Lower Extremity Amputation Rates Research Articles

Postural control imbalance in individuals with a minor lower extremity amputation: a scoping review protocol.

Introduction Lower extremity amputations (LEA) impact the quality of life and physical abilities and increase the risk of developing secondary health complications. Current literature predominantly focuses on major LEA, leaving a gap in understanding biomechanics related to balance and postural control in minor LEA. The shifts towards increased rates of minor LEA, due to improved quality of care and patient management, highlights the need for a focused exploration of postural control deficits in this population. The scoping review will address this gap in the literature. Objectives The purpose of the review is to synthesize current research on postural control deficits following a minor foot amputation, focusing on any resections through or distal to the ankle joint, and to evaluate interventions aimed at improving balance in affected individuals. Inclusion criteria The review will encompass individuals of all ages who underwent a minor foot amputation, including various levels and etiologies. It will focus on quantitative data related to standing posture, ability to perform self-balanced activities of daily living, and external aids or treatments to improve postural control. The outcomes will include modifications in the sensation of balance, fall predictors, and biomechanical changes in postural control. Methods A preliminary search of MEDLINE (PubMed) was conducted to develop a full search strategy aimed at compiling all existing scientific articles on postural control and balance in individuals with a minor LEA. A comprehensive search will be performed across multiple databases and grey literature. Two reviewers will independently extract the data. The Mixed Methods Appraisal Tool will be used to assess risk and quality. Discussion By emphasizing the understudied aspects of postural control imbalances induced by minor LEA, the review will highlight potential areas for therapeutic intervention and contribute to a better understanding of rehabilitation for those affected.

The Effect of Limb Salvage Efforts in Different Age Groups: Relationships Between Major and Minor Amputations

“Limb salvage” efforts, such as performing minor amputations before infections spread proximally from the foot to decrease major lower extremity amputation, are an important part of healthcare today. It is unclear whether these efforts are preventing the number of major amputations and improving patients’ quality of life and the cost-effectiveness of the U.S. healthcare system. Rates of non-traumatic lower extremity amputation (NLEA) among patients with diabetes decreased in the early 2000s but rebounded in the 2010s. We analyzed the proportion of major amputations and differences in amputation rates between age groups in Texas. Patient data was extracted from the Texas Hospital Discharge Data Public Use Data File. Population estimates were obtained from the Texas Population Estimates Program from 2011 to 2015 and from intercensal estimates provided by the U.S. Census Bureau from 2006 to 2010. Raw numbers of minor, major, and all NLEA surgeries and the ratio of major amputations to total amputations per year were reported for each age group. Poisson regression and Joinpoint analyses were performed to capture these changes in trends. Rates of amputations increased, with significant decreasing relative prevalence of major amputations. Patients aged 45 to 64 with diabetes are likely driving these increases. Rates of lower extremity amputation in patients with diabetes increased from 2009 to 2015. This holds for all and minor amputations. In contrast, the ratio of major to all amputations decreased from 2010. Utilization of major and minor amputation differs between age groups, remaining stable in the youngest subjects, with minor amputation rates increasing in those aged 45 to 64.

Disparities and Trends in Major Lower Extremity Amputation Rates in Philadelphia Region from 2012 to 2021

Disparities and Trends in Major Lower Extremity Amputation Rates in Philadelphia Region from 2012 to 2021

Advancing Wound Care And Lower Limb Preservation In Northwestern Ontario Through Dedicated People, Pathways And Technology

Northwestern Ontario is home to 88 Indigenous communities, many remote and isolated. Lower extremity amputation rates are high in the region, and even higher among Indigenous populations. The Central Wound Intake system was developed over the past few years in consultation with a clinical working group with representatives from across Northwestern Ontario. The system attempts to address key components such as points of entry, triage and the development and communication of a wound care plan, with an ultimate goal of reducing amputation rates.

The relationship between plasma atherogenic index and long-term outcomes after endovascular intervention in superficial femoral artery lesions.

