A new commentary published in the prestigious Lancet journal by global diabetic foot expert William Jeffcoate and colleagues clearly underlines the critical impact that a region’s diabetic foot services can have on their hospitalisation and amputation rates. The commentary paper “uses data to tackle the burden of diabetes-related amputations” by summarising an enormous analysis of hospitalisation and amputation data across 200+ regions in England performed by Public Health England.
The analysis found the incidence of major amputations in England had decreased, while minor amputations and diabetic foot hospitalisations had increased. Major amputations decreased significantly from 9 (per 10,000 people with diabetes) in 2010/11 to 8 in 2015/16. In contrast, minor amputations increased significantly from 20 to 21 (per 10,000 people with diabetes), and so too did diabetic foot hospitalisations from 123 to 138 (per 10,000 people with diabetes) over the same period.
The Public Health England analysis also found a 3-7 fold difference between the best and worst regions in England for the incidence of major amputations, minor amputations and diabetic foot hospitalisations. Major amputations showed a 7-fold difference (3 to 21 per 10,000 people with diabetes), minor amputations a 6-7 fold difference (7 to 45), and hospitalisations a 3-4 fold difference (60 to 227) between the best and worst regions.
The analysis found the incidence of major amputations in England had decreased, while minor amputations and diabetic foot hospitalisations had increased.
On the face of it these findings don’t seem too novel, as major amputations have been falling in many nations, with minor amputations and hospitalisations increasing. Also Prof Jeffcoate reported himself a similar 7-10 fold differences in amputation rates across different regions of England in a 2012 Diabetologia article. However, the difference in this analysis is that Public Health England was able to elegantly control for many more confounding factors that are thought to impact on these rates across regions, better than ever before. They cleverly linked data from three different robust data sources including hospital data (for demographics and amputations), general practice data (for diabetes prevalence in each region) and national diabetes audit data (for ethnicity and age distributions in people with diabetes). This allowed them to control for a range of factors including demographic, social deprivation, ethnicity and the exact demographic make-up of each regions’ diabetes population.
The 7-fold difference between the best and worse regions for diabetes amputations was found after controlling for all these factors. This left factors they could not control as the only explanations. Of these remaining factors, Professor Jeffcoate suggests the most likely factors to explain these differences were local access to well-structured evidence-based diabetic foot services, and the local beliefs of surgeons and other health professionals.
Of course we still cannot definitively conclude this, as other factors that could not be controlled need to be considered as well, including: medical conditions (such as kidney disease or stroke), social factors (such as an individual’s education status) and the specific elements of access to quality diabetic foot services (such as adherence to best practice guideline care). However, these findings enable us to more strongly than ever before suggest that the structure and access to a region’s diabetic foot services are the most critical factors influencing a region’s hospitalisation and amputation rates.
For those of you who love the detail, the Diabetic Footcare Profile technical document and dataset that formed the backbone of this Lancet commentary paper are definitely worth the read.
In conclusion, global diabetic foot disease guru Professor David Armstrong always says “you cannot improve what you do not measure”. This Lancet commentary is perhaps the best example of this yet and highlights the enormous benefit of measuring regional diabetic foot disease hospitalisation and amputation outcomes to guide improvements in our regions’ diabetic foot services. This aligns beautifully with Diabetes Feet Australia’s key recommendation to report and monitor the diabetic foot disease hospitalisation and amputation rates of all regions in Australia if we are to truly reach our national goal of ending avoidable amputations within a generation.
To find out more about this and other key recommendations to end avoidable amputations within a generation head to the recently launched Australian diabetes-related foot disease strategy 2018-2022: The first step towards ending avoidable amputations within a generation.