes.

Methods

We studied two cohorts of people with long standing type 1 diabetes: GENEDIAB (n = 456) and GENESIS (n = 611). Subsets of the cohorts (n = 260, n = 544) were followed for 9 and 5 years, respectively. Outcomes were the incidence of end stage renal disease (ESRD), myocardial infarction, stroke and mortality during follow-up. Analyses were performed in pooled cohorts.

Results

The prevalence of LEA at baseline was 9.3 % (n = 99). A positive history of LEA was associated with the baseline prevalence of established (OR 4.50, 95 % CI 2.33–8.91, p < 0.0001) and advanced diabetic nephropathy (OR 5.50, 95 % CI 2.89–10.78, p < 0.0001), ESRD (OR 2.86, 95 % CI 1.43–5.50, p = 0.004), myocardial infarction (OR 3.25, 95 % CI 1.68–6.15, p = 0.0006) and stroke (OR 3.88, 95 % CI 1.67–8.72, p = 0.002, adjusted for sex, age, and cohort membership). A positive history of LEA at baseline was associated with the incidence during follow-up of ESRD (HR 2.69, 95 % CI 1.17–6.20, p = 0.02), and myocardial infarction (HR 3.53, 95 % CI 1.79–6.97, p = 0.0001). History of LEA was also associated with increased risk for all-cause (HR 3.55, 95 % CI 2.05–6.16, p < 0.0001), cardiovascular (HR 3.30, 95 % CI 1.36–8.02, p = 0.008), infectious disease (HR 5.18, 95 % CI 1.13–23.84, p = 0.03) and other-cause mortality (HR 2.81, 95 % CI 1.09–7.26, p = 0.03). History of LEA at baseline was associated with a 40 % reduction in the duration of survival in the subset of patients who died during follow-up. Population attributable risk of the history of LEA at baseline for total mortality during follow-up was 0.31.

Conclusions

Patients with LEA have a higher risk of ESRD, myocardial infarction and cardiovascular and non-cardiovascular mortality. Our results highlight the importance of LEA as a key-predictor for major vascular events and premature death in type 1 diabetic patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12933-015-0322-0) contains supplementary material, which is available to authorized users.

When and how to audit a diabetic foot service

Quality improvement depends on data collection and audit of clinical services to inform clinical improvements. Various steps in the care of the diabetic foot can be used to audit a service but need defined audit standards. A diabetes foot service should have risk stratification system in place that should compare to the population-based figures of 76% having low-risk feet, 17% moderate risk and 7% being at high risk of ulceration. Resources can then be directed towards those with high-risk feet. Prevalence of foot ulceration needs to be audited. Community-based studies give an audit standard of around 2%, with 2 to 9% having had an ulcer at some stage in the past. Amputation rates should be easier to measure, and the best results are reported to be around 1.5-3 per 1000 people with diabetes. This is a useful benchmark figure, and the rate has been shown to decrease by approximately a third over the last 15 years in some centres. Ulceration rates and ulcer healing rates are the ultimate outcome audit measure as they are always undesirable, whilst occasionally for defined individuals, an amputation can be a good outcome. In addition to clinical outcomes, processes of care can be audited such as provision of clinical services, time from new ulcer to be seen by health care professional, inpatient foot care or use of antibiotics. Measurement of clinical services can be a challenge in the diabetic foot, but it is essential if clinical services and patient outcomes are to be improved.

Epidemiology of Diabetic Foot Ulcers and Amputations in Romania: Results of a Cross-Sectional Quality of Life Questionnaire Based Survey

This is a post hoc analysis of quality of life in diabetic neuropathy patients in a cross-sectional survey performed in 2012 in Romania, using the Norfolk QOL-DN in which 21,756 patients with self-reported diabetes were enrolled. This current analysis aims to expand research on the diabetic foot and to provide an update on the number of foot ulcers found in Romania. Of the 21,174 patients included in this analysis, 14.85% reported a history of foot ulcers and 3.60% reported an amputation. The percentage of neuropathy patients with foot ulcers increased with age; the lowest percentage was observed in the 20-29-year age group (6.62%) and the highest in the 80-89-year age group (17.68%). The highest number of amputations was reported in the 70-79-year age group (largest group). Compared to patients without foot ulcers, those with foot ulcers had significantly higher scores for total DN and all its subdomains translating to worse QOL (p < 0.001). This analysis showed a high rate of foot ulcers and amputations in Romanian diabetic patients. It underscores the need for implementation of effective screening and educational programs.

