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Lower extremity amputation rates in diabetic patients

How to cite this article: Cisneros-González N, Ascencio-Montiel IJ, Libreros-Bango VN, Rodríguez-Vázquez H, Campos-Hernández Á, Dávila-Torres J, Kumate-Rodríguez J, Borja-Aburto VH. [Lower extremity amputation rates in diabetic patients]. Rev Med Inst Mex Seg Soc 2016 Jul-Aug;54(4):472-9.

PubMed: http://www.ncbi.nlm.nih.gov/pubmed/27197105


ORIGINAL CONTRIBUTIONS


Received: March 19th 2015

Accepted: April 28th 2015

Lower extremity amputation rates in diabetic patients


Nelly Cisneros-González,a Iván de Jesús Ascencio-Montiel,a Vita Norma Libreros-Bango,b Héctor Rodríguez-Vázquez,b Ángel Campos-Hernández,b Javier Dávila-Torres,c Jesús Kumate-Rodríguez,d Víctor Hugo Borja-Aburtoe


aCoordinación de Vigilancia Epidemiológica

bDivisión de Información en Salud

cDirección de Prestaciones Médicas

dFundación IMSS, A. C.

eUnidad de Atención Primaria a la Salud


Instituto Mexicano del Seguro Social, Ciudad de México, México


Communication with: Nelly Cisneros-González

Teléfonos: (55) 5211 2728, (55) 5211 9903

Email: nelly.cisneros@imss.gob.mx


Background: The lower extremity amputations diminish the quality of life of patients with Diabetes Mellitus (DM). The aim of this study was to describe the lower extremity amputation rates in subjects with DM in the Mexican Social Security Institute (IMSS), comparing 2004 and 2013.

Methods: A comparative cross-sectional study was done. Amputations were identified from the hospital records of System of Medical Statistics (DataMart). The DM patient census was obtained from the System of Integral Attention to Health. Major and minor amputations rates were expressed per 100,000 DM patients.

Results: We observed 2 334 340 and 3 416 643 DM patients during 2004 and 2013, respectively. The average age at the time of the amputation was similar in 2004 and 2013 (61.7 and 65.6 years old for minor and major amputations respectively). The major amputations rates were 100.9 and 111.1 per 100,000 subjects with DM in during 2004 and 2013 (p = 0.001); while minor amputations rates were 168.8 and 162.5 per 100,000 subjects with DM in during 2004 and 2013 respectively (p = 0.069).

Conclusions: The lower extremity amputations rates at IMSS are very high compared with that reported in developed countries. The major amputations rate increased in 2013 compared with 2004.

Keywords: Amputation; Diabetes mellitus; Lower extremity


The diabetic foot is one of the most common complications associated with diabetes mellitus (DM); it is estimated that approximately 15 to 25% of patients with DM develop diabetic foot during the course of their disease, i.e. six people with diabetes will have an ulcer during their lifetime. Published studies have shown that this occurs mainly in men and is related to prolonged inadequate blood glucose control from DM.1-3

Globally, the annual incidence of diabetic foot ulcers in patients with diabetes ranges from 1.0 to 4.1%. In developed countries it has been reported that up to 5% of people with diabetes have diabetic foot problems that often result in amputation.2,3

Amputations lead to disability and premature mortality. This disabling condition is one of the most frequent causes of hospitalization for people with diabetes because it generates additional costs of medical care, rehabilitation, treatment, disability, and economic spending due to disability. It is estimated that the direct cost of an amputation associated with the diabetic foot is between 30,000 and 60,000 USD.1,2,4

Studies have shown that the presence of lower extremity amputations in persons with diabetes mellitus is a predictor in the reduction in quality of life.5-10

There are few data related to diabetic foot and/or amputations, but according to the Asociación Latinoamericana de Diabetes, 58.2% of patients with DM in Brazil have diabetic foot complications, and the incidence reported in Rio de Janeiro of major amputations from DM was 6.4/100,000 per year; Chile reports 13% of amputations in patients with DM; in Mexico between 2004 and 2005, diabetic foot hospital discharges increased by 10%, and the number of amputations increased to 4%.11-13

