The International Journal of Lower Extremity Wounds http://ijl.sagepub.com/
Reducing Major Lower Extremity Amputations After the Introduction of a Multidisciplinary Team for the Diabetic Foot José Antonio Rubio, Javier Aragón-Sánchez, Sara Jiménez, Gregorio Guadalix, Agustín Albarracín, Carmen Salido, José Sanz-Moreno, Fernando Ruiz-Grande, Nuria Gil-Fournier and Julia Álvarez International Journal of Lower Extremity Wounds 2014 13: 22 DOI: 10.1177/1534734614521234 The online version of this article can be found at: http://ijl.sagepub.com/content/13/1/22
Published by: http://www.sagepublications.com
Additional services and information for The International Journal of Lower Extremity Wounds can be found at: Email Alerts: http://ijl.sagepub.com/cgi/alerts Subscriptions: http://ijl.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
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21234
2014
IJLXXX10.1177/1534734614521234The International Journal of Lower Extremity WoundsRubio et al
Translational Research
Reducing Major Lower Extremity Amputations After the Introduction of a Multidisciplinary Team for the Diabetic Foot
The International Journal of Lower Extremity Wounds 2014, Vol. 13(1) 22–26 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614521234 ijl.sagepub.com
José Antonio Rubio, MD, PhD1,3, Javier Aragón-Sánchez, MD, PhD2, Sara Jiménez, DPM1, Gregorio Guadalix, MD1, Agustín Albarracín, MD4, Carmen Salido, MD1, José Sanz-Moreno, MD, PhD1,3, Fernando Ruiz-Grande, MD, PhD1, Nuria Gil-Fournier, MD1, and Julia Álvarez, MD, PhD1,3
Abstract We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of −6.6% (95% CI = −10.2 to −2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes. Keywords diabetic foot, foot ulcer, lower extremity amputation, multidisciplinary team, diabetic foot clinic Lower extremity amputations (LEAs) are a well-known and feared complication of diabetes mellitus, and up to 85% of all amputations are preceded by an ulcer. The management of a diabetic ulcer is complex, and a multidisciplinary approach has been recommended by the International Working Group on the Diabetic Foot.1 Offloading, debridement, glycemic control, early detection of the infection and its appropriate treatment, including advanced surgical techniques such as revascularization, are frequently required to save the patient’s limb. Between 45% and 85% of all LEAs could be avoided by using this multidisciplinary model.1 In Spain, the current statistics on amputations in the diabetic population show high variability and are very disappointing. Sixteen years ago, it was reported that the incidence of LEAs in both diabetic and nondiabetic populations in 7th Health Care Area in Madrid was the lowest reported in all European countries.2 However, these data are exceptional rather than being typical of Spain. Our group
reported a high rate of LEAs in our area,3 and other Spanish teams have also reported higher rates.4,5 Furthermore, López-de-Andrés et al recently reported an increase, over the whole of Spain, in major and minor amputations in patients with type 2 diabetes between 2001 and 2008.6 These results may be explained in part by 2 reasons: (a) podiatrists are not included within the public health system to provide preventive foot care and (b) it has been 1
Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain 2 Hospital La Paloma, Las Palmas de Gran Canaria, Spain 3 University of Alcalá, Alcalá de Henares, Madrid, Spain 4 Madrid Health Service, Madrid, Spain Corresponding Author: José Antonio Rubio, MD, PhD, Endocrinology and Nutrition Department, Hospital Universitario Príncipe de Asturias, Meco-Alcalá Road s/n, Alcalá de Henares, 28850 Madrid, Spain. Email: [email protected]
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Rubio et al reported recently that the number of Multidisciplinary Diabetic Foot Units (MDFUs) is low, and foot care is only provided for 1 out of 4 Spanish patients.7 Both reasons make it difficult to provide appropriate foot care for patients with diabetes.8,9 These data confirm the need to address urgently the management of foot lesions in Spain. In March 2008, an MDFU was introduced in the 3rd Health Care Area of Madrid, Spain. It is a hospital-based multidisciplinary team for the diagnosis and treatment of diabetic foot disease, coordinated by an endocrinologist and a podiatrist. Establishing the incidence of amputations in people with diabetes after any change to the management of diabetic foot care is essential. However, the great variability in the incidence of diabetic foot disease between regions does not allow regional comparisons,10 and it is necessary to know how rates change over time in the population analyzed. The aim of this study was to analyze the effect of the introduction of an MDFU in our hospital, by evaluating trends in amputation rate in people with and without diabetes in our health care area between 2001 and 2011.