Trends in diabetes-related lower extremities amputations in Romania-A five year nationwide evaluation

The aim of the study was to perform a nationwide evaluation of the frequency, incidence and trends of diabetes-related LEA (lower extremities amputations) in Romania. We have retrospectively analysed DRG data (ICD 10 AM codes) from all hospitals in the country, over a 5 year period (2006-2010). Knowing the shortcomings of this approach, we have assumed that our study can serve as a platform for future comparisons. The total number of non-traumatic diabetes related LEA procedures was 24,312, they were performed in 16,873 patients with diabetes, 22.55% with type 1 diabetes, 70.26 with type 2 diabetes and 7.19% with non-specified diabetes at discharge. The total number of hospital admissions for these patients was 46,985. During the five years of the study there was an increase in the absolute number of major amputations (above the ankle), as well as of minor amputations. The rate of amputations decreased in type 1 diabetes, from baseline (2006): -8.15% in 2007, -25.83% in 2008, -23.43% in 2009, -27.71% in 2010, whereas it increased in type 2 diabetes in the respective years: 16.96%, 60.75%, 66.91%, and 104.64%, due to an increase in minor amputations and mainly in elderly people. Male: female amputations rate was 2:1 in type 1 diabetes patients and 2.4:1 in type 2 diabetes patients. This study, the first of its kind in the Romanian population, offers a starting point for future comparisons and identifies a target for preventive measures.

National trends in incidence and outcomes in lower extremity amputations in people with and without diabetes in Spain, 2001-2012

AIMS

To describe trends in the incidence and outcomes of lower-extremity amputations (LEAs) in patients with T1DM and T2DM in Spain, 2001-2012.

METHODS

We used national hospital discharge data. Incidence of discharges attributed to LEA procedures were calculated stratified by diabetes status and type of LEA. Joinpoint log-linear regression for incidence trends and logistic regression for factors associated with in-hospital mortality were used.

RESULTS

From 2001 to 2012, 73,302 minor LEAs and 64,710 major LEAs were performed. We found that incidence of minor LEA procedures in T1DM patients decreased by 9.84% per year from 2001 to 2008 and then remained stable through 2012. In T2DM patients, LEA increased by 1.89% per year over the entire study period. Among patients with T1DM, major LEA incidence rate decreased by 10.5% from 2001 to 2012. In patients with T2DM, it increased by 4.29% from 2001 to 2004, and then decreased by 1.85% through 2012. In-hospital mortality after major or minor LEAs was associated with older age in all groups and with being female in T2DM and in people without diabetes.

CONCLUSIONS

Our national data show a decrease in the incidence of minor LEAs in patients with diabetes and in major LEAS in patients with T1DM over the period of study. In patients with T2DM, we found a decrease between 2004 and 2012. An additional improvement in preventive care, such as the introduction of diabetes foot units in hospitals, is necessary.

National trends in incidence and outcomes of abdominal aortic aneurysm among elderly type 2 diabetic and non-diabetic patients in Spain (2003-2012)

BACKGROUND

This study aims to describe trends in the rate of abdominal aortic aneurysm (AAA) and use of open surgery repair (OSR) and endovascular aneurysm repair (EVAR) in elderly patients with and without type 2 diabetes in Spain, 2003-2012.

METHODS

We select all patients with a discharge of AAA using national hospital discharge data. Discharges were grouped by diabetes status: type 2 diabetes and no diabetes. In both groups OSR and EVAR were identified. The incidence of discharges attributed to AAA were calculated overall and stratified by diabetes status and year. We calculated length of stay (LOHS) and in-hospital mortality (IHM). Use of OSR and EVAR were calculated stratified by diabetes status. Multivariate analysis was adjusted by age, sex, year, smoking habit and comorbidity.

