DISCOURSE AND DIALOGUE
Letter to the Editor The Amputation Prevention Initiative To the Editor: In the January/February 2014 issue of JAPMA, the article entitled ‘‘The Amputation Prevention Initiative,’’ by Cook et al, reported that diabetic patients suffer more than 80,000 amputations per year. We were unable to verify this figure in the article referenced by the authors.1 Also, a recent query of the Healthcare Cost and Utilization Project’s online system for access to national statistics found a total of 62,119 limb amputations at the level of the ankle and proximal in 2011.2 The authors’ figure of 80,000 may refer to both toes and limbs. We agree with the authors’ conclusion that more research is needed on the appropriate level of care for diabetics to prevent amputation. Accurate measurement and description of the amputation problem diabetics potentially face is basic to that research. RONALD RENZI, DPM KATHLEEN WISE, RN Abington Memorial Hospital 2002 Woodland Rd, Abington PA 19001
References 1. GREGG EW, SORLIE P, PAULOSE-RAM R, ET AL: Prevalence of lower-extremity disease in the US adult population .¼40 years of age with and without diabetes: 1999–2000 national health and nutrition examination survey. Diabetes Care 27: 1591, 2004. 2. Healthcare Cost and Utilization Project. Available at: http://hcupnet.ahrq.gov/
Author’s Response To the Editor: We would like to thank all those interested in this manuscript. Just 3 months after our publication of ‘‘The Amputation Prevention Initiative,’’1 a publication from the New England Journal of Medicine coincidentally found that nontraumatic diabetesrelated amputation cases have fortunately declined
from 80,658 in 2000 to 73,067 in 2010.2 Our publication did not have this information available at that time.1 In regard to our introductory comment that 80,000 nontraumatic amputations were performed annually in diabetic patients in the year 2000, we were referencing the article ‘‘Association between renal failure and foot ulcer or lowerextremity amputation in patients with diabetes’’ by Margolis et al.3 Consistency across publications does help further verify the accuracy of the estimated 80,000 nontraumatic amputations from diabetes in the year 2000. Our Amputation Prevention Initiative group also agrees on and emphasizes the importance of delineating level of amputation. That is why we worked directly with the Massachusetts Department of Public Health to obtain the most accurate data available that divided amputations by level. We found that the age-adjusted rate of hospitalizations for lower-extremity amputation (LEA) among diabetic individuals was estimated to be 30.8 per 100,000 Massachusetts residents in 2004. Of these, 17% were midfoot amputations, 25% were major amputations (below or above knee), and 58% were digital amputations. As noted in our manuscript, these data were obtained from the Uniform Hospital Data Discharge System, which likely represents an underestimation of LEAs, as duplicates and misclassification may occur in 15% of cases and LEA coding misses between 4.2% and 8.7% of total amputations.1 Despite amputation rates declining, we believe there are still too many nontraumatic lower-limb amputations occurring from diabetes. While studies have found that multi-component interdisciplinary care teams using standardized guidelines have been effective in preventing LEAs, there are still numerous barriers that we face when trying to implement known prevention strategies. Our survey findings indicate that the quality of a lowerlimb examination is one important consideration that is often overlooked.1 We hope that the findings from this research, as well as the research from other groups, helps identify the most effective prevention measures that can be used for future
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amputation prevention efforts both in the US and globally. EMILY COOK, DPM, MPH Division of Podiatric Surgery, Mount Auburn Hospital Harvard Medical School 330 Mount Auburn St, Cambridge, MA 02138
102
References 1. COOK EA, COOK JJ, LABRE MP, ET AL: The amputation prevention initiative. JAPMA 104: 1, 2014. 2. GREGG EW, LI Y, WANG J, ET AL: Changes in diabetes-related complications in the United States, 1990–2010. N Engl J Med 370: 1514, 2014. 3. MARGOLIS DJ, HOFSTAD O, FELDMAN HI: Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care 31: 1331, 2008.
