Lower-extremity amputations in people with and without diabetes in Germany, 2008–2012 – an analysis of more than 30 million inhabitants

Heiner Claessen,1–3,* Maria Narres,1–3,* Burkhard Haastert,4 Werner Arend,2 Falk Hoffmann,5 Stephan Morbach,2,6 Gerhard Rümenapf,7 Tatjana Kvitkina,1–3 Heiko Friedel,8 Christian Günster,9 Ingrid Schubert,10 Walter Ullrich,11 Benjamin Westerhoff,11 Adrian Wilk,8 Andrea Icks1–3 1Institute for Health Services Research and Health Economics, German Diabetes Center (DDZ) Leibniz Center for Diabetes Research at Heinrich Heine University Düsseldorf, Düsseldorf, Germany; 2Institute for Health Services Research and Health Economics, Center for Health and Society, Faculty of Medicine, Heinrich Heine University Düsseldorf, Düsseldorf, Germany; 3German Center for Diabetes Research (DZD), Neuherberg, Germany; 4mediStatistica, Neuenrade, Germany; 5Department of Health Services Research, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany; 6Department of Diabetes and Angiology, Marienkrankenhaus, Soest, Germany; 7Upper Rhine Vascular Center Speyer-Mahnheim, Diakonissen-Stiftungs-Krankenhaus, Speyer, Germany; 8Team Gesundheit, Gesellschaft für Gesundheitsmanagement mbH, Essen, Germany; 9AOK Research Institute, Berlin, Germany; 10PMV-Research Group, Department for Child and Adolescent Psychiatry and Psychotherapy, University of Cologne, Cologne, Germany; 11BARMER GEK, Head Quarters, Product Development/Health Care Management, Team Medical Analysis/Health Care Programs, Wuppertal, Germany *These authors contributed equally to this work Background and purpose: Lower-extremity amputations (LEAs) in people with diabetes are associated with reduced quality of life and increased health care costs. Detailed knowledge on amputation rates (ARs) is of utmost importance for future health care and economics strategies. We conducted the present cohort study in order to estimate the incidences of LEA as well as relative and attributable risk due to diabetes and to investigate time trends for the period 2008–2012.Methods: On the basis of the administrative data from three large branches of German statutory health insurers, covering ~34 million insured people nationwide (about 40% of the German population), we estimated age-sex-standardized AR (first amputation per year) in the populations with and without diabetes for any, major, and minor LEAs. Time trends were analyzed using Poisson regression.Results: A total of 108,208 individuals (diabetes: 67.3%; mean age 72.6 years) had at least one amputation. Among people with diabetes, we observed a significant reduction in major and minor ARs during 2008–2012 from 81.2 (95% CI 77.5–84.9) to 58.4 (55.0–61.7), and from 206.1 (197.3–214.8) to 177.0 (169.7–184.4) per 100,000 person-years, respectively. Among people without diabetes, the major AR decreased significantly from 14.3 (13.9–14.8) to 11.6 ([11.2–12.0], 12.0), whereas the minor AR increased from 15.8 (15.3–16.3) to 17.0 (16.5–17.5) per 100,000 person-years. The relative risk (RR) comparing the diabetic with the nondiabetic populations decreased significantly for both major and minor LEAs (4% and 5% annual reduction, respectively).Conclusion: In this large nationwide population, we still found higher major and minor ARs among people with diabetes compared with those without diabetes. However, AR and RR of major and minor LEAs in the diabetic compared with the nondiabetic population decreased significantly during the study period, confirming a positive trend that has been observed in smaller and regional studies in recent years. Keywords: diabetes, lower-extremity amputations, epidemiology, incidence, cohort study, relative risk, amputation rate, time tren