RESULTS

From 2003 to 2012, 115,020 discharges with AAA were identified. The mean age was 74.91 years and 16.7% suffered type 2 diabetes. Rates of discharges due to AAA increased significantly in diabetic patients (50.09 in 2003 to 78.23 cases per 100,000 in 2012) and non diabetic subjects (69.24 to 78.66). The incidences were higher among those without than those with diabetes in all the years studied. The proportion of patients that underwent EVAR increased for both groups of patients and the open repair decreased. After multivariate analysis we found that LOHS and IHM have improved over the study period and diabetic patients had lower IHM than those without diabetes (OR 0.81; 95%CI 0.76-0.85).

CONCLUSIONS

Incidence rates were higher in non-diabetic patients. For diabetic and non diabetic patients the use of EVAR has increased and open repair seems to be decreasing. IHM and LOHS have improved from 2003 to 2012. Patients with diabetes had significantly lower mortality.

Temporal trends in initial and recurrent lower extremity amputations in people with and without diabetes in Western Australia from 2000 to 2010

AIMS

To examine temporal trends in lower extremity amputations in people with type 1 diabetes, type 2 diabetes and cardiovascular disease (CVD) without diabetes in Western Australia (WA) from 2000 to 2010.

METHODS

We used linked health data to identify all non-traumatic lower extremity amputations in adults aged ≥20 years with diabetes and/or CVD from 2000 to 2010 in WA. Annual age- and sex-standardised rates of total, initial and recurrent amputations, stratified by major and minor status, were calculated for type 1 and type 2 diabetes, and CVD without diabetes, from the at-risk population for each group. Age- and sex-adjusted trends were estimated from Poisson regression models.

RESULTS

5891 lower extremity amputations were identified. Peripheral vascular disease (71%), hypertension (70%) and chronic kidney disease (60%) were highly prevalent. Average annual rates of total amputations were 724, 564 and 66 per 100,000 person-years in type 1, type 2 diabetes and CVD without diabetes respectively. Rates of initial amputations fell significantly by 2.4%/year (95% CI -3.5, -1.4) in type 2 diabetes, with similar declines for type 1 diabetes and CVD without diabetes (interaction p=0.96), driven by large falls in major amputations. There was limited improvement in recurrence rates overall, with recurrent minor amputations increasing significantly in type 2 diabetes (+3.5%/year, 95% CI +1.3%, +5.7%).

CONCLUSION

Lower extremity amputation rates have declined at a population level in people with diabetes and CVD without diabetes, suggesting improvements in prevention and management for this high-risk patient group, however limited declines in recurrent amputations requires further investigation.

Trends in Major Lower Limb Amputation Related to Peripheral Arterial Disease in Hungary: A Nationwide Study (2004-2012)

OBJECTIVES

To assess the trends of peripheral arterial disease associated major lower limb amputation in Hungary over a 9 year period (2004-2012) in the whole Hungarian population.

METHODS

This was a retrospective cohort study employing administrative health care data. Major amputations were identified in the entire Hungarian population during a 9 year period (2004-2012) using the health care administrative data. Direct standardization was used to eliminate the potential bias induced by the different age and sex structure of the compared populations. For external direct standardization, the ESP 2013 was chosen as reference.

RESULTS

76,798 lower limb amputations were performed. The number of major amputations was 38,200; these procedures affected 32,084 patients. According to case detection, 50.4% of the amputees were diabetic. The overall primary amputation rate was 71.5%. The annual crude and age adjusted major amputation rates exhibited no significant long-term pattern over the observation period. The major lower limb amputation incidence for the overall period was 42.3/10(5) in the total population and 317.9/10(5) in diabetic population.

CONCLUSION

According to this whole population based study from Hungary, the incidence of lower limb major amputation is high with no change over the past 9 years. An explanation for this remains to be determined, as the traditional risk factors in Hungary do not account for it. The characteristics of major amputation (the rate of primary amputation, the ratio of below to above knee amputation and the age of the affected population) underline the importance of screening, early detection, improved vascular care and an optimal revascularization policy. Standardization and validation of amputation detection methods and reporting is essential.

Incidence and risk factors of lower extremity amputations in people with type 2 diabetes in Taiwan, 2001-2010

BACKGROUND

Diabetic patients have an increased risk of lower extremity amputations (LEAs). In the present study we analyzed the incidence of LEA in patients with type 2 diabetes mellitus (T2DM) in Taiwan from 2001 to 2010, and determined risk factors for LEA.

