1. Diabetes and Lower Extremity Amputations in Nova Scotia
Prepared by the Diabetes Care Program of Nova Scotia
Halifax, Nova Scotia
May 2018

2. Overview
DCPNS foot care initiatives
Burden of lower extremity amputations in Nova Scotia (1996/ /12)
Impact of diabetes on lower extremity amputation
Recommendations going forward

3. DCPNS’ sustained focus on the diabetic foot for over 25 years…
1992 – DCPNS guidelines highlight need for routine foot assessments
1997 – Released Surveying and Preventing Diabetes Complications in Nova Scotia
1998 – Public / provider campaigns bring awareness to diabetes-related foot problems
2004 – Hosted Provincial Diabetes Foot Care Roundtable
2007 – Released The Diabetic Foot in Nova Scotia: Challenges
and Opportunities
2010 – Revised standardized provider / patient resources and
tools for use across multiple care settings
Over the last 25 years, the DCPNS has provided ongoing leadership for a number of initiatives that focus intensive prevention efforts on patients at highest risk for foot problems, while promoting population-based prevention messages to the broader diabetes population in NS (p. 3 of Full Report).

4. Focus on the foot continues…
2017 – Completed Diabetes and Lower Extremity Amputations in Nova Scotia
Three broad sections
Detailed analysis of LEA admissions
(i.e., hospital admissions)
Description of adults with and without diabetes
who had one or more LEA admission in a given
year relative to the population as a whole
Drew on diagnostic data in the DCPNS Registry
to present an in-depth analysis of the burden of LEA
separately for those with type 1 and type 2 diabetes
This report describes the most extreme foot problem, LEA, including trends over time and place as well as differences in the timing of LEA relative to diagnosis and survival post-LEA by type of diabetes (type 1 or 2). The report is timed to sustain DCPNS’ focus on foot care and to reenergize efforts in a variety of settings to reduce the risk of LEA through more effective management of diabetes, focused provider and patient education, and access to the required foot care supports for those with the greatest needs (p. 5 of Full Report).

5. Burden of LEA admissions among NS adults, 1996/97-2012/13
affecting 3,491 NS adults
An average of
281
LEAs per year
194
among those
with diabetes
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Over the 17-year period, there were 4,772 LEA admissions affecting 3,491 adult Nova Scotians (pp. 8 & 12 of Full Report)
This number equates to an average of 281 LEA admissions per year
194 per year among people with diabetes (more than two thirds of the annual LEAs)
87 per year among people without diabetes 87
among those
without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

6. Burden of LEA admissions varied across the province
28%
19%
17%
16%
24%
21%
29%
41%
Burden of LEA admissions varied across the province
19%
of adults lived in Eastern Zone
They accounted for
28%
of LEAs
Central Zone
Eastern Zone
Northern Zone
Western Zone
Adult population
LEA admissions
41%
of adults lived in Central Zone
They accounted for 29%
of LEAs
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Relative to the size of the adult population, there were fewer LEA admissions in Central Zone and more in Eastern Zone (p. 9 of Full Report)
The adult population of Central Zone (310k) was more than double that of Eastern Zone (141k), but
The number of LEA admissions was nearly the same (Central: 1,371 vs Eastern: 1,322)
The geographic distribution of LEA admissions was similar for people with and without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

7. LEA admissions among those with diabetes were…
41%
of the LEAs among those with diabetes
involved the toes, foot, or ankle
compared to
26%
among those
without diabetes
…more often at the level of the toes, foot, or ankle
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Level of LEA The location on the lower extremity where the amputation occurred – For admissions with multiple procedures, level refers to the procedure performed closest to the pelvis
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
For people with diabetes, LEAs were more likely to be at the level of the toes, foot, or ankle (p. 10 of Full Report)
At first glance, this finding may appear positive, but more likely, it reflects the progressive nature of LEAs in the diabetes population – starting at the toes and progressing upward if the person survives long enough to have subsequent amputations
■ Toes,
foot, ankle
■ Below knee
■ Knee and above
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

