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Changes in the Incidence of Lower
Extremity Amputations in Individuals With
and Without Diabetes in England Between
2004 and 2008
ESZTER P. VAMOS,
MD, PHD
1
ALEX BOTTLE,
MSC, PHD
1
MICHAEL E. EDMONDS,
FRCP
2
JONATHAN VALABHJI,
MD, FRCP
3
AZEEM MAJEED,
MD, FRCGP
1
CHRISTOPHER MILLETT,
PHD, FFPH
1
OBJECTIVE — To describe recent trends in the incidence of nontraumatic amputations
among individuals with and without diabetes and estimate the relative risk of amputations
among individuals with diabetes in England.
RESEARCH DESIGN AND METHODS — We identified all patients aged ⬎16 years
who underwent any nontraumatic amputation in England between 2004 and 2008 using na-
tional hospital activity data from all National Health Service hospitals. Age- and sex-specific
incidence rates were calculated using the total diabetes population in England every year. To test
for time trend, we fitted Poisson regression models.
RESULTS — The absolute number of diabetes-related amputations increased by 14.7%, and
the incidence decreased by 9.1%, from 27.5 to 25.0 per 10,000 people with diabetes, during the
study period (P⬎0.2 for both). The incidence of minor and major amputations did not
significantly change (15.7–14.9 and 11.8–10.2 per 10,000 people with diabetes; P⫽0.66 and
P⫽0.29, respectively). Poisson regression analysis showed no statistically significant change in
diabetes-related amputation incidence over time (0.98 decrease per year [95% CI 0.93–1.02];
P⫽0.12). Nondiabetes-related amputation incidence decreased from 13.6 to 11.9 per 100,000
people without diabetes (0.97 decrease by year [0.93–1.00]; P⫽0.059). The relative risk of an
individual with diabetes undergoing a lower extremity amputation was 20.3 in 2004 and 21.2 in
2008, compared with that of individuals without diabetes.
CONCLUSIONS — This national study suggests that the overall population burden of am-
putations increased in people with diabetes at a time when the number and incidence of ampu-
tations decreased in the aging nondiabetic population.
Diabetes Care 33:2592–2597, 2010
D
iabetic foot lesions remain a consid-
erable cause of morbidity and a
leading cause of hospitalization in
people with diabetes (1). Despite inten-
sive interventions, many of these patients
require a lower extremity amputation
(LEA), with high social impact and poor
clinical prognosis for the patients, as well
as considerable financial implications for
health care systems (2).
The number of people diagnosed as
having diabetes has more than doubled
over the last 10 years in England (3). As
the prevalence of diabetes increases due
to an aging population and an increasing
rate of obesity, an increase in the number
of amputations is to be expected. We have
recently reported that whereas the num-
ber of type 1 diabetes- and nondiabetes-
related LEAs decreased in England
between 1996 and 2005, there was a con-
sistent upward trend in type 2 diabetes-
related procedures (4). However, because
of the lack of accurate information on di-
abetes prevalence, particularly for the
early years of this period, we were unable
to calculate diabetes-specific LEA inci-
dence in England.
During the last decade, several initia-
tives have been undertaken in England to
improve diabetes management across pri-
mary, community, and secondary care
settings and specialist services (5,6). Cor-
responding with many studies from Eu-
rope and the U.S., a series of regional
studies and centers highly specialized in
diabetic foot care have shown significant
decline in the incidence of LEAs after spe-
cific interventions were instituted (7–13).
Others reported unchanged incidence of
amputations in people with diabetes de-
spite increasing vascular intervention
rates (14–16). However, most studies re-
port incidence rates from single centers
and small geographical areas, and these
data are unlikely to reflect national trends.
Furthermore, the relative risk of amputa-
tions in diabetes has been rarely studied,
particularly in larger geographical areas
or nationally.
