Determinants of decreasing major amputation rates in Germany.

BACKGROUND: We analysed a potential association between the decrease in major amputations in Germany and the number of doctors, prescribed podologic foot care (PFC) and antidiabetic drugs, and performed percutaneous endoluminal angioplasties (PTA). PATIENTS AND METHODS: Data of all lower limb major amputations between 2007 and 2011, the cases hospitalised with an additional diagnosis of diabetes mellitus, and the numbers of PTAs, and the number of doctors in private practices and in hospitals were obtained from the Federal Statistical Office. Furthermore, the number of PFC treatments and prescribed antidiabetics for each of the five years were derived from the federal report of the statutory health insurance. RESULTS: Within the 5 year time period, major amputations decreased by 19.0%, from 17,846 in 2007 to 14,463 in 2011. There is an inverse relation between the number of major amputations and the increasing number of prescribed PFC, of doctors working in hospital and of below-the-knee PTA in the multiple Poisson regression analysis. The number of prescribed antidiabetics and that of all PTA showed a positive relation. In the multiple linear regression analysis with the dependent variable ratio of amputations and the cases hospitalised with an additional diagnosis of diabetes mellitus, only numbers of prescribed PFC and below-the-knee PTA still showed an inverse relation that reached a level of significance. CONCLUSIONS: While substantial improvements in patients care by doctors, endovascular interventions, prescriptions of PFC and antidiabetic drugs are under discussion to reduce major amputation rates, in this approach including comprehensive data from Germany, only prescriptions of PFC and the number of below-the-knee PTA had an independent and significant impact on the reduction of major amputations. It has to be pointed out that such a statistical association does not prove any causality.

Association of diabetic foot care and amputation rates in Germany.

Podologists are nurses who care for the diabetic foot (orthotics, offloading devices, blisters, calluses, treatment of fungus infection and patient education). In contrast to podiatrists, they are not qualified to perform any surgical treatment or wound care. We analysed whether there is an association between the decrease in major amputations and the number of podologic foot care (PFC) visits prescribed in Germany. Detailed list of all major lower limb amputations (OPS 5-864) performed from 2007 to 2011 was provided by the Federal Statistical Office. Data were separated for the 16 federal states in Germany. Detailed lists of the number of PFC treatments for each of the 5 years were derived from the federal report of the statutory health insurance. The total numbers of hospitalised cases per year having diabetes mellitus documented as an additional diagnosis were used to adjust for the different rates of people with diabetes in each federal state. Within a 5-year time period, population-based major amputations per 100 000 people dropped from 21·7 in 2007 to 17·5 in 2011 (-18·5%); whereas the number of PFC treatments per 1000 insured increased from 22 in 2007 to 60 in 2011 (+172·7%). The total number of major amputations divided by the total number of hospitalised cases with the additional diagnosis of diabetes mellitus (DM) shows an inverse correlation with the number of PFC treatments per 1000 insured (Pearson's correlation factor is -0·52049). The five countries with the highest increase in PFC compared with the five countries with the lowest increase (35·6 versus 15·4 per 1000 insured) will have only small differences in the decrease in major amputation rates in this period (-5·1 versus -3·4 per 100.000). There is a strong association between increasing utilisation PFC and decreasing major amputations in Germany. Further study is required to document the cost-effectiveness of this service.