Diabetes-related major lower limb amputation incidence is strongly related to diabetic foot service provision and improves with enhancement of services: peer review of the South-West of England

Abstract

Aims: To investigate the relationship between high diabetes-related lower limb amputation incidence and foot care services in the South-West region of England.

Methods: The introduction of 10 key elements of foot care service provision in one area of the South-West resulted in stabilization of foot ulcer incidence and sustained reduction in amputation incidence from 2007. Services introduced included administrative support, standardized general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, availability of an orthotist and audit. Peer reviews of the region's diabetes foot care services were undertaken to assess delivery of these service provisions and compare this with major amputation incidence in other regions with data provided by Yorkshire and Humber Public Health Observatory Hospital Episode Statistics. Recommendations were made to improve service provision. In 2015 changes in service provision and amputation incidence were reviewed.

Results: Initial reviews in 2013 showed that the 3-year diabetes-related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R² =0.51). Repeat reviews in 2015 found that two or more foot care service improvements were reported by six diabetes foot care providers, with improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012-2015 and in the year 2015 only (P ≤0.0012, adjusted R² =0.56, and P= 0.0005, R² =0.62, respectively).

Conclusions: Major diabetes-related lower limb amputation incidence is significantly inversely correlated with foot care services provision. Introduction of more effective service provision resulted in significant reductions in major amputation incidence within 2 years. Failure to improve unsatisfactory service provision resulted in continued high amputation incidence.

Figure 1

Diabetes‐related foot ulcer prevalence and incidence, and major amputation incidence in the period 2005 to 2015 in South Devon as improved key services were introduced. Columns show service provision. Reduction in amputation over time, P=0.0115, z value= –2.526, residual deviance = 3.4 using a Poisson regression of log‐transformed number of major amputations with a right‐side offset of patient population by year using statistical software ‘R’.

Figure 2

Audit of case records and results of structured interviews.

Figure 3

Relationship between major diabetes related lower limb amputation incidence in the period 2009 to 2012 and diabetes foot care service provision in 2013. Amputation incidence and CIs were taken from Hospital Episodes Statistics data. Diabetes foot care service provision rated out of 10 at peer reviews. P =0.0024, adjusted R ² = 0.51, F‐statistic=14.6.

Figure 4

Relationship between major diabetes‐related lower limb amputation incidence in the period 2012 to 2015 and diabetes foot care service provision in 2015. Amputation incidence and CIs were taken from Hospital Episodes Statistics data. Diabetes foot care service provision rated out of 10 at peer reviews. P =0.0012, adjusted R ² = 0.56, F‐statistic=17.2.

Figure 5

Relationship between major diabetes‐related lower limb amputation incidence in 2015 and diabetes foot care service provision in 2015. Amputation incidences were taken from Hospital Episodes Statistics data and CIs were calculated from amputation numbers and diabetic populations in 2015. Diabetes foot care service provision rated out of 10 at peer reviews. P =0.0005, R ² = 0.62, F statistic 22.1.