The Encuesta Nacional de Salud y Nutrición in 2012 reported that, of the total number of individuals with a previous diagnosis of DM, 47.6% (3 million) reported burning, pain, or loss of sensation in the feet, and 2% (128,000) reported amputations.14

The Organization for Economic Co-operation and Development (OECD) includes lower limb amputations in the indicators of quality of care of patients with DM.15,16

A lower limb amputation may be major or minor, depending on the site of amputation. Although there is no international standard definition, the definition that appears most frequently and recently published in the literature defines amputation proximal to the ankle joint as major and amputation distal to the ankle joint as minor.17,18

The OECD considers that a minor lower limb amputation reflects better quality of care compared to a major amputation; therefore, it is important to analyze the two types of amputations separately, as this can provide us with more accurate data on the quality of care of patients with DM with these complications.

The aim of the study was to describe the rate of lower extremity amputations (major and minor) in subjects with DM enrolled at Instituto Mexicano del Seguro Social (IMSS), during the years 2004 and 2013.

Methods

A comparative cross-sectional study was conducted in subjects diagnosed with DM, identified through the Sistema de Información de Atención Integral de la Salud and hospital records from the IMSS Medical Statistics System (DataMart).

As the denominator of the lower limb amputation index, researchers used the count of subjects diagnosed with DM enrolled in Family Medicine (ICD-10: E10-E14) obtained from the Sistema de Atención Integral de la Salud.

Subjects with major and minor amputations were identified through hospital records of the Medical Statistics System (DataMart) (ICD-9: 8415-8419 and ICD-9: 8410-8414, respectively), excluding traumatic causes of amputations (ICD-10: S77, S78, S87, S88, S98, T053, T055, and T136) and obtaining the age at amputation.

The rate of major and minor amputations of lower extremities was calculated for each of the 35 delegations of IMSS and expressed as the number of subjects with amputations per 100,000 subjects diagnosed with DM enrolled in Family Medicine.

The average age at amputation was calculated for each of the 35 delegations of IMSS.

To compare rates of major and minor amputations, and their average ages between 2004 and 2013, p-values were calculated, using Chi-squared test for the rates, and Student’s t-test for average ages. A p-value of < 0.05 was considered statistically significant.

Results

The total number of subjects with DM assigned to Family Medicine was 2,334,340 in 2004 and 3,416,643 in 2013. With respect to major amputations of lower limbs, the number was 2356 and 3774 for the years 2004 and 2013, respectively; while the numbers of subjects with minor amputations were 3940 and 5551, respectively (Table I).


Table I Count of subjects with diabetes mellitus and major and minor lower extremity amputations, by delegation of the Instituto Mexicano del Seguro, comparing 2004 and 2013
Delegation Subjects with diabetes
(n)
Subjects with major amputations (n) Subjects with minor amputations (n)

Year
2004

Year
2013
Year
2004
Year
2013
Year
2004
Year
2013
National 2,334,340 3,416,643 2,356 3,774 3,940 5,551
Aguascalientes 28,310 45,043 6 27 25 52
Baja California 64,697 123,203 74 181 123 247
Baja California Sur 13,915 22,698 15 48 35 48
Campeche 14,793 26,434 22 41 48 62
Coahuila 118,378 165,513 114 304 269 310
Colima 14,357 24,134 34 16 69 58
Chiapas 27,871 43,088 14 29 59 46
Chihuahua 98,602 148,612 76 165 144 245
Durango 40,713 60,206 34 93 55 119
Guanajuato 104,516 140,967 85 120 144 195
Guerrero 34,461 59,795 25 23 35 82
Hidalgo 32,365 48,380 42 52 44 65
Jalisco 165,728 232,882 164 234 274 428
Mexico East 197,710 290,270 119 163 210 315
Mexico West 75,205 116,206 57 115 70 115
Michoacán 51,474 82,666 42 79 89 127
Morelos 35,267 55,579 15 45 48 42
Nayarit 21,266 30,083 30 39 66 65
Nuevo León 183,755 262,254 361 350 440 449
Oaxaca 20,304 32,981 15 42 64 56
Puebla 77,989 113,324 64 121 76 191
Querétaro 33,288 56,188 28 43 43 42
Quintana Roo 19,430 36,700 20 66 59 93
San Luis Potosí 54,442 85,391 31 56 75 119
Sinaloa 77,921 115,935 55 171 168 218
Sonora 67,070 103,034 73 175 134 235
Tabasco 20,110 34,156 27 29 43 72
Tamaulipas 101,243 132,251 120 226 226 334
Tlaxcala 14,074 20,696 11 10 28 46
Veracruz North 75,634 118,700 114 143 151 181
Veracruz South 65,896 90,815 56 129 114 270
Yucatán 63,997 87,239 87 75 78 154
Zacatecas 21,730 29,340 10 22 17 36
Mexico City North 146,024 163,019 170 155 256 268
Mexico  City South 151,805 218,861 146 187 161 166

