Diabetes-related lower-limb amputations in Australia
Craig B Payne
MJA 2000; 173: 352-354
For editorial comment, see Colman & Beischer;
see also Campbell et al.
More articles on Endocrinology
Objective: To identify the prevalence of
diabetes-related lower-limb amputations and its regional
variations in Australia.|
Design and setting: Cross-sectional analysis of a
hospital morbidity dataset in Australia.
Methods: Analysis of the National Hospital Morbidity
Database of all hospital separations for the ICD codes 84.10-84.19
(lower-limb amputations) and 250.0-250.9 (diabetes and its
complications) for the financial years 1995-96 to 1997-98.
Main outcome measure: Number of lower-limb amputations
in people with diabetes mellitus in Australia, and in each State and
Results: 7887 diabetes-related lower-limb amputations
were reported during the study period, with a mean ± SD of 2629 ± 47 per
year. The prevalence in Australia was 13.97 per 100 000 total
population, and varied from 11.34 per 100 000 in the Australian
Capital Territory to 20.68 per 100 000 in South Australia.
Conclusion: Diabetes-related lower-limb amputation
poses a substantial personal and public health cost in
The loss of a limb is a frequent complication of diabetes mellitus,
most commonly the result of diabetic foot problems such as ulcers and
infection. The risk of amputation of the lower limb is increased up to
15-fold in people with diabetes. Contributory factors include the
loss of sensation from the sensory neuropathy; deformity and gait
abnormalities from the motor neuropathy; abnormal blood flow
regulation from the autonomic neuropathy; ischaemia from the
macrovascular disease; limited joint mobility from the increased
glycolation of collagen; poor glycaemic control; and increased risk
of infection. It is usually some trigger or traumatic event
superimposed on these risk factors that causes a lesion such as
ulceration or infection which starts a pathway leading to
amputation.2,3 Inadequate and
inappropriate self-care is also a major factor.
The National Diabetic Foot Disease Management Program, as part of the
National Diabetes Strategy and Implementation Plan,4 has called for a
50% reduction in lower-limb amputations by the year 2005. Data on
diabetes-related lower-limb amputations in Australia are
lacking.4 The aim of my study was to
identify the prevalence of diabetes-related lower-limb
amputations in Australia, as well as variations among States and
Approval for the study was given by the Faculty of Health Sciences
Human Ethics Committee at La Trobe University (Victoria).
The dataset for my analysis was obtained from the Australian
Institute of Health and Welfare (AIHW) for the financial years
1995-96, 1996-97 and 1997-98. The AIHW obtained permission from the
relevant State and Territory agencies to release the information,
which did not include any personal identifying data. Information was
obtained from the National Hospital Morbidity Database (compiled by
the AIHW) on all separations from public and private hospitals in
Australia for the International Classification of Disease
(ICD)5 procedure codes 84.10 to
84.19 (amputations of the lower extremity) and diagnosis codes 250.0
to 250.9 (indicating diabetes and its complications) as the
principal or secondary diagnoses. Information was also obtained on
sex, age, ethnicity, duration of hospital stay, and State or
Territory of residence of each patient who had an amputation. A
spreadsheet was used to determine the number of amputations in each
region and the duration of hospital stay. The data for each State and
Territory were age- and sex-standardised6 to the estimated Australian
population as at 30 June 1998.7 This information was then
used to determine the rate for each State and Territory.
A total of 7887 diabetes-related lower-limb amputations (68.2% in
men) were recorded as occurring in the three-year period, with an
annual mean of 2629 ± 47 (SD) (Box 1). Most occurred in the 65-79 years
age groups (Box 2). The age- and sex-standardised prevalence of
lower-limb amputation varied among the States and Territories (Box
3), from 11.34 per 100 000 total population in the Australian Capital
Territory to 20.68 per 100 000 total population in South Australia.
The duration of hospital stay (Box 3) also varied among the States and
Territories. The shortest mean hospital stay was 20.0 (95% CI,
17.4-22.6) days in South Australia and the longest was 40.2 (95% CI,
23.1-57.3) in the Northern Territory. It was not possible to analyse
the ethnicity data, as two States/Territories would not agree to the
release of this information.
The 2629 diabetes-related lower-limb amputations in Australia per
year represent a significant personal burden on people with diabetes
and on the healthcare system. The loss of a limb is a personal tragedy
for those with diabetes,8 and is associated with a
deterioration of functional status and residential
status,9 with a significant number
requiring long term care.10 People with diabetes who
have a lower-limb amputation have a higher mortality
perioperative mortality.12 Half the people with an
amputation will require an amputation of the remaining limb within
five years.13,14 This morbidity
results in high medical and rehabilitation costs: about 10% of
diabetes-related healthcare costs are associated with lower-limb
The sex differences in lower-limb amputation rates of about 2:1 for
men to women reported here are consistent with previous
reports,20 and may be related to the
levels of adherence to advice, the amount of social support,
psychological factors such as denial, or a higher prevalence of the
physiological risk factors for amputation such as macrovascular
disease.21 Ethnicity is a
well-recognised risk factor for lower-limb amputation,22,23 but was not
analysed in this project as two of the States/Territories would not
release this information.
The duration of hospital stay has been identified as one of the main
determinants of cost associated with a lower-limb
amputation.17 The mean number of
bed-days reported here (24.7 days) is less than the mean in the
Netherlands15 (42 days) and more than
that in the United States16 (15.9 days). There was a
large variation among the Australian States and Territories in the
mean hospital stay; South Australia has the highest prevalence of
lower-limb amputation, but the shortest mean stay. Regional
variations have been reported previously in New Zealand for hospital
admissions for diabetic foot complications.18 Such regional variations
are most likely to be due to variations in clinical practice and access
A number of shortcomings are inherent in the type of dataset analysed
here. Of primary concern is the accuracy of the recording of data.
Diabetes has been reported as being under-recorded on discharge
records,24,25 so the numbers
reported here are most likely an underestimate. There is also concern
that the dataset does not distinguish the number of multiple
amputations in the same individual; this will bias the population
towards the characteristics of these individuals.
A number of modifiable risk factors for diabetes-related lower-limb
amputation have been identified,26-28 including the
lowering of blood pressure, improving glycaemic control and
reducing or eliminating smoking. With proper foot care, patient
education and provision of appropriate services, such as regular
podiatric care, a reduction in the number of amputations can be
achieved.4 A number of studies have
shown the value of multidisciplinary teams in reducing amputations
by up to 50%.29-32 A reduction of this
magnitude has the potential to save up to $24 million (based on the
assumption that the direct cost of diabetes-related lower-limb
amputations in Australia is $48 million per year4). However, a
significant proportion of this potential saving will need to be
directed to programs to prevent the amputations.
Funding for this project was provided by the Australasian Podiatric
and Education Foundation.
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(Received 25 Nov 1999, accepted 20 Jul 2000)
Faculty of Health Sciences, La Trobe University, Melbourne, VIC.
Craig B Payne, DipPod(NZ), MPH, Lecturer, Department of
Reprints: Dr C B Payne, Department of Podiatry, School of
Human Biosciences, Faculty of Health Sciences, La Trobe University,
Bundoora, VIC 3083.
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|3: Age- and sex-standardised
prevalence and duration of hospital stay for lower-limb amputations in Australia
||Mean ±SD lower extremity
amputations per year
| Rate (95% CI) per
100000 total population
|New South Wales
Australian Capital Territory
||Duration of hospital stay
||Mean (95% CI) bed days
||Median (range) bed days
|New South Wales
Australian Capital Territory
| 18 (1-210)
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