Materials and Methods Principe de Asturias Hospital is a 530-bed teaching general hospital, located in the city of Alcalá de Henares (Madrid), providing health care to the population of the 3rd Health Care Area of the Community of Madrid, Spain. The Madrid Health Service (MHS) divided the population of the Community of Madrid into 11 health care areas for the provision of health care. According to MHS censuses (20012011), the total population in this health care area ranged from 292 512 to 371 449 people.11 The Spanish Minimum Basic Data Set (MBDS) is a database that stores the diagnoses and surgical procedures for all inpatients after discharge using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).12 The MHS is responsible for collecting data and updating the MBDS. In Spain the coding process is mandatory for all inpatients. LEAs performed at any Madrid hospital between January 1, 2001, and December 31, 2011, were identified by the MBDS procedure code field. To identify people living in our health care area, we only used cases with a CIAS_PRO code of 1603xx; the CIAS_PRO code identifies where a resident of the community of Madrid receives health care. Diabetes status was established by ICD-9-CM code 250.x. Any partial amputation of the foot but without involving the ankle joint (ICD-9-CM codes 84.10-84.12) was defined as a minor amputations; any LEA through or proximal to the ankle joint (ICD-9-CM codes 84.13-84.17) was defined as a major amputation. Traumatic or neoplastic LEAs (ICD9-CM codes 895-897, 905.9, 928-929, 959, 213.7, 213.8, and 195.5) were excluded from this study. Only the highest
level of amputation was considered for each hospital discharge. The code assignments were reviewed by 2 independent observers. The incidence of LEAs (mean and 95% confidence interval [CI]) was calculated overall and by diabetes status for each year. We calculated the yearly age- and sex-specific incidence rates (per 100 000 inhabitants) by dividing the number of cases per year per sex and age group by the corresponding number of residents in the 3rd Health Care Area. The incidence of LEAs was adjusted to the age of the standard European population by the direct method as previously reported.13 To determine whether LEA rates were different after the introduction of the MDFU, we compared the incidence and type of amputations in the 2001 to 2007 period (before the introduction of the MDFU) with data for the 2008 to 2011 period (after the introduction of the MDFU), in people with and without diabetes. Either the χ2 test or Student’s t test was used to compare the groups; these analyses were carried out with SPSS 15.0 (SPSS, Chicago, IL). Trends in rates of amputations were also tested by joinpoint regression analysis, using a Poisson distribution. Joinpoint regression involves the use of permutation tests to identify points where linear trends change significantly with respect to either direction or magnitude; it reveals annual percentage change (APC).14 We used the Joinpoint Regression Program, Version 4.0—December 2012; Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute. A P value
Reducing Major Lower Extremity Amputations After the Introduction of a Multidisciplinary Team for the Diabetic Foot José Antonio Rubio, Javier Aragón-Sánchez, Sara Jiménez, Gregorio Guadalix, Agustín Albarracín, Carmen Salido, José Sanz-Moreno, Fernando Ruiz-Grande, Nuria Gil-Fournier and Julia Álvarez International Journal of Lower Extremity Wounds 2014 13: 22 DOI: 10.1177/1534734614521234 The online version of this article can be found at: http://ijl.sagepub.com/content/13/1/22
Published by: http://www.sagepublications.com
Additional services and information for The International Journal of Lower Extremity Wounds can be found at: Email Alerts: http://ijl.sagepub.com/cgi/alerts Subscriptions: http://ijl.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> Version of Record - Mar 21, 2014 What is This?