8. LEA admissions among those with diabetes required…
…longer hospital stays
Median length of hospital stay
People with diabetes, stayed
in hospital
1 - 4 days
longer
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Length of Stay Days spent in hospital for a given admission (i.e., from admission to discharge)
Median Length The number of days spent in hospital at which point half of those admitted have been discharged
of Stay – If the median length of stay is 10 days, half of those admitted were discharged after 10 days or less in hospital
Level of LEA The location on the lower extremity where the amputation occurred – For admissions with multiple procedures, level refers to the procedure performed closest to the pelvis
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
To properly understand length of stay, the level of LEA must be taken into account (p. 11 of Full Report)
The overall median length of stay for people with and without diabetes was the same, at 16 days
However, when separated by level of LEA, people with diabetes stayed 1-4 days longer than people without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

9. Over time, the annual number of LEA admissions was…
…stable for those with diabetes, but
decreased for those without diabetes
the burden of LEA was increasingly borne by those with diabetes
Thus
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Recall from slide 5, there was an average of 281 LEA admissions per year (Diabetes = 194, No diabetes = 87)
Also, keep in mind that LEAs are rare, and we expect to see some fluctuation in the number of LEA admissions from year to year
The number of LEA admissions for people with diabetes was fairly stable, while the number of LEA admissions for people without diabetes declined (p. 12 of Full Report)
Diabetes: 193 per year to the end of 2003/04 & 195 per year from 2004/05 onward
No diabetes: 101 per year to the end of 2003/04 & 74 per year from 2004/05 onward
The proportion of LEA admissions occurring among people with diabetes increased over time
66% to the end of 2003/04
72% from 2004/05 onward
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

10. Now, let’s shift our focus…
…from LEA admissions to the people who experienced
those admissions
1996/ /99
5 out of 100
2010/ /13
11 out of 100
Keeping in mind that the
prevalence of diabetes
doubled
between 1996/97 & 2012/12
We will now shift our focus from the 4,772 LEA admissions (denoted by hospital icon) to the 3,491 people who experienced these admissions (denoted by group icon)
While doing so, it is important to keep in mind that the prevalence of diabetes doubled over the 17-year period
In the beginning, 5 out of 10 adult Nova Scotians had diabetes
By the end, 11 out of 100 had diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

11. Over time, the rate of LEA admissions decreased by…
55%
among those
with diabetes
50%
without diabetes
compared to
Diabetes prevalence
doubled
over the same period
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 2012/13
Location: Nova Scotia
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
The LEA admission rate decreased over time, and this decrease was greater for people with diabetes (p. 13 of Full Report)
Diabetes – 55% decrease from 47 per 10,000 to 21 per 10,000
No diabetes – 50% decrease from 2 per 10,000 to 1 per 10,000
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

12. For people with diabetes, the rate of LEA admissions was…
…2x higher among males than females
…2x higher in the oldest vs youngest age group 28
per 10,000 13
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 2010/11 – 2012/13 only
Location: Nova Scotia
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
For people with diabetes, the rate of LEA admissions varied by sex and age (p. 14 of Full Report)
Approximately 2 times higher for males compared to females (28 vs 13 per 10,000)
Increased with age such that it was approximately 2 times higher for adults 80 years and older compared to those years (31 vs 16 per 10,000)
A similar pattern was observed for people without diabetes
80 YEARS & UP
60-79 YEARS
20-59 YEARS 16
per 10,000 31 21
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

13. For people with diabetes, the rate of
in Central Zone 17
per
10,000
in Western Zone 23
in Eastern Zone
in Northern Zone 21
LEA admissions was…
…highest in Western and Eastern Zones
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 2010/11 – 2012/13 only
Location: Nova Scotia
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
For people with diabetes, the rate of LEA admissions varied by health management zone (p. 16 of Full Report)
It was highest in Western & Eastern Zone (23 per 10,000)
And, lowest in Central Zone (17 per 10,000)
In the past (before 2005), rates of some procedures (like LEAs) were under-counted for Northern Zone because the procedures were performed in New Brunswick
This under-counting is unlikely to be a problem for the results reported for 2010/ /13
We included LEAs that were performed in other provinces from 2005 onward (N=30) when information from other provinces became available
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

