Response

Abstract

We thank Holman et al. for their helpful letter clarifying that in the ‘NHS Atlas of Variation’ data were linked to the National Diabetes Audit (NDA). We agree that lack of recording diabetes is unlikely to be a major cause of the variation in amputations across England as reported in the atlas. However, the atlas states that up to 25% of adult patients with diagnosed diabetes are not included in the NDA, which indicates that this could still be a contributing factor to variation, especially if the proportions of those registered with diabetes and amputation differed between regions. However, we agree that the other possibilities that we described are probably more important. Our article was intended to provide an exploration of possible reasons for the variation in amputation rates reported from a variety of sources. The important issue is that we all agree that even in a time when evidence-based guidelines flourish, the delivery of good practice may be variable. We need to focus on more rapid implementation of evidence-based practice, and sharing best practice. The ‘NHS Atlas of Variation’ is well placed to provide information about geographical variation in outcomes. Graham Leese Consultant in Diabetes and Endocrinology*, Sarah Wild Reader in Epidemiology and Public Health , Mike Edmonds Consultant , * Department of Diabetes, Ninewells Hospital and Medical School, University of Dundee, UK, Centre for Population Health Sciences, University of Edinburgh, UK