Peripheral arterial disease (PAD) results from the systemic atherosclerotic process. In this study, we aimed to determine the relationship between plasma atherogenic index (AIP), a ratio of molar concentrations of triglycerides to HDL-cholesterol, and long-term outcomes after endovascular therapy (EVT) in patients with superficial femoral artery (SFA) stenosis. We retrospectively evaluated 673 patients who underwent EVT for PAD in our tertiary center between January 2015 and December 2020. In the receiver operating characteristic (ROC) curve analysis, the AIP value with the optimum cutoff value was determined as 0.576 to detect the presence of major adverse limb events (MALEs). Patients were divided into two groups according to low AIP (<0.576 as group 1) and high AIP (>0.576 as group 2). Among the major endpoints, long-term restenosis rates were significantly higher in patients in the high-AIP group than in the low-AIP group (p<.001). The lower extremity amputation rate was not statistically significant between the two groups. All-cause mortality rate (54 (31.6) versus 117 (68.4), p<.001) was significantly higher in patients in the high-AIP group than in the low-AIP group. In addition, the MALE rate (94 (29.2) versus 218 (62.1), p<.001) was significantly higher in patients in the high-AIP group than in those in the low-AIP group. In conclusion, we found that AIP is a significant independent predictor of long-term MALE in patients who underwent EVT for SFA.

Getting a Foothold on Diabetic Foot Disease-Outcomes of a Multidisciplinary Clinical Pathway for Inpatient Diabetic Foot Care: A 17-Year Institutional Review.

Diabetes foot disease (DFD) contributes to poor quality of life, clinical and economic burden. Multidisciplinary diabetes foot teams provide prompt access to specialist teams thereby improving limb salvage. We present a 17-year review of an inpatient multidisciplinary clinical care path (MCCP) for DFD in Singapore. This was a retrospective cohort study of patients admitted for DFD and enrolled in our MCCP to a 1700-bed university hospital from 2005 to 2021. There were 9279 patients admitted with DFD with a mean of 545 (±119) admissions per year. The mean age was 64 (±13.3) years, 61% were Chinese, 18% Malay and 17% Indian. There was a higher proportion of Malay (18%) and Indian (17%) patients compared to the country's ethnic composition. A third of the patients had end stage renal disease and prior contralateral minor amputation. There was a reduction in inpatient major lower extremity amputation (LEA) from 18.2% in 2005 to 5.4% in 2021 (odds ratio 0.26, 95% confidence interval 0.16-0.40, P < .001) which was the lowest since pathway inception. Mean time from admission to first surgical intervention was 2.8 days and mean time from decision for revascularization to procedure was 4.8 days. The major-to-minor amputation rate reduced from 1.09 in 2005 to 0.18 in 2021, reflecting diabetic limb salvage efforts. Mean and median length of stay (LOS) for patients in the pathway was 8.2 (±14.9) and 5 (IQR = 3) days, respectively. There was a gradual trend of increase in the mean LOS from 2005 to 2021. Inpatient mortality and readmission rate was stable at 1% and 11%. Since the institution of a MCCP, there was a significant improvement in major LEA rate. An inpatient multidisciplinary diabetic foot care path helped to improve care for patients with DFD.

Lower Extremity Amputation Rates in People With Diabetes Mellitus: A Retrospective Population Based Cohort Study in Zwolle Region, The Netherlands