The objective of this study was to as-
sess trends in nontraumatic LEAs among
people aged ⬎17 years with and without
diabetes between financial years 2004–
2005 and 2008 –2009 using national hos-
pital admission data from all National
Health Service (NHS) hospitals in En-
gland. We describe diabetes- and nondia-
betes-related incidence rates and assess
the relative risk of people with diabetes
undergoing a nontraumatic LEA (minor,
major, and any) compared with those
without diabetes in England.
RESEARCH DESIGN AND
METHODS — We examined Hospital
Episode Statistics (HES) between the fi-
nancial years 2004–2005 and 2008 –
2009 for all NHS hospital trusts in
England. The HES dataset covers all inpa-
tient hospital activity and day case admis-
sions to NHS (public) hospitals across
England including private patients
treated in NHS hospitals. Surgical inter-
●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●●
From the
1
Department of Primary Care and Public Health, Imperial College London, London, U.K.; the
2
Diabetic Foot Clinic, King’s College Hospital, London, U.K.; and the
3
Department of Diabetes and
Endocrinology, St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, U.K.
Corresponding author: Eszter P. Vamos, e.vamos@imperial.ac.uk.
Received 24 May 2010 and accepted 3 September 2010. Published ahead of print at http://care.
diabetesjournals.org on 10 September 2010. DOI: 10.2337/dc10-0989.
© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly
cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.
org/licenses/by-nc-nd/3.0/ for details.
The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby
marked “advertisement” in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.
Epidemiology/Health Services Research
ORIGINAL ARTICLE
2592 DIABETES CARE,VOLUME 33, NUMBER 12, DECEMBER 2010 care.diabetesjournals.org
ventions were defined using the Office of
Population Censuses and Surveys’ Classi-
fication of Surgical Operations (OPCS4)
codes that contains up to 12 procedure
fields. Data extracted for each hospital ad-
mission include patient demographics
(age and sex), length of hospital stay,
principal diagnosis, and up to 13 second-
ary diagnoses coded using the ICD-10.
All patients who underwent any LEA
between financial years 2004–2005 and
2008–2009 were identified through hav-
ing the procedure code for LEA in any
procedure field. Different amputation
codes during the same hospitalization on
the same limb were assigned as a single
procedure on the highest level. A con-
tralateral limb amputation during the
same admission was counted as a separate
amputation. Side and level of LEA were
recorded for each procedure (Z942 indi-
cates the right side and Z943 the left). A
minor amputation was defined as any
LEA distal to the ankle joint (OPCS4
codes X11.1, X11.2, X11.8, and X11.9); a
major amputation was defined as any LEA
through or proximal to the ankle joint
(OPCS4 codes X09.2–5, X09.9, X10.1– 4,
and X10.8–9). All traumatic LEAs, de-
fined by any trauma-related code of the
lower extremity in any diagnosis field
(S70–99, T00 –35, Wxx, and Xxx), were
excluded from our analysis. Diabetes sta-
tus was classified as no diabetes or type 1
or type 2 diabetes (ICD-10 code E10–
E11) codes recorded in any diagnosis
field. Other forms of diabetes (ICD-10
E12–E14) were excluded.
When age-, sex-, and diabetes-
specific LEAs were examined in patients
with multiple admissions during the same
financial year, only first admissions were
used to derive patient characteristics. We
used a combination of date of birth, sex,
and full postcode to distinguish patients,
as these were the only identifiers available
for all years in this study.
Data on the number of people aged
⬎17 years having a diagnosis of diabetes
in England were obtained from the Qual-
ity Management and Analysis System
(QMAS) for each study year (5). QMAS is
the financial database for the Quality and
Outcomes Framework (QOF), a national
pay for performance scheme for primary
care practices introduced in April 2004,
and contains diabetes counts and preva-
lence data for virtually all (⬎99%) family
practices in England (5). For 2004–2005
and 2005–2006, when diabetes figures
were available for the total population, we
calculated diabetes prevalence for pa-
tients aged ⱖ17 years for both years, us-
ing the age- and sex-standardized
diabetes prevalence in children and
young adults reported by the Royal Col-
lege of Pediatrics and Child Health (17).