METHODS

Data from the Taiwan National Health Insurance Research Database collected between 1 January 2001 and 31 December 2010 were analyzed. First, the incidence of LEA in the diabetic population was calculated. Subsequently, patients with new-onset T2DM during the study period were selected, and Cox's proportional hazards model was used to identify factors associated with LEA. The characteristics of patients who underwent major and multiple amputations were also analyzed.

RESULTS

From 2001 to 2010, 1588 non-traumatic LEAs were performed among the study subjects; 776 (48.9%) were minor and 812 (51.1%) were major LEAs. Over the period in question, the incidence of LEAs decreased from 3.08 to 1.65 per 1000 person-years. Factors associated with LEA included peripheral arterial occlusive disease (hazard ratio [HR] 4.134; 95% confidence interval [CI] 2.72-6.29), diabetic neuropathy (HR 2.34; 95% CI 1.62-3.38), diabetic retinopathy (HR 2.07; 95% CI 1.12-3.82), heart failure (HR 2.13; 95% CI 1.45-3.15), male gender (HR 1.64; 95% CI 1.24-2.18), and adult onset diabetes (HR 1.02; 95% CI 1.01-1.04). Patients with a history of stroke were more likely to undergo major and multiple amputations (P < 0.001 and P < 0.01, respectively).

CONCLUSIONS

The incidence of LEA in the Taiwan diabetic population decreased over the study period. The results indicate that efforts to improve diabetic care should be supported and sustainable, especially for those at high risk.

Trends in the prevalence of depression in hospitalized patients with type 2 diabetes in Spain: analysis of hospital discharge data from 2001 to 2011

BACKGROUND

This study aims to describe trends in the prevalence of depression among hospitalized patients with type 2 diabetes in Spain, 2001-2011.

METHODS

We selected patients with a discharge diagnosis of type 2 diabetes using national hospital discharge data. Discharges were grouped by depression status. Prevalence of depression globally and according to primary diagnoses based on the Charlson comorbidity index (CCI) were analyzed. We calculated length of stay (LOHS) and in-hospital mortality (IHM). Multivariate analysis was adjusted by age, year and comorbidity.

RESULTS

From 2001 to 2011, 4,723,338 discharges with type 2 diabetes were identified (4.93% with depression). Prevalence of depression in diabetic patients increased from 3.54% in 2001 to 5.80% in 2011 (p<0.05). The prevalence of depression was significantly higher in women than in men in each year studied and increased from 5.22% in 2001 to 9.24% in 2011 (p<0.01). The highest prevalence was observed in the youngest age group (35-59 years). The median LOHS decreased significantly over this period. Men with diabetes and depression had higher IHM than women in all the years studied (p<0.05). Older age and greater comorbidity were significantly associated with a higher risk of dying, among diabetic patients with concomitant depression.

CONCLUSIONS

Prevalence of depression increased significantly among hospitalized diabetic patients from 2001 to 2011 even if the health profile and LOHS have improved over this period. Programs targeted at preventing depression among persons with diabetes should be reinforced in Spain.

Subsequent ischemic events associated with lower extremity amputations in patients with type 2 diabetes: a population-based cohort study

AIMS

To explore the risk of subsequent ischemic events in type 2 diabetes mellitus (DM) patients who had lower extremity amputations (LEAs) were compared with DM patients without LEAs.

METHODS

A population-based cohort study was conducted utilizing the data of 2011 patients with newly diagnosed DM with and without LEAs sourced from the Longitudinal Health Insurance Database 2000 (LHID 2000) of the Taiwan National Health Insurance (NHI) program between 1996 and 2008.

MAIN OUTCOME MEASURES

Relative risks (RRs), hazard ratios (HRs), and disease-free rates for various ischemic events.

RESULTS

In contrast with the comparison group, subjects with LEAs were more likely to reside in less urbanized areas, be white collar workers, and have higher DM-related costs (p<0.05). Subjects with LEAs also had significantly higher risks of developing ischemic diseases, except intestinal ischemia. In the multivariate Cox proportional hazards regression model analysis, the HR of end-stage renal disease (ESRD) was highest (HR=3.91, 95% CI=2.38-6.42), followed by embolism and thrombosis (HR=3.47, 95% CI=2.12-5.67), other peripheral vascular diseases (HR=3.11, 95% CI=2.11-4.57), atherosclerosis (HR=2.64, 95% CI=1.60-4.35), retinopathy (HR=2.24, 95% CI=1.79-2.80), cerebral ischemia (HR=1.61, 95% CI=1.25-2.06), and coronary artery disease (HR=1.44, 95% CI=1.18-1.74).