Lower extremity amputations are a major complication of diabetes mellitus (DM). In a previous Dutch study, the incident rate of major amputations was 89.2 per 100 000 person years. The primary aim of this study was to describe the lower extremity amputation rates in people with DM in the Zwolle region, where preventive and curative footcare is organised according to the guidelines of the International Working Group of the Diabetic Foot (IWGDF). The secondary aim was to evaluate outcomes and underlying characteristics of these people. This was a retrospective regional population based cohort study. Data from all people with DM treated in primary and secondary care, living in the region Zwolle were collected. All amputations in the period 2017 to 2019 were analysed. Comparisons were made between those with and without an amputation. In the analysis 5 915 people with DM were included, with a mean age of 67.8 (IQR 57.9, 75.9) years. Of those people, 47% were women and the median HbA1c was 53 (IQR 47, 62) mmol/mol. Over the three year study period 68 amputations were performed in 59 people: 46 minor, 22 major. This translated into an average annual crude amputation incidence rate of non-traumatic major and minor amputations of 41.5 and 86.9 per 100 000 person years among people with diabetes. Compared with those not undergoing amputations, those who underwent an amputation were more often men, older, mainly had T2DM, were treated in secondary care, had higher diastolic blood pressure, worse diabetic footcare profile, longer DM duration and higher HbA1c. At the end of the follow up, 111 people died: 96 (1.6%) without and 15 (25.4%) with amputations (p < .001). This retrospective study provides detailed insight into the rate of amputations in Dutch people with diabetes in the region Zwolle. Compared with previous Dutch estimates, these data suggest a considerable decrease in the major amputation incidence rate.

Quantifying the incidence of lower limb amputation in people with and without diabetes in Wales between 2008–2018

BackgroundThere is variance in the incidence of lower extremity amputation across and within countries including within the UK. National data shows up to a fourfold variance in the amputation rate throughout the regions of England and differences in amputation incidence have been reported in Scotland and Ireland. Lower extremity amputation rate has yet to be documented within Wales. The aim of this cohort study was to examine trends in diabetes and non-diabetes related lower extremity amputation incidence within the Welsh population and to examine the influence of diabetes on the relative risk of amputation. Materials and MethodsAll first-time amputations between 2008-2018 were extracted from SAIL, a repository of all routine medical data of residents of Wales. People with diabetes were identified using an algorithm utilising data from several clinical and non-clinical sources. Crude and direct age and sex adjusted incidences were estimated over time. ResultsOver the period 3505 major amputations and 4335 minor amputations occurred. The diabetes population greater than 17 years of age increased by 29.4% from 143,595 in 2008 to 206,818 in 2018. There was a statistically significant rate reduction in major amputation in both populations. In the diabetes population the number of major amputations reduced from 6.9 [5.5–8.5]/10 000 person years (PY) in 2008 to 4.9 [5.4–6.2]/10 000 PY in 2018. However, for major amputation, the risk of incident amputation in people with diabetes was 7.3 fold higher [7.1–7.5] than those without diabetes. The relative risk of minor amputation for those with diabetes was higher at 11.9 [11.8 –1.01]. There was no reduction in this risk over the period. ConclusionThis study found that rates of major amputation decreased over the study period but the risk of amputation for persons with diabetes remained substantial. As the population with diabetes increases so do crude rates of amputation, providing a substantial financial and societal cost to the Welsh Population.

Evolution in Trends of Primary Lower-Extremity Amputations Associated With Diabetes or Peripheral Artery Disease From 2006 to 2019.

Given the importance in prevention of lower extremity amputations (LEAs) associated with diabetes or peripheral artery disease (PAD), we sought to document the trends of primary LEA in Québec, Canada, from years 2006 to2019. Using the Québec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of primary LEA associated with diabetes and PAD among adults ≥ 40 years (99% confidence intervals [CI]), and all-cause 1-year mortality proportion trends following a primary LEA (95% CI), stratified by minor or major as the highest level of LEA during the same hospital stay and age groups. Trends were assessed using multivariate regression models. In 2019, the crude rate of primary LEA was 116.0 per 100,000 (n= 825) with 93.7 and 21.9 per 100,000 of minor (n=665) and major (n= 160) LEA, respectively. A tendency of decrease by 8% (-15.0 to 0.4%) of age-standardized incidence of primary LEA was observed between 2006 and 2019, while the absolute number of primary LEA increased from 610 to 825 cases. Minor LEA increased by 14.2% (3.7 to 25.9%) and major LEA decreased by 49.5% (-57.1 to -40.5%). Incidence trends remained stable among the 40 to 64 years, and declined by 14.6% and 20.1% for the 65 to 79 and ≥ 80 years of age groups, respectively. Major LEA decreased in all age groups, whereas minor LEA increased by 26.2% among the patients 40 to 64 years of age only. Age-standardized 1-year mortality decreased by 35.1% (95% CI, -43.4 to -25.7%) between 2006 and 2019, with a crude 1-year mortality of 11.3% in2019. The reduction of major LEA and 1-year mortality are encouraging, although increased minor LEA, especially in younger age groups, emphasizes the importance to improve preventive care further.

