No clear cause, but experts suggest numerous possibilities.
Over the past 7 years, California clinicians have been amputating toes, feet, ankles and legs of patients with diabetes-related ischemia with much greater frequency than before, and public health officials, diabetes clinicians, and surgeons said they’re puzzled by the trend.
Statewide, there was a 31% increase in these non-trauma amputations after adjusting for changes in population from 2010 to 2016. Adjusted increases reached 66% in San Diego County, with a population of 3.3 million.
In other populous areas of the state, Riverside County (population 2.4 million) had a 62% increase in diabetes amputations among residents. San Bernardino County (2.1 million) had a 61% increase. Sacramento County (1.5 million people), 47%. And Los Angeles County, with more than 10 million people, saw a 20% increase.
By raw numbers statewide, there were 12,490 diabetes-related amputations in 2016, up from 8,980 in 2010, with almost all counties seeing steady increases year over year.
The data — filtered for more than 100 ICD-9 and ICD-10 codes by county, hospital, body part surgery, and payer — was requested from the Office of Statewide Health Planning and Development, the California agency that collects diagnostic codes for inpatients treated by all hospitals within the state. It was then analyzed to adjust for changes in population.
Asked for comment, officials for the California Department of Public Health responded with one sentence, saying it “does not have information” on possible reasons.
CDC Taking Note
Edward Gregg, chief of epidemiology and statistics for the CDC, said the trend is troublesome. National statistics for 2010 to 2014 show a 27% increase; before 2009, amputation rates had been dropping.
Gregg said that from a public health standpoint, “the rate of amputations is a very important indicator of overall diabetes care. If we see it going down, then it’s a good sign, because so many aspects of good diabetes care in theory are affected. And when you see it going up, that’s a concern,” he said.
He couldn’t say definitively why rates have been increasing, adding that the CDC will be working on the issue. But he and others offered theories.
For starters, the nation is aging, and advancing age is a risk factor for diabetes, and more people are being diagnosed with diabetes. But neither explanation can account for much of the recent increases, Gregg said. For one thing, rates in the diabetic population are increasing too, even after adjusting for age: from 2.7 per 1,000 in 2009 to 4.1 in 2014.
Though amputations can stop infection and save lives, diabetes-related amputations deprive patients of independence, increase the need for social services, and add to disability and medical costs. On occasion, they must be repeated when infections spread and amputation incisions don’t heal. But amputations are drastic, and should be performed only when other remedies fail, many experts stressed.
But too many clinicians are impatient, said Caesar Anderson, MD, a University of California San Diego diabetes wound and emergency medicine specialist, who said he was “shocked” by the data. He pointed to emergency room personnel and surgeons who he sees rushing to amputate “even when the wound is not that alarming.”
Anderson blamed a “culture of frustration” among clinicians who say to the patient “you’ll never get better; we’ll probably just save you the headache and just amputate … and we have some fantastic protheses we can get you into … let’s just get it over with.”
Misty Humphries, MD, a vascular surgeon and diabetes-related amputation researcher at the University of California Davis, also noticed the increase with data she collected between 2010 and 2013. She suggested hospitals may be more diligently coding patients with diabetes because of payment rule changes that increase reimbursement when health services involve patients with multiple comorbidities.
But that appeared unlikely, at least for parts of the California. According to the state’s data, the number of patients admitted to any San Diego hospital for any reason who were coded for diabetes increased only one-fifth of 1 percent from 2010 to 2016.
Humphries said that better medication and devices such as pacemakers are keeping people with high blood pressure and cardiac disease alive longer, but those medical advances don’t “protect the rest of their body from age-related deterioration” of blood vessels in their lower limbs. “We do see an increase in amputations for that particular group of patients who are now elderly, non-ambulatory, and not really doing as much but they are still alive.”
Humphries said she believes a big part of the problem is how common diabetes now is, with an estimated 29 million nationally with the disease. Being diabetic may have become so much the norm, patients think they “can just take a pill … and you don’t really have to change your diet.”
Benjamin Cullen, MD, a foot and ankle surgeon with Scripps Mercy Hospital, noted that many patients may delay care until a family member notices the wound, and rushes them to the emergency room.
California’s data underscored Cullen’s point: At least in San Diego County, more than 76% of the patients who received an amputation entered the hospital through the emergency room, suggesting that patients waited, or even didn’t recognize a problem, until it became acute.
“With diabetes, patients have neuropathy, so they can’t feel their foot,” Cullen said. “They get a wound, don’t know it’s there, the wound gets infected and they don’t realize it. The first sign that they have is a foul odor coming from their foot, or a family member notices drainage.”
