PracticeUpdate: Diabetes

EDITOR’S PICKS 12

Decreasing Rates of Major Lower-Extremity Amputation in People With Diabetes Diabetologia Take-home message • In prior studies, outcomes data have demonstrated a significant decrease in lower-extremity amputations (LEAs) due to diabetes after institution of multidisciplinary interventions, including better wound care, access to foot specialists, and improvements in HbA1c. In this study, the authors investigated the annual rates of LEA in people with and without diabetes in Belgium to determine the prevalence and the factors in that time period that may have contributed to any changes. Results of this population study showed that, throughout the observational period (2009–2013), the risk of major amputation was six times higher in people with diabetes compared with those without. In people with diabetes, the rates of amputation declined significantly from 42.3 per 100,000 person-years in 2009 to 29.9 in 2013, but there was no such significant decline in patients without diabetes. There was a similar significant decrease in minor LEA in patients with diabetes, although the effect was less profound than that seen with major LEA. • This is a countrywide association study of over 11,000 individuals with and without diabetes that clearly demonstrated a signif- icant decline in both major and minor LEA. Although these results are similar to those reported in prior population studies, the significant decrease in this instance can be traced back to stronger national efforts in Belgium to establish multidisciplinary foot care in patients with diabetes. It could benefit other countries, therefore, to consider a similar approach to help decrease the rates of LEA in people with diabetes. Jason Sloane MD Abstract

AIMS/HYPOTHESIS The reduction of major low- er-extremity amputations (LEAs) is one of the main goals in diabetes care. Our aim was to estimate annual LEA rates in individuals with and without diabetes in Belgium, and correspond- ing time trends. METHODS Data for 2009-2013 were provided by the Belgian national health insurance funds, covering more than 99% of the Belgian popu- lation (about 11 million people). We estimated the age-sex standardised annual amputation rate (first per year) in the populations with and without diabetes for major and minor LEAs, and the corresponding relative risks. To test for time trends, Poisson regression models were fitted.

and without diabetes (5% and 3% annual reduc- tion, respectively, p<0.001). CONCLUSIONS/INTERPRETATION In this nationwide study, the risk of undergoing a major LEA in Belgium gradually declined for individuals with diabetes between 2009 and 2013. However, continued efforts should be made to further reduce the number of unnecessary amputations. Decreasing Rates of Major Lower-Extremity Amputation in People With Diabetes but Not in Those Without: A Nationwide Study in Belgium. Diabetologia 2018 Jun 16;[EPub Ahead of Print], H Claessen, H Avalosse, J Guillaume, et al. www.practiceupdate.com/c/69788

RESULTS A total of 5438 individuals (52.1% with diabetes) underwent a major LEA, 2884 people with above- and 3070 with below-the-kneemajor amputations. A significant decline in the major amputation rate was observed in people with diabetes (2009: 42.3; 2013: 29.9 per 100,000 per- son-years, 8% annual reduction, p<0.001), which was particularly evident for major amputations above the knee. The annual major amputa- tion rate remained stable in individuals without diabetes (2009: 6.1 per 100,000 person-years; 2013: 6.0 per 100,000 person-years, p=0.324) and thus the relative risk reduced from 6.9 to 5.0 (p<0.001). A significant but weaker decrease was observed for minor amputation in individuals with

COMMENT By Michael T. Watkins MD, FACS, FAHA T he article by Classen et al provides information to indicate that concerted nationwide efforts to address diabetic foot care have had an impact on the incidence of amputation in diabetic but not nondiabetic patients in Belgium. This was accomplished through an Initiative for Quality Improvement and Epidemiology in Multidisciplinary Diabetic Foot Clinics. The authors met their aim, which was to analyze the major and minor lower-extremity amputation (LEA) rates in people with and without diabetes. It is important to note that, although there was a statistically sig- nificant decrease in LEA in the diabetic patient population vs the nondiabetic patient population, the major overall risk remained more than six times higher in the people with diabetes in the study period. Another significant finding was that the LEA rate was twice as high in men vs women; however, the reduction in LEA rate was greater in women. The authors have undertaken a descriptive statistical tour de force assessing both above- and below-knee amputations along with minor amputations in diabetic and nondiabetic patients. What is

missing in their analysis and the analysis of others 1,2 who have studied this important topic is what specific indications for ampu- tation have been impacted over the study period in diabetic and nondiabetic patients. Until we know how interventions modify the indications for amputations in these patient populations, the kind of operations they receive will be less relevant. References 1. Kennon B, Lesse GP, Cochrane L, et al. Reduced incidence of lower- extremity amputations in people with diabetes in Scotland. Diabetes Care 2012;35(12):2588-2590. 2. Kayssi A, de Mestral C, Forbes TL, Roche-Nagle G. A Canadian population- based description of the indications for lower extremity amputations and outcomes. Can J Surg 2016;59(2):99-106.

Dr. Watkins is the Director of Vascular Surgery Basic Science Laboratory at the Massachusetts General Hospital, Associate Professor of Surgery at Harvard Medical School, and the Isenberg Scholar in Academic Surgery at Massachusetts General Hospital in Boston, Massachusetts.

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