14. For people with diabetes, the rate of LEA admissions was…
…25x higher compared to those without diabetes
This number varied by age
For
working
age adults (20-59yr)
with diabetes, the rate of
LEAs was
52x
higher than for those without diabetes in 2010/ /13
However
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 1998/99 to 2010/11 – 2012/13
Location: Nova Scotia
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
LEA Admission The rate of LEA admissions among those with diabetes divided by the rate among those without
Rate Ratio diabetes
– A high rate ratio indicates an excess burden for LEA admissions is associated with having diabetes
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
LEA admission rate ratios decreased with age, and this pattern was fairly stable over time (p. 15 of Full Report)
Fluctuations from year to year are expected as there were few LEA admissions among the population without diabetes
These fluctuations are most apparent in the youngest age group (20-59)
In 2010/ /13, working age adults with diabetes (20-59) were 52 times more likely to have an LEA than similar aged people without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

15. Now, let’s zero in on diabetes type…
Drawing on the strength of the DCPNS Registry for …
Date of diagnosis
Type of diabetes
We will draw on the strength of DCPNS’ population-based Diabetes Registry to examine LEA admissions by diabetes type (pp. 6 & 33 of Full Report)
Type 1 and type 2 diabetes are distinct diseases with different underlying causes and patterns of progression
Comorbid conditions are often present at diagnosis with type 2 diabetes, but not with type 1
It is vital to understand type 1 and 2 diabetes as separate entities and to reflect the distinction when reporting on burden
As of March 2017, the DCPNS Registry included records for nearly 107,000 people with diabetes/prediabetes referred to the province’s 38 Diabetes Centres (DCs) since 1994
Included in this number are the 70%-80% of Nova Scotian adults with diabetes who attended a DC at least once

16. People with type 1 diabetes were
At the time of their first LEA admission, people with type 1 diabetes were…
…much younger than those with type 2 diabetes
People with type 1 diabetes were
13 years younger
at their first LEA
… … Age 53 54 63
Type 1 65 67 71
Type 2
■ Toes, foot, ankle
■ Below knee
■ Knee and above
Age at first LEA
Note: This slide deals with the people who had one or more LEA admissions (denoted by group icon) – focusing on the first (and in many cases the only) LEA admission
Time Period: 1996/97 – 2013/14 (additional year allows everyone to be followed up for at least one year)
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Age at First LEA Age in years as of the date of discharge for the first LEA admission in the period
Diabetes type Type 1 or type 2 diabetes as recoded in the DCPNS Registry (i.e., clinically confirmed type)
Adult 20 years of age or older
People with type 1 diabetes were on average 13 years younger at the time of their first LEA admission compared to people with type 2 diabetes (p. 18 of Full Report)
Type 1: years
Type 2: years
A similar pattern was evident for the maximum age at the time of their first LEA admission
Type 1: 86 years
Type 2: 96 years
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

17. At the time of their first LEA admission,
people with type 1 diabetes had their disease for…
13 years
for those with
type 2 diabetes
30 years
compared to
… … Duration 30 37
Type 1
■ Toes, foot, ankle
■ Below knee
■ Knee and above 14 13 12
Type 2
Diabetes (Years)
Duration of
Note: This slide deals with the people who had one or more LEA admissions (denoted by group icon) – focusing on the first (and in many cases the only) LEA admission
Time Period: 1996/97 – 2013/14 (additional year allows everyone to be followed up for at least one year)
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Duration of The number of years between the date of diabetes diagnosis and the date of discharge for the first
Diabetes LEA admission in the period
at First LEA – A negative duration means that individuals were diagnosed with diabetes after their first
LEA in the period
Diabetes type Type 1 or type 2 diabetes as recoded in the DCPNS Registry (i.e., clinically confirmed type)
Adult 20 years of age or older
People with type 1 diabetes had the disease on average 17 years longer than people with type 2 diabetes at the time of their first LEA admission (p. 19 of Full Report)
Type 1: years
Type 2: years
This finding is not surprising – type 1 diabetes has an acute onset and most often is diagnosed in childhood or adolescence
Type 2 diabetes is a progressive disease with blood sugar rising slowly over time – it is most often diagnosed in adulthood
For some people, diabetes-related complications are already apparent at diagnosis – meaning they had the disease for a long time before it was detected
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