The average age at amputation during 2004 was 61.7 years for minor amputations, and 65.6 years for major amputations. These averages were very similar for 2013 (61.7 years, p = 0.068 and 65.4 years, p = 0.817, respectively) (Tables II and III).


Table II Age and rate of major lower extremity amputation in subjects with DM, by delegation of the Instituto Mexicano del Seguro, comparing 2004 and 2013
Delegation Age of subjects with major lower extremity amputation (average) Rate of major lower extremity amputation (x 100,000 subjects with diabetes)
Year 2004 Year 2013 p Year 2004 Year 2013 p
National 65.6 65.4 0.817 100.9 111.1 0.001*
Aguascalientes 69.3 63.6 0.129 21.2 60.5 0.019*
Baja California 64.6 64.7 0.918 114.4 148.0 0.075
Baja California Sur 61.5 65.6 0.260 107.8 212.9 0.02*
Campeche 68.9 64.0 0.133 148.7 156.0 1.000
Coahuila 63.3 64.5 0.480 96.3 184.8 < 0.001*
Colima 70.0 68.1 0.607 236.8 66.6 < 0.001*
Chiapas 65.6 67.7 0.576 50.2 67.8 0.436
Chihuahua 64.4 64.8 0.834 77.1 111.2 0.008*
Durango 64.7 66.0 0.795 83.5 155.8 0.002*
Guanajuato 63.6 64.9 0.574 81.3 85.8 0.402
Guerrero 68.8 64.9 0.225 72.5 38.7 0.035*
Hidalgo 63.8 68.9 0.104 129.8 108.1 0.400
Jalisco 66.3 66.8 0.723 99.0 101.2 0.919
Mexico East 65.0 66.0 0.873 60.2 56.5 0.585
Mexico West 65.6 61.7 0.115 75.8 99.6 0.102
Michoacán 69.8 65.8 0.175 81.6 96.2 0.455
Morelos 71.7 63.5 0.034* 42.5 81.4 0.033*
Nayarit 70.2 66.5 0.246 141.1 130.3 0.716
Nuevo León 65.1 65.7 0.478 196.5 134.2 <0.001*
Oaxaca 70.9 65.8 0.107 73.9 127.8 0.076
Puebla 65.3 65.4 0.799 82.1 107.5 0.099
Querétaro 68.4 63.5 0.084 84.1 76.9 0.713
Quintana Roo 60.3 61.4 0.616 102.9 180.8 0.031*
San Luis Potosí 65.2 65.2 0.388 56.9 66.2 0.583
Sinaloa 66.3 68.1 0.280 70.6 148.4 < 0.001*
Sonora 66.2 67.6 0.972 108.8 171.0 0.001*
Tabasco 67.0 63.0 0.223 134.3 85.3 0.096
Tamaulipas 66.0 62.7 0.005* 118.5 171.6 0.001*
Tlaxcala 70.1 65.9 0.397 78.2 48.6 0.275
Veracruz North 67.6 66.6 0.106 150.7 121.1 0.084
Veracruz South 66.5 67.2 0.994 85.0 142.8 0.001*
Yucatán 64.6 68.2 0.066 135.9 86.5 0.004*
Zacatecas 64.2 64.9 0.680 46.0 75.6 0.215
Mexico City North 65.6 64.7 0.249 116.4 95.5 0.075
Mexico City South 64.8 65.4 0.817 96.2 85.9 0.290
P-value by Chi-squared test and Student's t for rate of major lower extremity amputations and average ages, respectively.
*P < 0.05