Construction of Smart Biomaterials for Promoting Diabetic Wound Healing.

Diabetes mellitus is a complicated metabolic disease that has become one of the fastest-growing health crises in modern society. Diabetic patients may suffer from various complications, and diabetic foot is one of them. It can lead to increased rates of lower-extremity amputation and mortality, even seriously threatening the life and health of patients. Because its healing process is affected by various factors, its management and treatment are very challenging. To address these problems, smart biomaterials have been developed to expedite diabetic wound closure and improve treatment outcomes. This review begins with a discussion of the basic mechanisms of wound recovery and the limitations of current dressings used for diabetic wound healing. Then, the categories and characteristics of the smart biomaterial scaffolds, which can be utilized as a delivery system for drugs with anti-inflammatory activity, bioactive agency, and antibacterial nanoparticles for diabetic wound treatment were described. In addition, it can act as a responsive system to the stimulus of the pH, reactive oxygen species, and glucose concentration from the wound microenvironment. These results show that smart biomaterials have an enormous perspective for the treatment of diabetic wounds in all stages of healing. Finally, the advantages of the construction of smart biomaterials are summarized, and possible new strategies for the clinical management of diabetic wounds are proposed.

Diabetes-Related Lower Extremity Amputations in Romania: Patterns and Changes between 2015 and 2019

Lower extremity amputations (LEAs) are a feared complication of diabetes mellitus (DM). Here we evaluated the recent trends in DM-related LEAs in Romania. We collected data from a national database regarding minor and major LEAs performed between 2015 and 2019 in patients with DM admitted to a public hospital. Absolute numbers of LEAs were presented by year, diabetes type, sex and age; incidence rates of LEAs in the general population were also calculated. Over the study period, 40,499 LEAs were recorded nationwide (83.16% in persons with type 2 DM [T2DM]); on average, the number of LEAs increased by 5.7%/year. This trend was driven by an increased number of LEAs in patients with T2DM; in patients with type 1 DM (T1DM), LEAs decreased over the study period. In patients with T2DM, the increase in minor LEAs was more pronounced than that in major LEAs. The overall number of LEAs showed an increasing trend with age (r = 0.72), which was most pronounced in patients aged ≥70 years. Men had a higher frequency of LEAs than women, regardless of DM type. These data support renewed efforts to prevent and decrease the burden of amputations among patients with DM.

Deriving International Classification of Diseases, 9th and 10th revision, codes for identifying and following up patients with diabetic lower extremity ulcers.