18. Time from first LEA (years)
Following their first LEA admission, people with type 1 diabetes lived…
…only 1 year longer compared to those with type 2 diabetes Regardless of the level at which an LEA was performed
100%
80%
60%
40%
20% 0%
Percentage Alive
Time from first LEA (years)
Median survival time
■ Type 1
■ Type 2
4.7 years
5.6 years
Note: This slide deals with the people who had one or more LEA admissions (denoted by group icon) – focusing on the first (and in many cases the only) LEA admission
Time Period: 1996/97 – 2013/14 (additional year allows everyone to be followed up for at least one year)
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Survival Time The length of time between individuals’ discharge from the first LEA admission in the period until their death or the end of the period
Median The length of time after discharge from the first LEA admission in the period by which half the
Survival Time individuals have died and half remain alive, taking into account that some were followed for a longer period than others
– Median survival is often displayed graphically using a special chart called a survival
■ The percentage of people alive is displayed vertically (from 0% to 100%)
~ 50% = median survival
■ The time since the event (in our case first LEA) is displayed horizontally
Post_LEA Period after an individuals’ discharge from the first LEA admission in the period
Diabetes type Type 1 or type 2 diabetes as recoded in the DCPNS Registry (i.e., clinically confirmed type)
Adult 20 years of age or older
People with type 1 diabetes lived one year longer post-LEA compared to people with type 2 diabetes (p. 21 of Full Report)
Median survival = 5.6 years for type 1 vs 4.7 years for type 2
This pattern held for each level of LEA
So despite have their first LEA admission at a much younger age, people with type 1 diabetes only lived one year longer post-LEA than people with type 2 diabetes.
Emphasizes the importance of prevention – the key to surviving an LEA is preventing it.
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

19. Five years after their first LEA admission…
57%
of people with
type 1 diabetes
were still alive
48%
type 2 diabetes
compared to
100%
80%
60%
40%
20% 0%
Percentage Alive
Time from first LEA (years)
■ Type 1
■ Type 2
48%
57%
5 years
13%
24%
15 years
Note: This slide deals with the people who had one or more LEA admissions (denoted by group icon) – focusing on the first (and in many cases the only) LEA admission
Time Period: 1996/97 – 2013/14 (additional year allows everyone to be followed up for at least one year)
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Survival Time The length of time between individuals’ discharge from the first LEA admission in the period until their death or the end of the period
Median The length of time after discharge from the first LEA admission in the period by which half the
Survival Time individuals have died and half remain alive, taking into account that some were followed for a longer period than others
– Median survival is often displayed graphically using a special chart called a survival
■ The percentage of people alive is displayed vertically (from 0% to 100%)
~ 50% = median survival
■ The time since the event (in our case first LEA) is displayed horizontally
Post_LEA Period after an individuals’ discharge from the first LEA admission in the period
Diabetes type Type 1 or type 2 diabetes as recoded in the DCPNS Registry (i.e., clinically confirmed type)
Adult 20 years of age or older
If we focus on time since first LEA (horizontal axis)…
At any given time post-LEA, the percentage of people with type 1 diabetes still alive exceeded that of people with type 2 diabetes by 7% to 11% (p. 21 of Full Report)
5 years after being discharged from their first LEA admission,
57% of those with type 1 diabetes were still alive, vs
48% of those with type 2 diabetes
15 years after being discharged from their first LEA admission,
24% of those with type 1 diabetes were still alive, vs
13% of those with type 2 diabetes
By 15 years post-LEA, these numbers dropped to
24% and 13%
respectively
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