Table III Age and rate of minor lower extremity amputation in subjects with DM, by delegation of the Instituto Mexicano del Seguro, comparing 2004 and 2013
Delegation Age of subjects with minor lower extremity amputation (average) Rate of minor lower extremity amputation (x 100,000 subjects with diabetes)
Year 2004 Year 2013 p Year 2004 Year 2013 p
National 61.7 61.7 0.068 168.8 162.5 0.069
Aguascalientes 61.8 59.5 0.252 88.3 115.4 0.293
Baja California 60.8 61.3 0.869 190.1 200.5 0.662
Baja California Sur 63.2 62.3 0.453 251.5 211.5 0.431
Campeche 63.5 59.5 0.088 324.5 234.5 0.092
Coahuila 62.1 60.9 0.162 227.2 187.3 0.023*
Colima 64.8 61.1 0.080 480.6 240.3 < 0.001*
Chiapas 62.2 64.1 0.173 211.7 106.8 0.001*
Chihuahua 59.5 61.0 0.628 146.0 164.9 0.255
Durango 59.5 62.5 0.104 135.1 197.7 0.02*
Guanajuato 61.1 63.4 0.213 137.8 138.3 1.000
Guerrero 63.8 65.1 0.955 101.6 137.1 0.150
Hidalgo 64.8 63.1 0.540 135.9 134.4 1.000
Jalisco 62.6 60.3 0.004* 165.3 183.8 0.180
Mexico East 62.0 60.7 0.239 106.2 108.5 0.824
Mexico West 59.9 59.8 0.738 93.1 99.0 0.707
Michoacán 64.1 63.5 0.738 172.9 153.6 0.401
Morelos 67.3 63.7 0.080 136.1 75.6 0.007*
Nayarit 62.4 65.4 0.124 310.4 216.1 0.041*
Nuevo León 60.2 61.2 0.319 239.4 171.2 < 0.001*
Oaxaca 64.2 63.3 0.493 315.2 169.8 0.001*
Puebla 62.8 62.3 0.657 97.4 168.5 < 0.001*
Querétaro 60.0 59.1 0.462 129.2 74.7 0.013*
Quintana Roo 58.9 59.8 0.692 303.7 253.4 0.306
San Luis Potosí 62.4 61.7 0.466 137.8 139.4 1.000
Sinaloa 62.7 63.6 0.533 215.6 188.0 0.194
Sonora 63.0 61.6 0.128 199.8 228.1 0.241
Tabasco 59.8 58.7 0.506 213.8 210.8 0.923
Tamaulipas 61.4 60.4 0.073 223.2 252.6 0.159
Tlaxcala 62.8 65.2 0.291 198.9 222.3 0.723
Veracruz North 63.0 61.6 0.177 199.6 152.5 0.015*
Veracruz South 62.1 62.6 0.909 173.0 297.3 < 0.001*
Yucatán 62.1 63.5 0.563 121.9 176.5 0.008*
Zacatecas 62.2 60.8 0.605 78.2 122.7 0.129
Mexico City North 60.6 62.0 0.655 175.3 164.4 0.484
Mexico City South 61.3 62.2 0.929 106.1 75.8 0.003*
P-value by Chi-squared test and Student's t for rate of major lower extremity amputations and average ages, respectively.
*P < 0.05

The rate of major amputations of lower limbs had a value of 100.9 x 100,000 subjects with DM in 2004, and 111.1 x 100,000 subjects with DM in 2013 (p = 0.001); on the other hand, the rate of minor lower limb amputations had similar values ​​in the years mentioned (168.8 and 162.5 x 100,000 subjects with DM in 2004 and 2013, respectively, p = 0.069) (Tables II and III).

The delegations Mexico East, Nuevo Leon, Jalisco, Mexico City South, Mexico City North, and Coahuila had a greater number of subjects with DM enrolled in Family Medicine (over 140,000 in 2004 and over 150,000 in 2013).

