Diabetes-related lower-limb amputations in Australia

Craig B Payne
Med J Aust 2000; 173 (7): 352-354.
Published online: 2 October 2000

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.

Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details
- - More articles on Endocrinology

Abstract 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 Territory.

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 Australia.

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 Territories.

Methods 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.

Results 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.

Discussion 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 rate,1,11 especially 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 amputations.15

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 to services.19

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)

Authors' details
Faculty of Health Sciences, La Trobe University, Melbourne, VIC.
Craig B Payne, DipPod(NZ), MPH, Lecturer, Department of Podiatry.

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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1: Number of diabetes-related lower-limb amputations in Australia
Men Women Total

Mean ±SD

1795 ±61

834 ±14 2629 ±47
Total 5382
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3: Age- and sex-standardised prevalence and duration of hospital stay for lower-limb amputations in Australia for 1995-1998
Mean ±SD lower extremity
amputations per year
Rate (95% CI) per
100000 total population

New South Wales
South Australia
Western Australia
Northern Territory
Australian Capital Territory
801 ±13
695 ±12
468 ±8
308 ±6
219 ±4
67 ±2
36 ±1
35 ±1
2629 ±47
12.59 (9.54-15.78)
14.87 (11.6-18.17)
13.48 (10.56-16.45)
20.68 (17.18-24.18)
11.89 (8.90-14.88)
14.21 (12.63-16.17)
18.86 (15.53-22.19)
11.34 (8.34-13.56)
13.97 (11.98-15.87)
Duration of hospital stay

Mean (95% CI) bed days Median (range) bed days

New South Wales
South Australia
Western Australia
Northern Territory
Australian Capital Territory
24 (23-26)
22 (21-23)
30 (28-33)
20 (17-23)
26 (22-29)
27 (19-35)
40 (23-57)
33 (18-47)
25 (24-26)
18 (1-210)
16 (1-183)
21 (1-283)
13.5 (1-176)
18 (1-183)
21 (1-197)
24 (1-224)
24 (1-223)
17 (1-283)
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Received 2 March 2024, accepted 2 March 2024

  • Craig B Payne



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