20. Following their first LEA admission, people lived…
…longest if their LEA was at the level of the toes, foot, or ankle
…at the toes, foot, or ankle lived 3x
longer
…below the knee lived 2x
People who had their first LEA…
compared to
people who had their first LEA
at the knee or above
100%
80%
60%
40%
20% 0%
Percentage Alive
Time from first LEA (years)
Median survival time
2.1 years
6.3
years
■ Toes, foot, ankle
■ Below knee
■ Knee and above
4.3 years
Note: This slide deals with the people who had one or more LEA admissions (denoted by group icon) – focusing on the first (and in many cases the only) LEA admission
Time Period: 1996/97 – 2013/14 (additional year allows everyone to be followed up for at least one year)
Location: Nova Scotia
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Level of LEA The location on the lower extremity where the amputation occurred – For admissions with multiple procedures, level refers to the procedure performed closest to the pelvis
Survival Time The length of time between individuals’ discharge from the first LEA admission in the period until their death or the end of the period
Median The length of time after discharge from the first LEA admission in the period by which half the
Survival Time individuals have died and half remain alive, taking into account that some were followed for a longer period than others
– Median survival is often displayed graphically using a special chart called a survival
■ The percentage of people alive is displayed vertically (from 0% to 100%)
~ 50% = median survival
■ The time since the event (in our case first LEA) is displayed horizontally
Post_LEA Period after an individuals’ discharge from the first LEA admission in the period
Diabetes type Type 1 or type 2 diabetes as recoded in the DCPNS Registry (i.e., clinically confirmed type)
Adult 20 years of age or older
For each level of LEA, people with type 1 diabetes lived approximately one year longer post-LEA compared to people with type 2 diabetes (p. 22 of Full Report)
If people with type 1 and type 2 diabetes are grouped together, those who had their first LEA at the level of the toes/foot/ankle lived the longest – median survival was…
6.3 years if the first LEA was at the toes, foot, or ankle vs 4.3 years if it was below the knee vs 2.1 years if it was at the knee or above
Difference in survival were evident at discharge (Time from first LEA = 0)
97% of people lived long enough to be discharged from hospital if their first LEA was at the toes, foot, or ankle (vs 90% if it was below the knee and 85% if it was at the knee or above)
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

21. There has been sustained focus on the diabetic foot for over 25 years
To summarize…
There has been sustained focus on the diabetic foot for over 25 years
Guidelines & standardized resources
Awareness campaigns
Roundtable discussions
Surveillance reports
Most recently… Diabetes and Lower Extremity Amputations in Nova Scotia

22. Significant decrease in LEA rate over time
To summarize…
About 281 LEAs annually
Mostly affecting people with diabetes, who tend to require longer hospitalizations
Significant decrease in LEA rate over time
Greater decrease among people with diabetes, possibly reflecting ongoing focus on the diabetic foot
Yet, LEAs remain a significant problem
Especially for males, older adults, and those living in the Eastern and Western Zones
For those with type 1 diabetes, LEAs occur during productive working years
Regardless of type, prognosis is grim, with approximately ½ dying within 5 years of the first LEA

23. Moving forward, we need to…
Educate health care professional
Perform and document routine foot assessments using standardized tools
Educate people with diabetes
About foot problems and preventive practices
Advocate for better foot care services
Mechanisms to off-set cost of routine foot care for moderate and high-risk feet
Guidelines for need-based coverage for appropriate footwear and off-loading devices
for more details see p of the Full Report

24. Moving forward, we need to…
Provide appropriate and timely treatment
Foot care and vascular services
Address underlying psychosocial determinate of health
Provide care in holistic manner
Consider the whole patient not just the foot pathology
for more details see p of the Full Report

25. For more details about LEAs in Nova Scotia…
Diabetes and Lower Extremity Amputations in Nova Scotia
Full Report
Available at
Highlights
Available at

26. Supplementary slides for Western Zone

27. Burden of LEA admissions among Western Zone adults, 1996/97-2012/13
1,142 LEA admissions over 17 years 46
among those
with diabetes
An average of 67
LEAs per year
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Western Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Over the 17-year period, there were 1,142 LEA admissions in Western Zone (p. 9 of Full Report)
This number equates to an average of 67 LEA admissions per year
46 per year among people with diabetes (more than two thirds of the annual LEAs)
21 per year among people without diabetes 21
among those
without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