Diabetes-specific incidence rates were ex-
pressed per 10,000 people with diabetes.
Data for the age and sex distribution of
individuals with diabetes were obtained
from the Health Survey for England 2006
(3). When age- and sex-specific preva-
lence rates of known diabetes were calcu-
lated for the general population of
England, we assumed that the age and sex
distribution of the diabetic population re-
mained constant between 2004 and
2008. The estimated resident population
of England was used to calculate inci-
dence of amputations in individuals with-
out diabetes for each year and incidence
rates are expressed per 100,000 people
without diabetes.
Ethical approval
We have Section 251 approval from the
National Information Governance Board
for Health and Social Care (formerly
Section 60 approval from the Patient
Information Advisory Group) to hold
confidential data and analyze them for re-
search purposes. We also have approval
from the South East Research Ethics
Committee.
Statistical analysis
Statistical analyses were performed using
the Stata statistical package. Median
lengths of stay were compared by type of
LEA and diabetes status with the Brown-
Forsythe test (18). To test time trends in
LEA rates, we fitted separate Poisson re-
gression models for patients with and
without diabetes, using age, sex, and level
of amputation as independent variables.
We estimated relative risk of an individual
with diabetes undergoing a LEA (minor,
major, and any) compared with that of an
individual without diabetes.
RESULTS — Over the study period be-
tween 2004 and 2008, there were 49,487
nontraumatic LEAs performed on 45,424
patients in England. Of all amputations,
51% occurred among people with diabe-
tes (59.6% of minor and 42.6% of major
LEAs). There was a considerable male ex-
cess of LEAs among people with diabetes
with the male-to-female ratio being nearly
twice that of people without diabetes
(male-to-female ratio diabetes 2.7 [95%
CI 1.7–3.7] and nondiabetes 1.4 [0.8–
2.1]). Most LEAs occurred in individuals
aged ⬎65 years (60.4% of diabetes-
related and 68.3% of nondiabetes-related
LEAs). Minor amputations were more
common than major LEAs in individuals
with diabetes, whereas there was a pre-
dominance of major LEAs in individuals
without diabetes (minor-to-major ratio
for diabetes 1.4 [1.2–1.7] and for nondia-
betes 0.7 [0.6– 0.8]).
Diabetes-related amputations
Between 2004 and 2008, the number of
patients who underwent an amputation
and the number of amputations per-
formed increased significantly among in-
dividuals with diabetes in England (Table
1). Overall amputation incidence rates
(minor and major combined) decreased
by 9.1%, from 27.5 per 10,000 people
with diabetes in 2004 to 25.0 per 10,000
people with diabetes in 2008. During the
study period, the incidence of minor
LEAs (15.7 to 14.9 per 10,000 people
with diabetes; P⫽0.66) and major LEA
rates (11.8 to 10.2 per 10,000 people
with diabetes; P⫽0.29) decreased
slightly, but this decrease did not reach
statistical significance (Fig. 1A). Inci-
dence of LEAs was significantly higher
among men than among women with di-
abetes (P⬍0.001). However, changes in
overall LEA rates did not significantly dif-
fer between men and women (19.9 to
18.3 vs. 7.6 to 6.7 per 10,000 people with
diabetes; P⫽0.81) (Fig. 2). When strat-
ified by age, the incidence was the highest
among individuals aged ⬎65 years in
both men and women (Fig. 2). Poisson
regression analysis showed no significant
decrease in incidence of amputations after
adjustment for age, sex, year, and level of
amputation (0.98 decrease per year [95%
CI 0.93–1.02]; P⫽0.12).
Nondiabetes-related amputations
The number of people without diabetes
who underwent a LEA and the number
of amputations performed decreased dur-
ing the study period. Although the per-
centage of men undergoing minor
amputations increased significantly, male
predominance was not evident among
minor amputees (Table 1). Amputation
incidence (minor and major combined)
decreased from 13.6 per 100,000 people
without diabetes in 2004 to 11.9 per
100,000 people without diabetes in 2008.