January/February 2015 Vol 105 No 1 Journal of the American Podiatric Medical Association
Letter to the Editor The Amputation Prevention Initiative To the Editor: In the January/February 2014 issue of JAPMA, the article entitled ‘‘The Amputation Prevention Initiative,’’ by Cook et al, reported that diabetic patients suffer more than 80,000 amputations per year. We were unable to verify this figure in the article referenced by the authors.1 Also, a recent query of the Healthcare Cost and Utilization Project’s online system for access to national statistics found a total of 62,119 limb amputations at the level of the ankle and proximal in 2011.2 The authors’ figure of 80,000 may refer to both toes and limbs. We agree with the authors’ conclusion that more research is needed on the appropriate level of care for diabetics to prevent amputation. Accurate measurement and description of the amputation problem diabetics potentially face is basic to that research. RONALD RENZI, DPM KATHLEEN WISE, RN Abington Memorial Hospital 2002 Woodland Rd, Abington PA 19001
References 1. GREGG EW, SORLIE P, PAULOSE-RAM R, ET AL: Prevalence of lower-extremity disease in the US adult population .¼40 years of age with and without diabetes: 1999–2000 national health and nutrition examination survey. Diabetes Care 27: 1591, 2004. 2. Healthcare Cost and Utilization Project. Available at: http://hcupnet.ahrq.gov/
Author’s Response To the Editor: We would like to thank all those interested in this manuscript. Just 3 months after our publication of ‘‘The Amputation Prevention Initiative,’’1 a publication from the New England Journal of Medicine coincidentally found that nontraumatic diabetesrelated amputation cases have fortunately declined
from 80,658 in 2000 to 73,067 in 2010.2 Our publication did not have this information available at that time.1 In regard to our introductory comment that 80,000 nontraumatic amputations were performed annually in diabetic patients in the year 2000, we were referencing the article ‘‘Association between renal failure and foot ulcer or lowerextremity amputation in patients with diabetes’’ by Margolis et al.3 Consistency across publications does help further verify the accuracy of the estimated 80,000 nontraumatic amputations from diabetes in the year 2000. Our Amputation Prevention Initiative group also agrees on and emphasizes the importance of delineating level of amputation. That is why we worked directly with the Massachusetts Department of Public Health to obtain the most accurate data available that divided amputations by level. We found that the age-adjusted rate of hospitalizations for lower-extremity amputation (LEA) among diabetic individuals was estimated to be 30.8 per 100,000 Massachusetts residents in 2004. Of these, 17% were midfoot amputations, 25% were major amputations (below or above knee), and 58% were digital amputations. As noted in our manuscript, these data were obtained from the Uniform Hospital Data Discharge System, which likely represents an underestimation of LEAs, as duplicates and misclassification may occur in 15% of cases and LEA coding misses between 4.2% and 8.7% of total amputations.1 Despite amputation rates declining, we believe there are still too many nontraumatic lower-limb amputations occurring from diabetes. While studies have found that multi-component interdisciplinary care teams using standardized guidelines have been effective in preventing LEAs, there are still numerous barriers that we face when trying to implement known prevention strategies. Our survey findings indicate that the quality of a lowerlimb examination is one important consideration that is often overlooked.1 We hope that the findings from this research, as well as the research from other groups, helps identify the most effective prevention measures that can be used for future
Journal of the American Podiatric Medical Association Vol 105 No 1 January/February 2015
101
amputation prevention efforts both in the US and globally. EMILY COOK, DPM, MPH Division of Podiatric Surgery, Mount Auburn Hospital Harvard Medical School 330 Mount Auburn St, Cambridge, MA 02138
102
References 1. COOK EA, COOK JJ, LABRE MP, ET AL: The amputation prevention initiative. JAPMA 104: 1, 2014. 2. GREGG EW, LI Y, WANG J, ET AL: Changes in diabetes-related complications in the United States, 1990–2010. N Engl J Med 370: 1514, 2014. 3. MARGOLIS DJ, HOFSTAD O, FELDMAN HI: Association between renal failure and foot ulcer or lower-extremity amputation in patients with diabetes. Diabetes Care 31: 1331, 2008.
January/February 2015 Vol 105 No 1 Journal of the American Podiatric Medical Association