28. Over time, the annual number of LEA admissions in Western Zone…
…increased for those with diabetes, but
decreased for those without diabetes
the burden of LEA was increasingly borne by those with diabetes
Thus
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Western Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Recall there was an average of 67 LEA admissions per year in Western Zone (Diabetes = 46, No diabetes = 21)
Also, keep in mind that LEAs are rare, and we expect to see some fluctuation in the number of LEA admissions from year to year
The number of LEA admissions for people with diabetes increased, while the number of LEA admissions for people without diabetes declined (p. 28 of Full Report)
Diabetes: 44 per year to the end of 2003/04 & 49 per year from 2004/05 onward
The increase was heavily influenced by the 69 LEA admissions in 2011/12
No diabetes: 23 per year to the end of 2003/04 & 19 per year from 2004/05 onward
The proportion of LEA admissions occurring among people with diabetes increased over time
66% to the end of 2003/04
72% from 2004/05 onward
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

29. Over time, the rate of LEA admissions in Western Zone decreased by…
51%
among those
with diabetes
34%
without diabetes
compared to
Diabetes prevalence
doubled
over the same period
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 2012/13
Location: Western Zone
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Diabetes prevalence more than doubled between 1996/ /99 and 2010/ /13
Increased from 6% to 13%
The LEA admission rate decreased over time, and this decrease was greater for people with diabetes (p. 30 of Full Report)
Diabetes – 51% decrease from 47 per 10,000 to 23 per 10,000
No diabetes – 34% decrease from just less than 2 per 10,000 to just over 1 per 10,000
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

30. Supplementary slides for Northern Zone

31. Burden of LEA admissions among Northern Zone adults, 1996/97-2012/13
832 LEA admissions over 17 years 33
among those
with diabetes
An average of 49
LEAs per year
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Northern Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Over the 17-year period, there were 832 LEA admissions in Northern Zone (p. 9 of Full Report)
This number equates to an average of 49 LEA admissions per year
33 per year among people with diabetes (more than two thirds of the annual LEAs)
16 per year among people without diabetes 16
among those
without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

32. Over time, the annual number of LEA admissions in Northern Zone…
…increased for those with diabetes, but
decreased for those without diabetes
the burden of LEA was increasingly borne by those with diabetes
Thus
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Northern Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Recall there was an average of 49 LEA admissions per year in Northern Zone (Diabetes = 33, No diabetes = 16)
Also, keep in mind that LEAs are rare, and we expect to see some fluctuation in the number of LEA admissions from year to year
The number of LEA admissions for people with diabetes increased, while the number of LEA admissions for people without diabetes declined (p. 28 of Full Report)
Diabetes: 30 per year to the end of 2003/04 & 36 per year from 2004/05 onward
No diabetes: 19 per year to the end of 2003/04 & 13 per year from 2004/05 onward
The proportion of LEA admissions occurring among people with diabetes increased over time
61% to the end of 2003/04
73% from 2004/05 onward
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

33. Over time, the rate of LEA admissions in Northern Zone decreased by…
58%
among those
with diabetes
61%
without diabetes
compared to
Diabetes prevalence
doubled
over the same period
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 2012/13
Location: Northern Zone
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Diabetes prevalence more than doubled between 1996/ /99 and 2010/ /13
Increased from 5% to 11%
The LEA admission rate decreased over time for people with and without diabetes (p. 30 of Full Report)
Diabetes – 58% decrease from 50 per 10,000 to 21 per 10,000
No diabetes – 61% decrease from just over 2 per 10,000 to just under 1 per 10,000
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

34. Supplementary slides for EAstern Zone

35. Burden of LEA admissions among Eastern Zone adults, 1996/97-2012/13
1,322 LEA admissions over 17 years 55
among those
with diabetes
An average of 78
LEAs per year
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Eastern Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Over the 17-year period, there were 1,322 LEA admissions in Eastern Zone (p. 9 of Full Report)
This number equates to an average of 78 LEA admissions per year
55 per year among people with diabetes (more than two thirds of the annual LEAs)
22 per year among people without diabetes 22
among those
without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

36. Over time, the annual number of LEA admissions in Eastern Zone was…
…fairly stable for those with diabetes, but
decreased for those without diabetes
the burden of LEA was increasingly borne by those with diabetes
Thus
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Eastern Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Recall there was an average of 78 LEA admissions per year in Eastern Zone (Diabetes = 55, No diabetes = 22)
Also, keep in mind that LEAs are rare, and we expect to see some fluctuation in the number of LEA admissions from year to year
The number of LEA admissions for people with diabetes was fairly stable, while the number of LEA admissions for people without diabetes declined (p. 29 of Full Report)
Diabetes: 57 per year to the end of 2003/04 & 54 per year from 2004/05 onward
No diabetes: 25 per year to the end of 2003/04 & 20 per year from 2004/05 onward
The proportion of LEA admissions occurring among people with diabetes increased over time
69% to the end of 2003/04
74% from 2004/05 onward
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

