National trends in incidence and outcomes in lower extremity amputations in people with and without diabetes in Spain, 2001–2012
Introduction
Nontraumatic lower extremity amputations (LEAs) are significant complications in people with diabetes with a heavy social impact and poor clinical prognosis, as well as being a considerable burden on the health services [1]. LEA rates are 15 to 40 times higher in people with diabetes than in those without diabetes [2].
The number of people with diabetes has more than doubled over the last decade in Spain due to an increasing obesity rate and an aging population [3]. As the prevalence of diabetes increases, the number of LEAs in people with diabetes will go up [1]. A recent report showed an increase in major and minor amputations in patients with T2DM, while the number of T1DM -related LEAs decreased in Spain between 2001 and 2008 [4]. However, in Europe the principal trend is a reduction in major amputation rates, and in some countries the improvement observed in the incidence of amputation could be related to the implementation of the recommendations published by the International Working Group on the Diabetic Foot or as a benefit of the Multidisciplinary Diabetic Foot Units (MDFU) [5], [6], [7], [8], [9], [10].
Limited information is available regarding the trend changes for LEAs in Spain and these reports were compiled in small areas of Spain. Rubio et al. reported that the incidence of LEAs showed a significant reduction in major amputations in people with diabetes following the introduction of an MDFU (6.1 per 100,000 in the 2001–2007 period vs. 4.0 per 100,000 per year in the 2008–2011 period) in Spain [10]. Another Spanish group reported a significant decrease in the proportion of total major amputations (47%) in the period 2001–2012 period after the implementation of better foot care [11].
Establishing the incidence of LEAs in patients with diabetes is essential after any change in diabetic foot care management and it is necessary to find out how rates change over time in the population analyzed [10].
In this study, we used national hospital discharge data to examine trends in the incidence of LEA procedures (major and minor) among hospitalized patients with T1DM and T2DM between 2001 and 2012 in Spain. We analyzed in-hospital outcomes such as in-hospital mortality and length of hospital stay.
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Materials and methods
This retrospective, observational study was conducted using the Spanish National Hospital Database (CMBD, Conjunto Minimo Básico de Datos). This database is managed by the Spanish Ministry of Health, Social Services and Equality and compiles all public and private hospital data, hence covering more than 95% of hospital discharges [12]. The CMBD includes patient variables (sex, date of birth), admission date, discharge date, up to 14 discharge diagnoses, and up to 20 procedures performed during
Results
From 2001 to 2012, a total of 138,012 nontraumatic amputations (73,302 minor and 64,710 major), corresponding to 132,057 discharges, were identified in Spain. We found 4.3% (n = 5955) of simultaneous bilateral procedures. Over the study period, 65.8% of all discharges following LEA occurred in patients with diabetes, with T1DM patients accounting for 3.1% and T2DM patients accounting for 62.7% of discharges. Minor LEAs were more common than major LEAs in patients with diabetes (minor-to-major
Discussion
Using the Spanish National Hospital Database, we found different trends over the last 12 years in the hospitalization of people with and without diabetes who underwent nontraumatic LEA procedures.
Our results reveal that patients with diabetes account for 65.8% of all nontraumatic LEA procedures in Spain. We found a decline in hospital admissions for minor (2001–2008) and major LEAs in patients with T1DM (2001–2012). For T2DM, an upward trend was observed for minor LEAs (2001–2012); however,
Conflict of interest statement
The authors declare that they have no conflict of interest.
Acknowledgements
This study forms part of research funded by the FIS (Fondo de Investigaciones Sanitarias—Health Research Fund, grant no. PI13/00118, Instituto de Salud Carlos III).
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2017, Journal of Vascular NursingCitation Excerpt :The present study shows that most NLEA procedures were performed on patients without diabetes. These results diverge from findings in the literature in which patients with DM comprise more than half the population who receive NLEA procedures.12-14 These results might reflect the limitations inherent in studies based on secondary data sources regarding the quality and accuracy of the records, especially in Brazil where the diagnosis of DM might be underestimated on the hospital discharge form.