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

https://doi.org/10.1016/j.diabres.2015.01.010Get rights and content

Highlights

  • For T1DM incidence of minor LEA decreased by 9.84% per year from 2001 to 2008.

  • For T2DM incidence of minor LEA procedures increased by 1.89% per year from 2001 to 2012.

  • For T1DM, major LEA incidence decreased by 10.51% per year from 2001 to 2012.

  • For T2DM, major LEA incidence increased by 4.29% per year from 2001 to 2004, and then decreased by 1.85% per year through 2012.

  • IHM was associated with higher age in all groups and with being female in T2DM.

Abstract

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.

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.

Section snippets

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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