37. Over time, the rate of LEA admissions in Eastern Zone decreased by…
56%
among those
with diabetes
41%
without diabetes
compared to
Diabetes prevalence
doubled
over the same period
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 2012/13
Location: Eastern Zone
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Diabetes prevalence more than doubled between 1996/ /99 and 2010/ /13
Increased from 6% to 13%
The LEA admission rate decreased over time, and this decrease was greater for people with diabetes (p. 31 of Full Report)
Diabetes – 56% decrease from 52 per 10,000 to 23 per 10,000
No diabetes – 41% decrease from just less than 2 per 10,000 to just over 1 per 10,000
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

38. Supplementary slides for Central Zone

39. Burden of LEA admissions among Central Zone adults, 1996/97-2012/13
1,371 LEA admissions over 17 years 55
among those
with diabetes
An average of 81
LEAs per year
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Central Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Over the 17-year period, there were 1,371 LEA admissions in Central Zone (p. 9 of Full Report)
This number equates to an average of 81 LEA admissions per year
55 per year among people with diabetes (more than two thirds of the annual LEAs)
26 per year among people without diabetes 26
among those
without diabetes
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

40. Over time, the annual number of LEA admissions in Central Zone was…
…stable for those with diabetes, but
decreased for those without diabetes
the burden of LEA was increasingly borne by those with diabetes
Thus
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with LEA admissions (denoted by hospital icon) – A person can have more than one LEA admission
Time Period: 1996/97 – 2012/13
Location: Central Zone
LEA Admission An acute in-patient hospital admission for which there is one or more procedure codes denoting an amputation of the lower limb at any point during the admission
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Recall there was an average of 81 LEA admissions per year in Central Zone (Diabetes = 55, No diabetes = 26)
Also, keep in mind that LEAs are rare, and we expect to see some fluctuation in the number of LEA admissions from year to year
The number of LEA admissions for people with diabetes was stable, while the number of LEA admissions for people without diabetes declined (p. 29 of Full Report)
Diabetes: 54 per year to the end of 2003/04 & 56 per year from 2004/05 onward
No diabetes: 30 per year to the end of 2003/04 & 22 per year from 2004/05 onward
The proportion of LEA admissions occurring among people with diabetes increased over time
65% to the end of 2003/04
72% from 2004/05 onward
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017

41. Over time, the rate of LEA admissions in Central Zone decreased by…
58%
among those
with diabetes
65%
without diabetes
compared to
Diabetes prevalence
Nearly doubled
over the same period
NOTE: Interpret with caution as the number of LEAs among those without diabetes is very low
Note: This slide deals with the people who had one or more LEA admissions in a given year (denoted by group icon)
Time Period: 1996/97 – 2012/13
Location: Central Zone
LEA Admission The average number of adults with one or more LEA admissions in a given 3-year period (sum of
Rate LEAs divided by 3) divided by the average population for that 3-year period (sum of population divided by 3)
– Individuals who had multiple admissions in a year were counted only once in that year
– Individuals who had admissions in multiple years were counted once in each of those years
Diabetes Person had 1 hospitalisation and/or 2 primary care claims with a diagnosis code for diabetes – Once a person is identified as a case, he/she remains a case for all subsequent years
Adult 20 years of age or older
Diabetes prevalence nearly doubled between 1996/ /99 and 2010/ /13
Increased from 5% to 9%
The LEA admission rate decreased over time for people with and without diabetes (p. 31 of Full Report)
Diabetes – 58% decrease from 42 per 10,000 to 18 per 10,000
No diabetes – 65% decrease from just less than 2 per 10,000 to less than 1 per 10,000
Data Source: Diabetes Care Program of Nova Scotia. Diabetes and Lower Extremity Amputations in Nova Scotia, November 2017