Often, the infection has gotten into the bone, he said, leaving “no choice but to go ahead with the amputation” to try to save other parts of the limb.
Cullen and others noted that after patients with diabetes-related infections or other wounds are seen by a doctor or at a hospital, surgeons often perform revascularization procedures to restore circulation.
Then, patients are often referred to wound clinics and given prevention instructions going forward.
But those strategies don’t work for everyone, said James Longobardi, DPM, chief of surgery at Scripps Mercy’s Chula Vista campus, just north of the Mexican border, and one who specializes in diabetes-related foot care.
He blamed the increase at his hospital on health literacy. Many of his patients — for a variety of cultural, dietary and other reasons — “can’t grasp the seriousness of the situation, and it’s very, very frustrating to many of our clinicians.”
Gregg speculated that the American Diabetes Association’s 2010 recommendation that clinicians use A1c tests to diagnose diabetes may be capturing patients with “worse heath status, higher blood pressure, worse circulation” than fasting glucose tests. “That could affect rates of amputations too,” he said.
Other factors include less attention to risk factor management by patients or clinicians, and perhaps some subgroups getting screened later or less often than recommended, Gregg said.
Linda Geiss, director of the CDC’s diabetes surveillance section, postulated some of the increase may be delayed fallout from the 2008 recession, when people lost jobs and health insurance, and perhaps skipped medical care for several years. The Affordable Care Act’s health coverage expansions could explain increases from 2014 to 2016, but not those between 2010 and 2013.
In California, many clinicians had numerous explanations for higher numbers, especially in certain counties.
Jonathan Labovitz, DPM, a Pomona foot and ankle surgeon and podiatry researcher affiliated with the UCLA Center for Health Policy Research, blamed the state Medicaid program’s policy change in July 2009, and documented his reasons in this June policy brief.
That cost-cutting move excluded podiatry services from being reimbursed, except in certain situations. That may have reduced wound and foot care services that allowed conditions to worsen, said Labovitz, who also is assistant dean at Western University of Health Sciences College of Podiatric Medicine.
State health officials confirmed the policy change, but declined to comment on whether it increased amputations.
David Armstrong, DPM, MD, PhD, of the University of Southern California’s Keck School of Medicine, theorized that a small portion of the increase might be due to the American Diabetes Association’s broadened definition of diabetes in 1997, from at least 140 mg/dL fasting glucose to at least 126 mg/dL.
That lower threshold resulted in healthier people being captured in the denominator, and made the rate of amputations among people with diabetes appear to drop over the next decade or so, he said. It’s possible that over the next 10 to 20 years, as those people with diabetes progressed, more developed severe blood circulation problems that since 2010 resulted in them having to undergo limb surgery, Armstrong suggested.
But if that indeed is an important factor, the increased rates of amputations would not be as dramatic since 2010, he acknowledged. In the California data, the denominator is hospitalized patients with diabetes, not all diabetes patients.
“It’s just as likely, if not more so, that the economic funk in 2009, [which also was] when podiatric care was eliminated for people with diabetes, contributed to a bump in amputation rates,” he said.
Anne Peters, MD, director of the University of Southern California Clinical Diabetes Program, blamed regional impediments to access to care.
For example, she said, San Diego has no county hospital, like Los Angeles and many other large counties. She stressed the need for better access to care and stronger prevention messages, “letting people know what to look for and where to go should they develop a small lower extremity lesion so it can be treated before it becomes an amputation.”
Could more amputations be better?
Several diabetes specialists and public health officials suggested the increase in amputations could be a good thing, a sign that persistent diabetes-related wounds are not being allowed to fester. Maybe with more distal amputations of toes, and feet, ankles and legs are being spared, they said.
It could be “more a marker of success than failure,” said Philip Goodney, MD, a vascular surgeon and limb amputation researcher with the Dartmouth Institute in New Hampshire, which analyzes Medicare data to see health trends.
While it’s hard to know what California’s data means without more complicated analyses, Goodney said amputations of toes and transmetatarsal procedures across the foot may spare the ankle and leg, and still maintain enough of the foot so patients can still walk.
“I tell my patients that the toes are there for decoration. If we can help you keep your foot, then you can live at home and live independently. It’s when you get your below-knee amputation or your above-knee amputation that the sort of major impacts on quality of life starts to happen,” Goodney said.
The CDC’s Gregg, however, was doubtful. “It’s hard to buy the argument that an increase is good,” he said.