Incidence of minor LEAs decreased sig-
nificantly from 5.9 to 5.0 per 100,000
people without diabetes (P⫽0.01).
There was a nonsignificant reduction in
the incidence of major LEAs among indi-
Vamos and Associates
care.diabetesjournals.org DIABETES CARE,VOLUME 33, NUMBER 12, DECEMBER 2010 2593
viduals without diabetes, from 7.7 to 6.9
per 100,000 people (P⫽0.39) (Fig. 1B).
The fall in LEA rates was achieved be-
tween 2004 and 2006, and incidence
rates remained constant afterward for
both minor and major procedures. Inci-
dence of LEAs declined among both men
and women (Fig. 2). Of all decreases, 76%
have been achieved through a reduction
in LEAs in people aged ⬎65 years (Fig. 2).
Poisson regression analysis showed that
the decline in nondiabetes-related LEAs
was marginally significant after adjust-
ment for age, sex, level of amputation,
and year (0.97 decrease by year [95% CI
0.93–1.00], P⫽0.059).
Relative risk of amputations
The risk of an individual with diabetes
undergoing a LEA was 20.3 times that of
an individual without diabetes in 2004
and did not significantly change by 2008
(P⫽0.317) (Table 2).
CONCLUSIONS — This nationwide
study was undertaken to quantify the in-
cidence and relative risk of nontraumatic
amputations in people with and without
diabetes between 2004 and 2008 in En-
gland. Our results indicate an increasing
number of procedures and a nonstatisti-
cally significant decline in the incidence
of amputations in people with diabetes.
Over the study period, the incidence of
diabetes-related amputations decreased
by 9.1%, from 27.5 to 25.0 per 10,000
people with diabetes. In contrast, the
number and incidence of LEAs decreased
in individuals without diabetes, and this
decline was marginally significant in a re-
gression model. As expected, we found a
markedly increased risk of amputations
in individuals with diabetes compared
with those without diabetes.
In recent years, a series of studies have
reported decreasing incidence of amputa-
tions from the U.S. and Western Europe
(6,7,10–12). Regional studies identified
large geographical variations in periph-
eral vascular disease and amputation in-
cidence. In England, the lowest diabetes-
related amputation rates were recorded in
centers in Leicester and Ipswich (11.0 and
16.0 per 10,000 people with diabetes, re-
spectively) and considerably higher inci-
dence was identified in Middlesbrough
(44.6 per 10, 000 people with diabetes)
(13,19). Wide variations in the incidence
of diabetes-related LEAs have been re-
ported across nationwide studies from
Western Europe. In Germany, incidence
was reported as 40.2 and 17.4 per 10,000
people with diabetes in men and women,
respectively and in the Netherlands as 36
per 10,000 people with diabetes (7,10).
Several factors have been described that
might explain these differences, such as
differences in study methodology, esti-
mation of the denominator, prevalence of
diabetes, case mix, availability of foot
clinics, diabetes specialists, treatment
programs and resources, the treatment
approach of an expert team, and demo-
graphic and clinical confounding factors,
among others (20). Canavan et al. (9)
identified prominently high major LEA
incidence (56.4 per 10,000 people with
diabetes) in the South Tees area, which
was attributed to the gaps in knowledge
and incomplete foot care in individuals
with diabetes. This rate decreased to 17.6
per 10,000 people with diabetes during a
5-year period as a result of better orga-
nized diabetes care. Schofield et al. (6)
found decreasing amputation rates in
Tayside, Scotland, and suggested that bet-
ter control for cardiovascular risk factors
might partly explain this reduction.
During the last decade, there have
been substantial improvements in quality
of diabetes management in U.K. primary
care in response to a wide range of initia-
tives such as national treatment standards
for the management of major chronic dis-
eases (5,21). Despite these developments,
this study found no evidence that the di-
abetes-related amputation incidence has
significantly decreased over the last 5
years. Risk factor intervention studies
have failed to demonstrate reduction in
peripheral arterial disease-related clinical
end points (22). It is possible that inter-
ventions to address the surrogate end
points measured and rewarded as part of
QOF have not been shown to translate
into reductions in clinical peripheral arte-
rial disease-related end points.
