Epidemiology of Foot Ulceration and Amputation Can Global Variation be Explained?

There is considerable apparent variation in the incidence of amputation for diabetes, both between countries and within them. Very many factors contribute to such variation and some of these relate to details of how relevant data are obtained and analysed, while others include race, social deprivation, and access to effective health care services. The rapidly increasing prevalence of known diabetes, as well as increasingly inclusive criteria for its diagnosis, will also result in an apparent variability in incidence, especially when diabetes-related amputation is expressed in terms of the total, as opposed to the at risk, population. The complexity of the interactions which may impact on the calculated incidence of amputation means that great care must be exercised before meaningful conclusions can be drawn from comparisons made between different countries. On the other hand, reports from the USA and UK of up to ten-fold variation in amputation incidence within the same country require more urgent consideration. While race, social deprivation and restricted access to effective health care are important, there is increasing evidence that a major explanation for observed variation may lie in differences in the structure of medical services available for people at risk of, or who develop, disease of the foot in diabetes, as well as differences in the skills and beliefs of those who care for them. One of the strongest pieces of evidence for the importance of the professional performance is the marked decline in incidence of amputation reported from an increasing number of centres and achieved simply by altering the way in which local foot care services are provided. It must be remembered that amputation is a treatment, and not a direct marker of the natural history of disease, and treatments are selected by patients on the advice of their caregivers.