Downloaded from ijl.sagepub.com at NORTHEASTERN UNIV LIBRARY on April 6, 2014
21234
2014
IJLXXX10.1177/1534734614521234The International Journal of Lower Extremity WoundsRubio et al
Translational Research
Reducing Major Lower Extremity Amputations After the Introduction of a Multidisciplinary Team for the Diabetic Foot
The International Journal of Lower Extremity Wounds 2014, Vol. 13(1) 22–26 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1534734614521234 ijl.sagepub.com
José Antonio Rubio, MD, PhD1,3, Javier Aragón-Sánchez, MD, PhD2, Sara Jiménez, DPM1, Gregorio Guadalix, MD1, Agustín Albarracín, MD4, Carmen Salido, MD1, José Sanz-Moreno, MD, PhD1,3, Fernando Ruiz-Grande, MD, PhD1, Nuria Gil-Fournier, MD1, and Julia Álvarez, MD, PhD1,3
Abstract We analyzed the incidence of lower extremity amputations (LEAs) in the 3rd Health Care Area of Madrid before and after the March 2008 introduction of a multidisciplinary team for managing diabetic foot disease. We compared the amputation rates in people with and without diabetes during 2 periods: before (2001-2007) and after (2008-2011) the introduction of a Multidisciplinary Diabetic Foot Unit (MDFU). We also analyzed the trend of the amputation rates by joinpoint regression analysis and measured the annual percentage change (APC). During the study period, 514 nontraumatic LEAs were performed, 374 (73%) in people with diabetes and 140 (27%) in people without the disease. The incidence of LEAs showed a significant reduction in major amputations in people with diabetes, from 6.1 per 100 000 per year (95% confidence interval [CI] = 4.9 to 7.2), in the 2001 to 2007 period, to 4.0 per 100 000 per year (95% CI = 2.6 to 5.5) in the 2008 to 2011 period (P = .020). There were no changes in incidence of minor or total amputations in the diabetic population or in amputations in the nondiabetic population during the study period. Joinpoint regression analysis showed a significant reduction in the incidence of major LEAs in diabetic population with an APC of −6.6% (95% CI = −10.2 to −2.8; P = .003), but there were no other significant changes. This study demonstrates that the introduction of a multidisciplinary team, coordinated by an endocrinologist and a podiatrist, for managing diabetic foot disease is associated with a reduction in the incidence of major amputations in patients with diabetes. Keywords diabetic foot, foot ulcer, lower extremity amputation, multidisciplinary team, diabetic foot clinic Lower extremity amputations (LEAs) are a well-known and feared complication of diabetes mellitus, and up to 85% of all amputations are preceded by an ulcer. The management of a diabetic ulcer is complex, and a multidisciplinary approach has been recommended by the International Working Group on the Diabetic Foot.1 Offloading, debridement, glycemic control, early detection of the infection and its appropriate treatment, including advanced surgical techniques such as revascularization, are frequently required to save the patient’s limb. Between 45% and 85% of all LEAs could be avoided by using this multidisciplinary model.1 In Spain, the current statistics on amputations in the diabetic population show high variability and are very disappointing. Sixteen years ago, it was reported that the incidence of LEAs in both diabetic and nondiabetic populations in 7th Health Care Area in Madrid was the lowest reported in all European countries.2 However, these data are exceptional rather than being typical of Spain. Our group
reported a high rate of LEAs in our area,3 and other Spanish teams have also reported higher rates.4,5 Furthermore, López-de-Andrés et al recently reported an increase, over the whole of Spain, in major and minor amputations in patients with type 2 diabetes between 2001 and 2008.6 These results may be explained in part by 2 reasons: (a) podiatrists are not included within the public health system to provide preventive foot care and (b) it has been 1
Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain 2 Hospital La Paloma, Las Palmas de Gran Canaria, Spain 3 University of Alcalá, Alcalá de Henares, Madrid, Spain 4 Madrid Health Service, Madrid, Spain Corresponding Author: José Antonio Rubio, MD, PhD, Endocrinology and Nutrition Department, Hospital Universitario Príncipe de Asturias, Meco-Alcalá Road s/n, Alcalá de Henares, 28850 Madrid, Spain. Email: [email protected]