Regarding the rate of major lower extremity amputations, the delegations of Baja California Sur, Coahuila, Quintana Roo, Tamaulipas, Sonora, Campeche, and Durango had the highest values ​​in 2013; while Veracruz North, Nuevo Leon, and Colima delegations presented the highest rates in 2004 (above 150 x 100,000 subjects with DM enrolled in Family Medicine). Sinaloa and Coahuila presented the most significant increases in the index, while Colima and Nuevo Leon had the most significant decreases (Table II, Figure 1).


Figure 1 Distribution of the index of lower limb amputations x 100,000 patients with diabetes, in the delegations of the Instituto Mexicano del Seguro Social, comparing 2004 and 2013. The upper figures correspond to the rate of major lower extremity amputations, while the lower figures correspond to the rate of minor amputations


For minor lower extremity amputations, Quintana Roo, Nayarit, Oaxaca, Campeche, and Colima presented the highest values ​​in 2004, while in 2013, these places were for Veracruz South, Quintana Roo, and Tamaulipas (above 250 x 100,000 subjects with DM enrolled in Family Medicine). Southern Veracruz and Puebla had the most significant increases in this index, while Puebla and Nuevo Leon presented the most significant decreases (Table III, Figure 1).

Discussion

Approximately 40 to 85% of lower extremity amputations are performed in subjects with DM; of these, 85% are preceded by ulceration of the foot.1 It has already been mentioned that DM is the leading cause of non-traumatic lower limb amputations, being responsible for approximately 50% of these.2 This problem may be accentuated in the future, since the incidence of DM is on the rise in developing countries, probably due to changes in eating habits and sedentary lifestyle. This, plus the extension of life expectancy with the consequent aging of the population, will inevitably increase the prevalence of diabetes and its chronic complications.19

Lower extremity amputations are 15 times more common in patients with diabetes than in the general population, and the risk increases with age: in patients > 65 years it is 7 times greater than in those < 45 years.20 Our study found that the average age for both minor and major amputations ranged between 60 and 70 years, coinciding with the information reported.

The increased number of amputations from 2004 to 2013 can be explained because DM had an increased prevalence from 7.5% in 2000 to 9.2% at the national level, as reported in 2012 by the Encuestas Nacionales de Salud y Nutrición.14

In the United States (US) Lavery et al. have identified a much higher prevalence of DM-related amputations in Latinos (82.7%) compared to African-Americans (61.6%) and non-Latino whites (56.8%).21

Lower limb amputation is a complication and a marker of quality of care in patients with DM. Rates of lower limb amputation vary in different communities;16 the annual incidence of lower limb amputations in patients with diabetes in England and the US were 450 and 250/100,000 people with DM, respectively, in the year 2008.22

In relation to the latest report from the OECD on the indicator of lower limb amputation (Figure 2), we can see that the rate of amputations of lower limbs found in our study is very high compared to countries published in that report; although for 2004, Aguascalientes had a rate comparable with Denmark (21.2), in 2013 all delegations had much higher rates than those reported by the OECD in 2009.23


Figure 2 Comparison of the rate of major lower limb amputation x 100,000 subjects in Instituto Mexicano del Seguro Social and member countries of the Organisation for Economic Co-operation and Development (OECD)23


Globally, studies have shown that reducing the risk of amputation in patients with DM reflects better metabolic control, as well as a systematic and routine review of the feet, so it is essential to prevent foot disorders in people with DM and consequently the risk of amputations; efforts must focus on educating the patient and family about foot care.24

This exam should not be dominion of doctors, but the whole health team should be able to do it and prescribe measures and health care that the patient and his family should perform; as well as early detection and timely referral of any irregularity to a specialist.25

Patient education and the use of proper footwear are cost-effective measures to decrease the development of ulcers and amputations by 25-50%.26-28

Acknowledgments

We thank the IMSS Foundation, A.C., especially Patricia Guerra Menéndez, for their invaluable support in the creation of this work.

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Conflict of Interest Statement: The authors declared that there is no personal or institutional conflict of interest of a professional, financial, or commercial nature, during the planning, execution, writing of this article.

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