Are we collectively making a dent? Amputation rates decreasing at the VA (and perhaps throughout the USA)

Enjoy this piece from today’s Diabetes Care courtesy of Len Pogach’s group. Congratulations to Chin-Lin Tseng and coworkers. Also enjoy the Reuters piece interviewing Jim Wrobel about it after the abstract:


OBJECTIVE To evaluate temporal trends in rates of initial lower extremity amputation (ILEAs) among patients with diabetes in the Veterans Health Administration (VHA).

RESEARCH DESIGN AND METHODS Retrospective administrative data analysis of VHA clinic users with diabetes in fiscal years (FY) 2000 to 2004 (1 October 1999–30 September 2004). We calculated annual age– and sex–standardized rates of initial major, minor, and total amputations for the overall population and for various racial/ethnic groups (African Americans, Hispanics, and whites). Trends in ILEA risk were evaluated with and without adjustment for demographic characteristics and other potential risk factors, including presence of microvascular and macrovascular diseases, and antiglycemic treatment.

RESULTS Study populations of VHA patients with diabetes and without prior amputations ranged from 405,580 in FY 2000 to 739,377 in FY 2004. Age- and sex-standardized ILEA rates decreased by 34% (7.08/1,000 in FY 2000 to 4.65/1,000 patients) during the 5-year period. Minor and major amputation rates decreased by 33% (4.59 to 3.06/1,000) and 36% (2.49 to 1.59/1,000), respectively. Of major amputations, below-knee rates decreased from 1.08 to 0.87/1,000 (−19%), and above-knee decreased from 1.41 to 0.72/1,000 (−49%). Similar trends were seen for all racial groups. ILEA risk decreased by 28% (odds ratio 0.72 [95% CI 0.68–0.75]) when FY 2004 was compared with FY 2000 in the model, adjusting for demographic characteristics. This risk decrease was 22% in the model adjusting for all independent variables (odds ratio 0.78 [95% CI 0.74–0.82]).

CONCLUSIONS Downward 5-year trends in ILEA rates were observed for all amputation levels and among all racial groups, even after adjustment for risk


(Reuters Health) – Rates of foot and leg amputations in people with diabetes may have decreased in recent years, according to a new study of patients at Veterans Affairs (VA) clinics.

Total rates of amputation, taking into account the age and gender of patients, were about 7 for every 1,000 patients in 2000 and between 4 and 5 for every 1,000 in 2004.

The findings could mean “that we are getting better at screening patients … and getting them the proper levels of care,” Dr. James Wrobel, the head of the Center for Lower Extremity Ambulatory Research in North Chicago, Illinois, who was not involved in the study, told Reuters Health.

Close to 26 million Americans have diabetes, according to the American Diabetes Association. The National Institutes of Health reports that more than 65,000 people with diabetes had leg or foot amputations in 2006, the most recent year with available data.

Amputation is a risk with diabetes because nerve damage causes many patients to lose feeling in their feet, so they may not notice a cut or ulcer on their foot until it’s infected. These cuts also take longer to heal because people with diabetes often have hardening of blood vessels, which causes less blood to flow to the feet and legs.

Previous studies have suggested that the rate of amputations in diabetics may be decreasing, but lead investigator Dr. Chin-Lin Tseng from New Jersey’s Department of Veteran Affairs and colleagues were concerned that might be due to higher numbers of people being diagnosed with early diabetes who generally don’t have serious leg problems.

While diabetes has been on the rise, the number of amputations wouldn’t necessarily have increased yet. “Usually you don’t see amputations in the first 10 years of somebody having diabetes,” explained Wrobel.

In their analysis, published in Diabetes Care, the authors consulted records of all patients with diabetes that were seen at VA clinics and also tracked amputations in these patients paid for by Medicare. The study included between 400,000 and 800,000 patients with diabetes each year, most of whom were white and male.

When the researchers compared two similar populations and accounted for trends in earlier diabetes diagnoses, they calculated that amputation rates still decreased by about 20 percent during the study period.

Rates of minor and major amputations decreased at similar rates – in both 2000 and 2004, minor amputations were roughly twice as common as major amputations. However, the biggest decrease in amputation rates was in above-the-knee procedures – the most serious type of amputation the researchers examined.

Wrobel, who also works part-time at the VA, said it’s hard to know if the findings are representative to the entire country, or if they are limited to VA clinics. He said that the VA has made improvements in screening patients with diabetes for foot problems and following their progress closely, and “the sum of all these things together could be explaining this,” he said.

But some of those improvements in prevention and care are also probably happening in non-VA hospitals, Wrobel said.

When foot problems in patients with diabetes are caught early, treatments such as therapeutic shoes can cut down on their risk of later needing an amputation, Wrobel said.

“People with diabetes receive more aggressive treatment for their condition and its risk factors than previously, due to increased awareness of diabetes and targeted interventions,” Dr. Eszter Vamos, who has studied amputation rates in diabetes patients at the Imperial College of London, told Reuters Health in an email.

Vamos, who was not involved in the current research, said that continued efforts are still needed to reduce the risk of amputation in patients with diabetes.

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