Downloaded from ijl.sagepub.com at NORTHEASTERN UNIV LIBRARY on April 6, 2014
23
Rubio et al reported recently that the number of Multidisciplinary Diabetic Foot Units (MDFUs) is low, and foot care is only provided for 1 out of 4 Spanish patients.7 Both reasons make it difficult to provide appropriate foot care for patients with diabetes.8,9 These data confirm the need to address urgently the management of foot lesions in Spain. In March 2008, an MDFU was introduced in the 3rd Health Care Area of Madrid, Spain. It is a hospital-based multidisciplinary team for the diagnosis and treatment of diabetic foot disease, coordinated by an endocrinologist and a podiatrist. Establishing the incidence of amputations in people with diabetes after any change to the management of diabetic foot care is essential. However, the great variability in the incidence of diabetic foot disease between regions does not allow regional comparisons,10 and it is necessary to know how rates change over time in the population analyzed. The aim of this study was to analyze the effect of the introduction of an MDFU in our hospital, by evaluating trends in amputation rate in people with and without diabetes in our health care area between 2001 and 2011.
Materials and Methods Principe de Asturias Hospital is a 530-bed teaching general hospital, located in the city of Alcalá de Henares (Madrid), providing health care to the population of the 3rd Health Care Area of the Community of Madrid, Spain. The Madrid Health Service (MHS) divided the population of the Community of Madrid into 11 health care areas for the provision of health care. According to MHS censuses (20012011), the total population in this health care area ranged from 292 512 to 371 449 people.11 The Spanish Minimum Basic Data Set (MBDS) is a database that stores the diagnoses and surgical procedures for all inpatients after discharge using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM).12 The MHS is responsible for collecting data and updating the MBDS. In Spain the coding process is mandatory for all inpatients. LEAs performed at any Madrid hospital between January 1, 2001, and December 31, 2011, were identified by the MBDS procedure code field. To identify people living in our health care area, we only used cases with a CIAS_PRO code of 1603xx; the CIAS_PRO code identifies where a resident of the community of Madrid receives health care. Diabetes status was established by ICD-9-CM code 250.x. Any partial amputation of the foot but without involving the ankle joint (ICD-9-CM codes 84.10-84.12) was defined as a minor amputations; any LEA through or proximal to the ankle joint (ICD-9-CM codes 84.13-84.17) was defined as a major amputation. Traumatic or neoplastic LEAs (ICD9-CM codes 895-897, 905.9, 928-929, 959, 213.7, 213.8, and 195.5) were excluded from this study. Only the highest
level of amputation was considered for each hospital discharge. The code assignments were reviewed by 2 independent observers. The incidence of LEAs (mean and 95% confidence interval [CI]) was calculated overall and by diabetes status for each year. We calculated the yearly age- and sex-specific incidence rates (per 100 000 inhabitants) by dividing the number of cases per year per sex and age group by the corresponding number of residents in the 3rd Health Care Area. The incidence of LEAs was adjusted to the age of the standard European population by the direct method as previously reported.13 To determine whether LEA rates were different after the introduction of the MDFU, we compared the incidence and type of amputations in the 2001 to 2007 period (before the introduction of the MDFU) with data for the 2008 to 2011 period (after the introduction of the MDFU), in people with and without diabetes. Either the χ2 test or Student’s t test was used to compare the groups; these analyses were carried out with SPSS 15.0 (SPSS, Chicago, IL). Trends in rates of amputations were also tested by joinpoint regression analysis, using a Poisson distribution. Joinpoint regression involves the use of permutation tests to identify points where linear trends change significantly with respect to either direction or magnitude; it reveals annual percentage change (APC).14 We used the Joinpoint Regression Program, Version 4.0—December 2012; Statistical Methodology and Applications Branch, Surveillance Research Program, National Cancer Institute. A P value