The relative risk of amputation in
Table 1—Characteristics of amputees between the financial years 2004–2005 and 2008–2009 in England
Diabetes-related LEAs
Pvalue
Nondiabetes-related LEAs
Pvalue2004–2005 2008–2009 2004–2005 2008–2009
Minor amputations —
No. of amputations 2,768 3,289 2,266 1,966
Patient-to-amputation ratio 0.89 (0.88–0.91) 0.88 (0.86–0.90) 0.81 0.95 (0.94–0.97) 0.95 (0.93–0.97) 0.81
Sex, male 2,044 (73.8) 2,450 (74.5) 0.57 1,125 (49.6) 1,064 (54.1) 0.004
Age-group
16–44 years 167 (6.0) 204 (6.2) 0.85 198 (8.8) 152 (7.7) 0.42
45–64 years 1,045 (37.8) 1,248 (37.9) 524 (23.1) 481 (24.5)
ⱕ65 years 1,556 (56.2) 1,837 (55.8) 1,544 (68.1) 1,333 (67.7)
Hospital length of stay (days) 15 (7–30) 13 (6–25) 0.001 5 (2–19) 6 (1–21) 0.41
Major amputations
No. of amputations 2,084 2,277 2,963 2,731
Patient-to-amputation ratio (95% CI) 0.88 (0.86–0.90) 0.88 (0.85–0.9) 0.98 0.95 (0.92–0.97) 0.94 (0.93–0.96) 0.81
Sex, male 1,465 (70.2) 1,640 (72.0) 0.21 1,860 (62.8) 1,699 (62.2) 0.68
Age-group
16–44 years 73 (3.5) 83 (3.6) 0.48 222 (7.5) 247 (9.0) 0.48
45–64 years 628 (30.1) 663 (29.1) 654 (22.1) 614 (22.5)
ⱕ65 years 1,383 (66.4) 1,531 (67.2) 2,087 (70.4) 1,870 (68.5)
Hospital length of stay (days) 38 (22–69) 34 (20–59) ⬍0.001 32 (17–58) 28 (15–52) ⬍0.001
Data are ratio (95% CI), n(%), or median (interquartile range).
Lower extremity amputation trends in England
2594 DIABETES CARE,VOLUME 33, NUMBER 12, DECEMBER 2010 care.diabetesjournals.org
people with diabetes compared with
those without diabetes did not signifi-
cantly change over the study period in
England (20.5 in 2004 and 21.2 in 2008).
Previous reports from small geographic
areas showed large variations in relative
risk of amputations in England (from 7.7
to 31.6) (9,19). Nationwide studies from
other Western European countries also
reported varying relative risk of LEAs
(20.3 in the Netherlands and 7.4 in Ger-
many) (10,23).
When calculating diabetes-specific
incidence rates, we used the total number
of people with diabetes in England as de-
nominator, based on data from QMAS
(5). During the study period, the preva-
lence of diabetes increased from 4.4 to
5.2% in people aged ⱖ17 years in En-
gland (5,17). The modest reduction in di-
abetes-related amputation incidence
occurred between 2004 and 2006, and
LEA rates remained fairly constant after-
ward. A clear explanation for this finding
is lacking because the rise in the denom-
inator was steady over the study period;
therefore, it is not likely to explain this
trend. Furthermore, a similar pattern was
found in people without diabetes. It is
possible that an increased number of sub-
jects with shorter diabetes duration and
without complications in the diabetic
population might explain this finding (6).
To the best of our knowledge, this is
the first study to identify diabetes-related
amputation incidence using a national
sample that covers the entire population
of England. Previous reports have mostly
documented center-oriented or regional
information (8,9,13,19). The results of
these studies may not be generalizable be-
cause these centers might be highly spe-
cialized in diabetic foot care and have a
relatively small number of amputations.