Administrative claims data offer a rich data source for clinical research. However, its application to the study of diabetic lower extremity ulceration is lacking. Our objective was to create a widely applicable framework by which investigators might derive and refine the International Classification of Diseases, 9th and 10th revision (ICD-9 and ICD-10, respectively) codes for use in identifying diabetic, lower extremity ulceration. We created a seven-step process to derive and refine the ICD-9 and ICD-10 coding lists to identify diabetic lower extremity ulcers. This process begins by defining the research question and the initial identification of a list of ICD-9 and ICD-10 codes to define the exposures or outcomes of interest. These codes are then applied to claims data, and the rates of clinical events are examined for consistency with prior research and changes across the ICD-9 to ICD-10 transition. The ICD-9 and ICD-10 codes are then cross referenced with each other to further refine the lists. Using this method, we started with 8 ICD-9 and 43 ICD-10 codes used to identify lower extremity ulcers in patients with known diabetes and peripheral arterial disease and examined the association of ulceration with lower extremity amputation. After refinement, we had 45 ICD-9 codes and 304 ICD-10 codes. We then grouped the codes into eight clinical exposure groups and examined the rates of amputation as a rudimentary test of validity. We found that the rate of lower extremity amputation correlated with the severity of lower extremity ulceration. We identified 45 ICD-9 and 304 ICD-10 ulcer codes, which identified patients at risk of amputation from diabetes and peripheral artery disease. Although further validation at the medical record level is required, these codes can be used for claims-based risk stratification for long-term outcomes assessment in the treatment of patients at risk of limb loss.

Diabetic foot in primary and tertiary (DEFINITE) Care: A health services innovation in coordination of diabetic foot ulcer (DFU) Care within a healthcare cluster - 18-month results from an observational population health cohort study.

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n=302) and 5.1% (n=176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P=.005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P=.002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.

Decreasing Osteomyelitis Occurrence in Remaining Bone After Partially Resected Infected Bone.

After partial bone resection for osteomyelitis there is a high rate of osteomyelitis occurrence in the remaining bone due to adherent bacterial biofilm, dysvascular infected spongiosum bone, and absence of a surgical technique that can prevent osteomyelitis developing in the remaining bone. Presented is a surgical procedure using a dicalcium phosphate bone void filler putty with antibiotics placed into the remaining bone to prevent the development of osteomyelitis, therefore preventing amputation. This procedure has an osteomyelitis eradication rate of 94.8% and also decreases the rate of lower-extremity amputations. This procedure provides a single stage surgical technique for infected open bone defects decreasing the previously reported high osteomyelitis reoccurrence rate of 57.1% to 5.2%.

Incidence, prevalence, and potential risk factors for diabetic foot ulceration: A retrospective review at a multidisciplinary centre in Barbados.

Diabetes and lower extremity amputation rates in Barbados are among some of the highest globally, with peripheral neuropathy and peripheral vascular disease found to be independent risk factors for this population. Despite this, there is currently a lack of research evidence on rates of diabetic foot ulceration, which has amputation as its sequela. We aimed to evaluate the incidence and prevalence rates of active ulceration in a population of people with diabetes in Barbados. Secondly, we explored the risk factors for new/recurrent ulceration. Data were extracted from the electronic medical records for the period January 1, 2019 to December 31, 2020 for a retrospective cross-sectional study for patients of a publicly-funded diabetes management programme. Eligible records included people aged 18 years and above with a diagnosis of type 1 or 2 diabetes. Potential risk factors were explored using univariable logistic regression models. A total of 225 patients were included in the study (96% type 2 diabetes, 70.7% female, 98.7% Black Caribbean). The 1-year period prevalence of diabetic foot ulceration was 14.7% (confidence interval [CI]: 10.5, 20.1). Incidence of ulceration in the same period was 4.4% (CI: 4.4, 4.5). Risk factors associated with diabetic foot ulceration included: retinopathy (OR 3.85, CI: 1.24, 11.93), chronic kidney disease (OR 9.86, CI: 1.31, 74.22), aspirin use (OR 3.326, CI: 1.02, 10.85), and clopidogrel use (OR 3.13, CI: 1.47, 6.68). This study provided some insight into potential risk factors for foot ulceration in this population, which previous studies have shown to have higher rates of lower extremity amputations. Further research in this understudied group through a larger prospective cohort would allow more meaningful associations with risk factors and would be useful for the creation of risk prediction models.

Disparities In Diabetes-Related Lower Extremity Amputations In The United States: A Systematic Review.

