Resurgence of Diabetes-Related Nontraumatic Lower Extremity Amputation in the Young and Middle-Aged Adult U.S. Population

We are grateful to Linda Geiss and her coworkers at CDC for their always intriguing efforts at revealing the big picture to us. These data– which certainly aren’t welcome news– are supremely important. Do they signal what we’ve posited for some time? Did the increase in the “denominator” of people with diabetes in the mid-1990s initially reduced the proportionate pool of high risk patients (and thereby reduced amputation rates)? Was it better team care? Whatever the explanation, we have yet more data on which to ruminate.

OBJECTIVES To determine whether declining trends in lower extremity amputations have continued into the current decade.

RESEARCH DESIGN AND METHODS We calculated hospitalization rates for nontraumatic lower extremity amputation (NLEA) for the years 2000–2015 using nationally representative, serial cross-sectional data from the Nationwide Inpatient Sample on NLEA procedures and from the National Health Interview Survey for estimates of the populations with and without diabetes.

RESULTS Age-adjusted NLEA rates per 1,000 adults with diabetes decreased 43% between 2000 (5.38 [95% CI 4.93–5.84]) and 2009 (3.07 [95% CI 2.79–3.34]) (P < 0.001) and then rebounded by 50% between 2009 and 2015 (4.62 [95% CI 4.25–5.00]) (P < 0.001). In contrast, age-adjusted NLEA rates per 1,000 adults without diabetes decreased 22%, from 0.23 per 1,000 (95% CI 0.22–0.25) in 2000 to 0.18 per 1,000 (95% CI 0.17–0.18) in 2015 (P < 0.001). The increase in diabetes-related NLEA rates between 2009 and 2015 was driven by a 62% increase in the rate of minor amputations (from 2.03 [95% CI 1.83–2.22] to 3.29 [95% CI 3.01–3.57], P < 0.001) and a smaller, but also statistically significant, 29% increase in major NLEAs (from 1.04 [95% CI 0.94–1.13] to 1.34 [95% CI 1.22–1.45]). The increases in rates of total, major, and minor amputations were most pronounced in young (age 18–44 years) and middle-aged (age 45–64 years) adults and more pronounced in men than women.

CONCLUSIONS After a two-decade decline in lower extremity amputations, the U.S. may now be experiencing a reversal in the progress particularly in young and middle-aged adults.