Furthermore, the calculation of denomi-
nators may be flawed because of the po-
tential overlap between the catchment
areas of different institutions and patient
referrals from or to other centers. In con-
trast, denominator data for our survey
were derived from a comprehensive na-
tional database. These estimates are likely
to be robust, given that an estimated 99%
of the U.K. population are registered with
a family practitioner and nearly 100% of
practices participate in the pay for perfor-
mance scheme that incentivizes com-
pleteness of disease registers (5).
We were able to distinguish individ-
ual patients and therefore multiple hospi-
talizations using information on date of
birth, sex, and full postcode. Information
on laterality of amputations was also
available in this study with very high
completeness, enabling identification of
LEAs on different limbs during the same
admission, and these procedures could be
counted separately. Furthermore, we ex-
amined both minor and major amputations
and reported LEA incidence separately by
level of procedure and also included a non-
diabetes comparator (11,24).
Limitations have to be considered in
interpretation of our results. Because of
the lack of accurate data on the age- and
sex-specific prevalence of diabetes, we
used the stratum-specific prevalence data
from 2006, the mid-term of our study pe-
riod and had to assume that this informa-
tion remained constant between 2004
and 2008 (3). The increase in prevalence
of diabetes during the study period might
be partly explained by better ascertain-
ment and recording of diabetes after the
implementation of pay for performance in
2004. However, the increase was consis-
tent during the study period and most of
the improved ascertainment is likely to
have occurred immediately before the
study period as practices responded to the
incentives in QOF. We did not distin-
guish between type 1 and type 2 diabetes
because separate data on national preva-
lence of different types were not available.
Furthermore, we could not evaluate mis-
classification due to undiagnosed and un-
recorded cases of diabetes.
Although concerns about the accu-
racy of routinely collected datasets has
been raised, these data are continuously
Figure 1—Changes in minor and major amputation incidence rates in (A) individuals with
diabetes expressed per 10,000 people with diabetes and (B) individuals without diabetes expressed
per 100,000 people without diabetes.
Vamos and Associates
care.diabetesjournals.org DIABETES CARE,VOLUME 33, NUMBER 12, DECEMBER 2010 2595
audited and the quality and validity of this
dataset has been assessed and proved use-
ful for health research (25).
In summary, in this study we found
no evidence that the incidence of ampu-
tations has significantly decreased over
the last 5 years among people with diabe-
tes in England. In contrast to the results
from regional studies in England, the
population burden of amputations in-
creased in people with diabetes at a time
when both the number and incidence of
amputations decreased in the aging gen-
eral population. There is strong evidence
to support the fact that much of this bur-
den is preventable through existing inter-
ventions, and our findings highlight the
need to further improve foot care for peo-
ple with diabetes.
Acknowledgments— The research leading
to these results has received funding from the
European Community Seventh Framework
Programme FP7/2007-11 under grant agree-
ment 236336. A.B. and the Dr Foster Unit at
Imperial College London are largely funded by
Dr Foster Intelligence, an independent health
care information company. C.M. is funded by
the Higher Education Funding Council for En-
gland and the National Institute for Health Re-
search. The Department of Primary Care and
Public Health at Imperial College London ac-
knowledges support from the National Insti-
tute for Health Research Biomedical Research
Centre Scheme and the National Institute for
Health Research Collaboration for Leadership
in Applied Health Research and Care Scheme.
No potential conflicts of interest relevant to
this article were reported.
E.P.V. conceived the idea for the study, re-
searched data, and wrote the manuscript. A.B.
researched data and reviewed/edited the
manuscript. M.E.E., J.V., and A.M. contrib-
uted to discussion and reviewed/edited manu-
script. C.M. conceived the idea for the study
and wrote the manuscript.
Parts of this study were presented in ab-
stract form at the 46th annual meeting of the
European Association for the Study of Diabe-
tes, Stockholm, Sweden, 20–24 September
2010.
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