Incidence of Lower-limb Amputations in the Diabetic Compared to the Non-diabetic Population. Findings from Nationwide Insurance Data, Germany, 2005–2007

Abstract

Introduction: One major objective is to reduce the risk of lower limb amputation in diabetes mellitus. Nationwide data to incidences of amputations in the diabetic and non-diabetic populations in Germany as well as relative and attributable risks due to diabetes are lacking so far.

Material and Methods: Using data of a nationwide statutory health insurance (1.6 million members), we assessed all first non-traumatic lower-limb amputations between 2005 and 2007. We estimated sex-age-specific and standardized incidences of amputations in the diabetic and non-diabetic populations, and relative and attributable risks due to diabetes.

Results: Of all subjects with a first amputation in the study period 2005–2007 (n=994), 66% had diabetes, 76% were male, mean age (SD) was 67 (13) years. Incidences per 100 000 person years (standardized to the 2004 German population) in the diabetic and the non-diabetic populations: 176.5 (95% confidence interval 156.0–196.9) and 20.0 (17.0–23.1) in men, and 76.9 (61.9–91.8) and 13.4 (10.7–16.2) in women. Standardized relative risks: 8.8 (7.3–10.7) in men and 5.7 (4.3–7.6) in women. Attributable risks among exposed: 0.89 and 0.83 and population attributable risks 0.59 and 0.40, each in men and women, respectively.

Discussion: In our first German nationwide study, we found the relative risk of lower limb amputation in the diabetic compared to the non-diabetic to be lower than in earlier regional studies in Germany, supporting results of regional reductions of the excess amputation risk due to diabetes. A repetition of the study is warranted to further evaluate trends according to the St. Vincent goals.

Key words

lower-limb amputation incidence in the diabetic and non-diabetic population - relative and attributable risks due to diabetes - nationwide insurance data