Disparities in rates of peripheral diabetic neuropathy and lower extremity amputation exist in the United States. To investigate the factors linked to this disparity, we performed a systematic review of the literature on the subject published during the period 2000-20. Nineteen observational studies were included. Disparities in rates of lower extremity amputation were reported according to patient race, ethnicity, sex, and age; across hospital referral regions, residential area characteristics, and income estimates; and on the basis of payer type and hospital characteristics. Several of these factors were interrelated. There was a reduction in major lower extremity amputation rates among Black, Hispanic, and White patients with diabetes over time, suggesting narrowing disparities in the odds of this procedure among Black and White patients. There is a need for a national strategy that integrates public awareness, screening, early initiated multidisciplinary care, and quality measures for peripheral artery disease management, as well as neighborhood-level public health interventions, to reduce the disproportionate burden of lower extremity amputation in underserved communities.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018

AimsThis study assessed temporal trends in the incidence of lower extremity amputations (LEA) in Belgium from 2009 to 2018, and subsequent secondary amputation rates. MethodsNationwide data on LEA were collected. Sex- and age-adjusted annual incidence rates were calculated. Time trends were analysed in negative binomial models. The incidence of secondary interventions, defined as either any ipsilateral reamputation or any contralateral amputation, was studied with death as competing risk. Results41 304 amputations were performed (13 247 major, 28 057 minor). In individuals with diabetes, the amputation rate (first amputation per patient per year) decreased from 143.6/100.000 person-years to 109.7 (IRR 0.97 per year, 95 %CI 0.96–0.98, p < 0.001). The incidence of major LEAs decreased from 56.2 to 30.7 (IRR 0.93, 95 %CI 0.91–0.94, p < 0.001); the incidence of minor amputations showed a non-significant declining trend in women (54.3 to 45.0/100 000 person years, IRR 0.97 per year, 95 %CI 0.96–0.99), while this remained stable in men with diabetes (149.2 to 135.3/100 000 person years, IRR 1.00 per year, 95 %CI 0.98–1.01). In individuals without diabetes, the incidence of major amputation didn’t change significantly, whereas minor amputation incidence increased (8.0 to 10.6, IRR 1.04, 95 %CI 1.03–1.05, p < 0.001). In individuals with diabetes, one-year secondary intervention rates were high (31.3% after minor, 18.4% after major LEA); the incidence of secondary amputations didn’t change. ConclusionsA significant decline in the incidence rate of major LEA was observed in people with diabetes. This decline was not accompanied by a significant rise in minor LEA. The incidence of secondary interventions remained stable.

Impact of “Defensive Medicine” on the Costs of Diabetes and Associated Conditions

Geographic variation in health care spending is typically attributed to differences in patient health status and provider practice patterns. While medicolegal considerations (i.e., "defensive medicine") anecdotally impact health care spending, this phenomenon is difficult to measure. The purpose of this study was to explore the association between the medicolegal environment and Medicare costs for diabetes and associated conditions of interest to vascular surgeons. Specifically, we hypothesized that an adverse medicolegal environment is associated with higher per capita Medicare costs for diabetic patients. Medicare data including the most recent (2018) Medicare Geographic Variation Public Use Files and Chronic Conditions Data Files were linked to National Practitioner Data Bank files from the preceding 5years (2013-2017), in addition to the US census data and American Medical Association workforce statistics. The state-level medicolegal environment was characterized by K-means clustering across a panel of metrics related to malpractice payment magnitude and prevalence. Per capita Medicare spending for diabetes was compared across 5 distinct medicolegal environments. Costs were standardized and risk-adjusted to account for known geographic variation in health care costs and patient population. Analysis of variance was applied to unadjusted data, followed by multivariate regression modeling. Readmission rates, per capita imaging studies, per capita tests, per capita procedures, and lower extremity amputation rates were compared between the least litigious quintile from the K-means clustering and the 2 most litigious quintiles. The median unadjusted Medicare per capita expenditure on diabetic patients was $15,963 ($14,885-$17,673), ranging from $13,762 (Iowa) to $21,865 (D.C.). A 1.6-fold variation persisted after payment standardization. Cluster analysis based on malpractice-related variables yields 5 distinct medicolegal environments, based on litigation frequency and malpractice payment amounts. Per capita spending on diabetes varied, ranging from $15,799 in states with low payments and infrequent litigation to $18,838 in states with the most adverse medicolegal environment (P<0.05). After cost standardization and risk adjustment with multiple linear regression, malpractice claim prevalence (per 100 physicians) remained an independent predictor of states with the highest diabetes mellitus spending (P=0.022). Moreover, diabetic patients in states with adverse medicolegal environments had more procedures, imaging studies, and readmissions (P<0.05 for all) but did not have significant differences in amputation rates compared to less litigious states. An adverse medicolegal environment is independently associated with higher health care costs but does not result in improved outcome (i.e. amputation rate) for diabetic Medicare beneficiaries. Across states, a 1% increase in lawsuits/100 physicians was associated with a >10% increase in risk-adjusted standardized per capita costs. These findings demonstrate the potential contribution of "defensive medicine" to variation in health care utilization and spending in a population of interest to vascular surgeons.

