Using data to tackle the burden of amputation in diabetes

Jeffcoate, William; Barron, Emma; Lomas, John; Valabhji, Jonathan; Young, Bob

doi:10.1016/s0140-6736(17)32401-7

Cited by 27 publications

(32 citation statements)

References 16 publications

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“…However, Gurney's paper is the first Australasian study to also adjust for key socio‐demographic factors . It closely follows a study by Jeffcoate et al ., which also adjusted for age, gender, diabetes, socio‐economic status, rurality and ethnicity across regions in the UK . After adjustment, Jeffcoate still found a six‐ to sevenfold variation in UK amputation rates, which was only slightly lower than the sevenfold to 10‐fold variation they earlier found using crude rates .…”

mentioning

confidence: 75%

“…It closely follows a study by Jeffcoate et al ., which also adjusted for age, gender, diabetes, socio‐economic status, rurality and ethnicity across regions in the UK . After adjustment, Jeffcoate still found a six‐ to sevenfold variation in UK amputation rates, which was only slightly lower than the sevenfold to 10‐fold variation they earlier found using crude rates . They hypothesized that the remaining variation could only be explained by factors not adjusted for, namely, comorbidities and available diabetic foot services …”

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confidence: 93%

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Regional variations in amputation rates: are regional diabetic foot services the reason?

Lazzarini

Fitridge

2019

ANZ Journal of Surgery

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confidence: 75%

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confidence: 93%

Regional variations in amputation rates: are regional diabetic foot services the reason?

Lazzarini

Fitridge

2019

ANZ Journal of Surgery

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“…Nationwide, the incidence of major amputation for diabetes has now fallen to 0.8 per 1,000 across England (75). Nevertheless, the persistence of considerable geographic variation, at least across England, suggests that the total should fall still more if all populations are managed to the same standard (76).…”

Section: Auditmentioning

confidence: 99%

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

et al. 2018

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Diabetic foot ulcers remain a major health care problem. They are common, result in considerable suffering, frequently recur, and are associated with high mortality, as well as considerable health care costs. While national and international guidance exists, the evidence base for much of routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individuals. It is probable that this contributes to the geographic variation in outcome that has been documented in a number of countries. This article considers these issues in depth and emphasizes the urgent need to improve the design and conduct of clinical trials in this field, as well as to undertake systematic comparison of the results of routine care in different health economies. There is strong suggestive evidence to indicate that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes.Despite considerable advances made over the last 25 years, diabetic foot ulcers (DFUs) continue to present a very considerable health care burdendone that is widely unappreciated. DFUs are common, the median time to healing without surgery is of the order of 12 weeks, and they are associated with a high risk of limb loss through amputation (1-4). The 5-year survival following presentation with a new DFU is of the order of only 50-60% and hence worse than that of many common cancers (4,5). While there is evidence that mortality is improving with more widespread use of cardiovascular risk reduction (6), the most recent datadderived from a Veterans Health Adminstration populationdreported that 1-, 2-, and 5-year survival was only 81, 69, and 29%, respectively, and the association between mortality and DFU was stronger than that of any macrovascular disease (7). Iversen et al. (8) have also shown that the occurrence of a DFU was an independent predictor of mortality even at 10 years.The cost to health care services is also enormous. The estimated global cost of diabetes in 2015 was $1.3 trillion (9), and it has been reported that up to one-third of diabetes expenditure is on lower-limb-related problems in the U.S. (10). The latest data from the U.K. estimate that the total annual cost of management of DFUs exceeds £1 billion ($1.32 billion) and represents almost 1% of the total National Health Service budget (11). The equivalent figure from the U.S. has been estimated to be $9-13 billion (12). GEOGRAPHIC DIFFERENCES IN CLINICAL OUTCOMEThere is also wide variation in clinical outcome within the same country (13-15), suggesting that some people are being managed considerably less well than others.

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“…This suggests that, even after adjusting for potential differences in the distribution of key explanatory factors such as ethnicity and deprivation, several regions in NZ are experiencing a disproportionate burden of lower‐limb amputation. Our observations from the three Auckland DHBs may suggest that access to high‐turnover health care services (including high‐volume diabetic foot care services) could be an important factor in amputation prevention . Unpicking this issue requires a detailed evaluation of the availability of evidence‐based, accessible and well‐resourced diabetic foot care services within those DHBs for which amputation rates (particularly major amputation rates) remain much higher than the national average.…”

Section: Discussionmentioning

confidence: 94%

“…3 Given the wide variation in risk of amputation across these factors, and that some of these factors vary by region, it stands to reason that there may also be geographical variation in the rate of amputation within a given country. 11 There is evidence of wide variation in the rate of amputation between regions in England, with an eight-fold difference in amputation rate between those regions with the lowest and highest amputation rates; 12 while in the US, there is evidence that regions that are geographically proximal to each other tend to have similar rates of amputation. 13 While part of this variation will be driven by geographical clustering of certain demographic groups by region, other service-level factors may also contributesuch as access to health care services (including quality diabetic foot care services).…”

Section: Introductionmentioning

confidence: 99%

Regional variation in the risk of lower‐limb amputation among patients with diabetes in New Zealand

Gurney

Stanley

York

et al. 2019

ANZ Journal of Surgery

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Background Lower‐limb amputation is one of the most substantial and debilitating consequences of diabetes mellitus; however, the risk of lower‐limb amputation is not equally shared across the diabetic population. The aims of this study were to (i) describe regional variation in the rate of lower‐limb amputation in New Zealand among a national prevalent cohort of patients with diabetes; and (ii) explore the plausible factors that could be contributing to this variation. Methods Our cohort were the national prevalent cohort of individuals with diabetes in New Zealand in 2011, according to the Virtual Diabetes Register (n = 215 676). Using descriptive analysis and Poisson regression, we compared the rate of lower‐limb amputation within each of New Zealand's 20 District Health Boards with the national rate of amputation, adjusting for demographic, health care access and patient‐level factors. Results We observed nearly four‐fold variation in the rate of major lower‐limb amputation between regions in New Zealand, as well as nearly two‐fold variation in the rate of minor lower‐limb amputation. Adjustment for differences between regions in terms of ethnicity reduced this variation substantially for many District Health Boards. Despite adjustment for sex, age, ethnicity, deprivation, rurality, comorbidity and prior amputation, the rate of lower‐limb amputation in a number of District Health Boards remained substantially higher than the national rate. Conclusions These observations could help to inform the funding and provision of diabetic foot care services across New Zealand; however, more work is required to further untangle the drivers of national variation in rates of lower‐limb amputation.

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Using data to tackle the burden of amputation in diabetes

Cited by 27 publications

References 16 publications

Regional variations in amputation rates: are regional diabetic foot services the reason?

Regional variations in amputation rates: are regional diabetic foot services the reason?

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

Regional variation in the risk of lower‐limb amputation among patients with diabetes in New Zealand

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