Pandemic Derails Small Success in Lowering Diabetes-Related Amputations

Rates of minor diabetes-related lower extremity amputations (LEAs) in hospitalized patients increased between 2009 and 2017 in all racial and ethnic groups, in both rural and urban areas, and in all geographic regions across the United States, a new retrospective, observational study indicates.

In contrast, major lower extremity amputation rates held steady during the study period with a few exceptions.

There was also a decline in major-to-minor amputation ratios, especially among Native Americans — a sign that diabetes was being better managed and foot ulcers were being caught earlier, preventing the need for a major amputation above the foot or below or above the knee.

Minor LEAs include the loss of a toe, toes, or a foot.

“While I know an amputation is devastating either way, having a minor amputation is better than having a major amputation, and trends [at least to 2017] show that comprehensive foot examinations are paying off,” lead author Marvellous Akinlotan, PhD, MPH, a research associate at the Southwest Rural Health Research Center in Bryan, Texas, told Medscape Medical News.

Asked to comment, Marcia Ory, PhD, MPH, director of the Center for Population Health & Aging, Texas A&M School of Public Health, College Station, who was not involved in the study, said: “It points to some successes, but it also points to the need for continued education and preventive care to reduce all types of amputations.”

The study was published online in Diabetes Care.

Amputations Increased During COVID-19

However, the study was conducted prior to the COVID-19 pandemic, and amputation rates appear to have significantly worsened during the past 18 months.

In a summary of recent evidence collated by the Amputee Coalition, the authors point out that not only does COVID-19 itself put patients at higher risk for limb loss because severe infection increases the risk of blood clots, but patients with diabetes appear to have been far more likely to undergo any level of amputation during the pandemic than before it began.

In a study of patients with diabetes attending a foot and ankle surgery service in Ohio, the risk of having any level of amputation was 10.8 times higher during compared with before the pandemic. And of patients undergoing any amputation, the odds for receiving a major amputation was 3.1 times higher than before the pandemic

Telehealth and web-based options for diabetes care and education could help improve health outcomes, particularly during lockdowns.

“Having a diabetes-related amputation is life-changing — it brings disability and functional limitations to the individual — and within the healthcare system, it reflects the failure of secondary prevention efforts, which ideally should slow the progression of diabetic complications,” noted Akinlotan.

Race and Geography Affect Risk of Amputation

In their study, Akinlotan and colleagues used data from the National Inpatient Sample to identify trends in LEAs among patients primarily hospitalized for diabetes in the United States between 2009 to 2017.

“The primary outcome variable was documentation of either minor or major LEA during a diabetes-related admission,” they explain.

Minor LEAs increased significantly across all ethnic groups.

Table. Change in Amputation Rates in Hospitalized Patients With Diabetes, 2009-2017 (all P < .001)

Racial/ethnic group Percentage change in amputations, 2009-2017
Hispanics 48.5%
Whites 58.4%
Blacks 58.5%
Asians/Pacific Islanders 94.1%
Native Americans 72.0%
Other 109.2%


Although major amputation rates remained steady, “we did find that some groups remained at risk for having a major amputation,” Akinlotan noted.

White populations, people in the Midwest, and rural areas saw notable increases in major LEAs, as did “…Blacks, Hispanics, [and] those living in the South,” she said.

Patients need to be encouraged to monitor and control their blood glucose, to offset modifiable risk factors, and to seek regular medical attention to prevent an insidious diabetic complication from developing further, she said.

“It’s important for patients to know that continuing care is necessary,” Akinlotan stressed. “Diabetes is chronic and complex, but it can be managed, so that’s the good news.”

Ory agrees: “Effective management will require an all-in approach, with doctors and patients working together.

“Given the limited time in doctor-patient encounters, physicians can benefit patients by referring them to evidence-based, self-management education programs, which are proliferating around in the county,” she added.

The authors and Ory have reported no relevant financial relationships.

Diabetes Care. Published online July 22, 2021. Abstract

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