Heterogeneity in the guidelines for the management of diabetic foot disease in the Caribbean.

The prevalence of diabetes mellitus, diabetic foot (DF) disease and, as a result, lower extremity amputation rates remain high in the Caribbean. This study was undertaken to determine whether Caribbean countries have designated individuals that monitor DF disease and whether there are DF protocols consistent with the International Working Group on the Diabetic Foot (IWGDF) guidance documents. Relevant DF health care personnel(s) from the CARICOM and Dutch Caribbean countries were called or sent questionnaires regarding the presence of structured programs to monitor and manage DF problems in the population. All 25 countries (100%) responded. 81% of respondents could not identify any Ministry, Hospital or individual initiatives that monitored the DF. Only 9 (36%) countries had any guidelines in place. Only 3 countries with guidelines in place utilized IWGDF guidelines. Only 6 (24%) countries had podiatrists and 10 (40%) had vascular surgery availability. 7 (28%) countries had the components for a multidisciplinary team. The presence or the appointment of a designated individual and/or a multidisciplinary approach within the countries for DF disease was absent in the majority of respondent countries. Only a minority of countries implemented DF guidelines or had expertise available to organize a DF multidisciplinary team. Vascular surgery and podiatric care were noticeably deficient. These may be critical factors in the variability and reduced success in implementation of strategies for managing DF problems and subsequent amputations amongst these Caribbean countries.

A Novel Marker Indicating Restenosis in Superficial Femoral Artery: C Reactive Protein to Albumin Ratio

In this study, we aimed to investigate the prognostic value of C-reactive protein (CRP) to albumin ratio (CAR) for predicting restenosis in superficial femoral artery (SFA) lesions and its association with subsequent clinical outcomes in patients undergoing endovascular intervention. The records of 685 consecutive patients who underwent endovascular intervention due to symptomatic peripheral artery disease were analyzed. Patients were divided into 2 groups, based on the CAR values. For each group, technical aspects of procedures and subsequent clinical outcomes were analyzed. According to our study, patients with high CAR values had higher rates of restenosis (30.2% vs. 10.3%, P<0.05) and mortality (31.3% vs. 12.9%, P<0.05). The rate of lower extremity amputations was also significantly higher in patients with high CAR values compared to those with low CAR values (9.1% vs. 3%, P<0.05). With respect to Receiver operating characteristic ROC curves of inflammatory markers, the area under the curve (AUC) value of CAR was statistically significant (AUC: 0.659; 95% confidence interval CI:0.611-0.706; P<0.01). Our data showed that CAR is an independent predictor of restenosis and poor clinical outcomes in patients undergoing endovascular intervention.