References

• 1 American Diabetes Association . Standards of medical care for people with diabetes.  Diabetes Care. 1998;  21 ((S1)) S21-S32
• 2 Arnold-Wörner N, Holle R, Rathmann W. et al . The importance of specialist treatment, treatment satisfaction, and diabetes education for the compliance of subjects with type 2 diabetes. Results from a population-based survey.  Exp Clin Endocrinol Diabet. 2008;  116 123-128
• 3 Boulton AJM, van Houtum WH. The Diabetic Foot: Proceedings of the 5^th International Symposium on the Diabetic Foot, 9–12 May 2007, Noordwijkerhout, The Netherlands.  Diabet Metab Res Rev. 2008;  24 ((Issue 1))
• 4 Bramesfeld A, Grobe TG, Schwartz FW. Who is diagnosed as suffering from depression in the German statutory health care system? An analysis of health insurance data.  Eur J Epidemiol. 2007;  22 397-403
• 5 Bundesversicherungsamt . Disease Management Program (DMP) Diabetes mellitus. http://www.bundesversicherungsamt.de/cln_091/nn_1046648/de/dmp/dmp__node.html?__nnn=true , (downloaded: December 17, 2008)
• 6 Calle-Pascual ALC, Gracia-Torre N, Moraga I. et al . Epidemiology of nontraumatic lower-extremity amputations in area 7, Madrid, between 1989 and 1999.  Diabetes Care. 2001;  24 1686-1688
• 7 Diabetes care and research in Europe . The Saint Vincent Declaration. World Health Organization, ICP/CLR 034 1989
• 8 Eskelinen E, Eskelinen A, Alback A. et al . Major amputation incidence decreases both in non-diabetic and in diabetic patients in Helsinki.  Scand J Surg. 2006;  95 185-189
• 9 Heller G, Günster C, Schellschmidt H. Wie häufig sind Diabetes-bedingte Amputationen unterer Extremitäten in Deutschland? Eine Analyse auf Basis von Routinedaten.  Dtsch Med Wochenschr. 2004;  129 ((9)) 429-433
• 10 Hoffmann F, Jung TI, Felsenberg D. et al . Pattern of intravenous bisphosphonate use in outpatient care in Germany.  Pharmacoepidemiol Drug Saf. 2008;  17 896-903
• 11 Icks A, Moebus S, Feuersenger A. et al . Diabetes prevalence and association with social status-widening of a social gradient? German national health surveys 1990–92 and 1998.  Diabet Research Clin Practice. 2007;  78 293-297
• 12 Jeffcoate WJ. The incidence of amputation in diabetes.  Acta Chir Belg. 2005;  105 140-144
• 13 Köster I, von Ferber L, Ihle P. et al . The cost burden of diabetes mellitus: the evidence from Germany-the CoDiM Study.  Diabetologia. 2006;  9 1498-1504
• 14 Larsson J, Apelquist J, Agardh CD. et al . Dcreasing incidence of major amputation in diabetic patients: a consequence of a multidisciplinary foot care team approach?.  Diabetic Medicine. 1995;  12 770-776
• 15 Meisinger C, Heier M, Doering A. et al . Prevalence of known diabetes and antidiabetic therapy between 1984/1985 and 2000/2001 in Southern Germany.  Diabetologia. 2004;  27 2985-2987
• 16 Mielck A, Reitmeir P, Rathmann W. Knowledge about diabetes and participation in diabetes training courses: The need for improving health care for diabetes patients with low ses.  Exp Clin Endocrinol Diabet. 2006;  114 240-248
• 17 Morris AD, AcAlpine R, Steinke D. et al . for the DARTS/MEMO Collaboration. Diabetes and lower-limb amputations in the community.  Diabetes Care. 1998;  21 738-743
• 18 Most RS, Sinnock P. The epidemiology of lower extremity amputations in diabetic individuals.  Diabetes Care. 1983;  6 87-91
• 19 Patout  Jr  CA, Birke JA, Horswell R. et al . Cerise FP. Effectiveness of a comprehensive diabetes lower-extremity amputation prevention program in a predominantly low-income African-American population.  Diabetes Care. 2000;  23 1339-1342
• 20 Rathmann W, Haastert B, Icks A. et al . High prevalence of undiagnosed diabetes mellitus in Southern Germany: Target populations for efficient screening. The KORA survey 2000.  Diabetologia. 2003;  46 182-189
• 21 Rothman KJ. Modern Epidemiology. Boston, MA, Little Brown 1986
• 22 Schnee M. Socioeconomic structure and morbidity in statutory health insurances. In: Böcken J, Braun B, Amhof R. Health Monitor (Gesundheitsmonitor) 2008. Gütersloh, Bertelsmann 2008
• 23 The Global Lower Extremity Amputation (LEA) Study Group . Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia.  British Journal of Surgery. 2000;  87 328-337
• 24 Trautner C, Haastert B, Spraul M. et al . Unchanged incidence of lower-limb amputations in a German city, 1990–1998.  Diabetes Care. 2001;  24 855-859
• 25 Trautner C, Haastert B, Mauckner P. et al . Reduced incidence of lower-limb amputations in the diabetic population of a German city, 1990–2005. Results of the Leverkusen Amputation Reduction Study (LARS).  Diabetes Care. 2007;  30 2633-2637
• 26 Trautner C, Haastert B, Giani G. et al . Incidence of lower limb amputations and diabetes.  Diabetes Care. 1996;  19 1006-1009
• 27 Trautner C, Haastert B, Giani G, Berger M. Amputations and diabetes: A case control study.  Diabetic Medicine. 2002;  19 35-40
• 28 Van Houtu W, Rauwerda JA, Ruwaard D. et al . Reduction in diabetes-related lower-extremity amputations in the Netherlands: 1991–2000.  Diabetes Care. 2004;  27 1042-1046
• 29 von Ferber L, Köster I, Hauner H. Medical costs of diabetic complications total costs and excess costs by age and type of treatment results of the German CoDiM Study.  Exp Clin Endocrinol Diabetes. 2007;  115 97-104

Correspondence