CONCLUSIONS

DM patients with LEAs had significantly higher risks for subsequent ischemic events, particularly among men. The greatest risk detected among DM patients with LEA's was for end-stage renal disease. Disease free survival rates also indicated that the course of generalized DM ischemia proceeded despite treatment.

Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot

We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of -6.6% (95% CI = -10.2 to -2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes.

National trends in incidence and outcomes of acute pancreatitis among type 2 diabetics and non-diabetics in Spain (2001-2011)

BACKGROUND

Diabetes is often observed in patients with acute pancreatitis (AP). Our aim was to compare trends in the clinical epidemiology and outcomes of AP in diabetic and non-diabetic patients in Spain.

METHODS

We conducted a retrospective observational study. We identified all patients who had a diagnosis of AP using national hospital discharge data (2001-2011). The incidence of discharges of patients with AP was calculated, stratified by diabetes status. We calculated length of stay and in-hospital mortality (IHM). We applied joinpoint log-linear regression to identify the years in which changes in tendency occurred in the diagnosis of AP. The multivariate analysis was adjusted for age, sex, year and Charlson comorbidity index (CCI).

RESULTS

The total number of subjects who had a diagnosis of AP was 282,349. Of them, 42,009 (14.9%) had type 2 diabetes. The annual percentage of change in the incidence of AP for the whole period was 4.90% for those suffering from type 2 diabetes and almost null (0.1%) for those without this disease. Among hospitalized patients with type 2 diabetes and acute pancreatitis, those with a CCI equal to or greater than three had 5.53 times more probability of dying in the hospital than those with a CCI of zero. The corresponding OR for the non-diabetic group was 6.50 (95%CI 6.15-6.87). Suffering from type 2 diabetes was significantly associated with a lower risk of dying in the hospital with a diagnosis of AP (OR 0.82; 95% CI 0.78-0.86).

CONCLUSIONS

In Spain, time trend analyses suggest that the incidence of AP is increasing more among those with prevalent type 2 diabetes than among those without this disease. Type 2 diabetes was associated with a lower risk of dying in hospital with AP.

Motivation, effort and life circumstances as predictors of foot ulcers and amputations in people with Type 2 diabetes mellitus

AIM

To investigate the predictive value of both patients' motivation and effort in their management of Type 2 diabetes and their life circumstances for the development of foot ulcers and amputations.

METHODS

This study was based on the Diabetes Care in General Practice study and Danish population and health registers. The associations between patient motivation, effort and life circumstances and foot ulcer prevalence 6 years after diabetes diagnosis and the incidence of amputation in the following 13 years were analysed using odds ratios from logistic regression and hazard ratios from Cox regression models, respectively.

RESULTS

Foot ulcer prevalence 6 years after diabetes diagnosis was 2.93% (95% CI 1.86-4.00) among 956 patients. General practitioners' indication of 'poor' vs 'very good' patient motivation for diabetes management was associated with higher foot ulcer prevalence (odds ratio 6.11, 95% CI 1.22-30.61). The same trend was seen for 'poor' vs 'good' influence of the patient's own effort in diabetes treatment (odds ratio 7.06, 95% CI 2.65-18.84). Of 1058 patients examined at 6-year follow-up, 45 experienced amputation during the following 13 years. 'Poor' vs 'good' influence of the patients' own effort was associated with amputation (hazard ratio 7.12, 95% CI 3.40-14.92). When general practitioners assessed the influence of patients' life circumstances as 'poor' vs 'good', the amputation incidence increased (hazard ratio 2.97, 95% CI 1.22-7.24). 'Poor' vs 'very good' patient motivation was also associated with a higher amputation incidence (hazard ratio 7.57, 95% CI 2.43-23.57), although not in fully adjusted models.

CONCLUSIONS

General practitioners' existing knowledge of patients' life circumstances, motivation and effort in diabetes management should be included in treatment strategies to prevent foot complications.