Amputation prevention

Position statement

Diabetes Canada:

• calls for affordable and timely access to medications, devices, education and care that are necessary to achieve optimal diabetes control and prevent serious complications, such as amputation;
• calls for access to publicly funded services and devices for all people with diabetes to prevent and treat foot ulcers and avoid amputation, including foot care education, professionally fitted footwear and devices, timely referrals and visits to a foot care specialist;
• recommends that health care professionals screen for diabetic neuropathy and peripheral vascular disease, perform annual examinations for foot complications (more frequent for those at high risk) and educate people with diabetes about proper foot care as an integral component of diabetes management, as outlined in the most current Diabetes Canada Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada;
• calls for an interdisciplinary approach to the prevention and management of diabetes foot complications, including coordination of care and communication between health care professionals who support people with diabetes in managing their disease; and
• urges people with diabetes to check their feet daily for cuts, cracks, bruises, blisters, sores, infection and unusual markings.

Background and rationale

Diabetes is the leading cause of non-traumatic lower limb amputation in Canadian adults, associated with approximately 70% of amputations performed in hospital. Compared to the general population, Canadian adults with diabetes are over 20 times more likely to undergo non-traumatic lower limb amputations, 85% of which are preceded by a foot ulcer (1,2). Diabetes foot ulcerations are often the result of diabetic neuropathy and/or peripheral vascular disease (poor circulation/blood supply to the foot); they can become infected and result in amputations. Diabetes foot complications place a tremendous emotional and financial burden on the individuals suffering from these complications, their families and the health care system (3).

The prevention of amputations involves regular foot exams by patients with diabetes and their health-care providers, as well as professional evaluation of amputation risk, regular callus debridement, patient education, professionally fitted therapeutic footwear and early detection and treatment of diabetic foot ulcers (4). Intensive glycemic control is associated with lower rates of amputation (5). While diabetes-related foot complications are largely avoidable, people with diabetes experience barriers to accessing preventative care. These challenges include:

• limited access to care for individuals with low income and living in rural or remote areas;
• key preventive services and supports for foot complications not publicly insured;
• inadequate foot screening as compared to that recommended by up-to-date clinical practice guidelines;
• lack of support for health care providers to implement recommended evidence-based prevention and care;
• lack of coordination and communication between health care providers; and
• lack of culturally appropriate care (6,7).

Improved education, screening, assessment and affordable and publicly funded treatment can prevent serious foot complications, including amputations, and help people with diabetes live healthier lives.

References

1. Public Health Agency of Canada (2011). Diabetes in Canada: Facts and Figures from a Public Health Perspective.
2. Singh, N., Armstrong, D.G., & Lipsky, B.A. (2005). Preventing foot ulcers in patients with diabetes. JAMA, 293, 217-228.
3. The five-year mortality rate for someone with a healable, diabetes-related foot wound is similar to, or higher than, that of the most common types of cancer, except for lung and pancreatic cancer. Up to two-thirds of people with diabetes who have had an amputation die within the following year and up to 80% die within 5 years (Singh et al. 2005; Armstrong et al. 2007).
4. Canadian Diabetes Association. 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes.
5. Hemmingsen B et al. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD008143. DOI: 10.1002/14651858.CD008143.pub3.
6. Canadian Institute for Health Information. (2009). Diabetes Care Gaps and Disparities in Canada. Ottawa, Ont.: Canadian Institute for Health Information. Retrieved form https://secure.cihi.ca/free_products/Diabetes_care_gaps_disparities_aib_e.pdf.
7. Canadian Diabetes Association. (2014). Diabetes Policy Summit: Exploring Policy Options for Better Diabetes Outcomes in Ontario. Summary Report. Available at: http://www.diabetes.ca/getmedia/04296601-abef-4342-9c02-71e68683baa3/diabetes-policy-summit-report.pdf.aspx.