Diabetic Amputation Rates Soar in California

Diabetic Amputation Rates Soar in California


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.

Asked for comment, officials for the California Department of Public Health responded with one sentence, saying it "does not have information" on possible reasons.

Benjamin Cullen, DPM, 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.

Jonathan Labovitz, DPM, a Pomona foot and ankle surgeon and podiatry researcher affiliated with the UCLA Center for Health Policy Research, pointed to the change in the state's Medicaid (Medi-Cal in CA) program's policy 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.


(Source: Cheryl Clark, Senior Staff Writer inewsource/MedPage Today [9/22/2017])