An in-depth assessment of diabetes-related lower extremity amputation rates 2000–2013 delivered by twenty-one countries for the data collection 2015 of the Organization for Economic Cooperation and Development (OECD)

  • Fabrizio CarinciEmail author
  • Luigi Uccioli
  • Massimo Massi Benedetti
  • Nicolaas Sieds Klazinga
Original Article



International comparisons of diabetes-related lower extremity amputation rates are still hampered by different criteria used for data collection and analysis. We aimed to evaluate trends and variation of major/minor amputations, using agreed definitions adopted by the Organization for Economic Cooperation and Development in 2015.


Direct age–sex standardized rates were calculated per 100,000 subjects per year between 2000 and 2013, using major/minor amputations with diabetes diagnosis as numerators and the total population or number of people with diabetes as denominators. Longitudinal trends were investigated using generalized estimating equations.


Twenty-one countries reported major amputations referred to the general population, showing a mean reduction from 10.8 to 7.5 per 100,000 (− 30.6%). Eleven countries also reported major amputations among people with diabetes, showing a mean reduction from 182.9 to 128.3 per 100,000 (− 29.8%). Minor amputations remained stable over the study period. Longitudinal trends showed a significant average annual decrease of − 0.19 per 100,000 in the general population (95% CI − 0.36 to − 0.02; p = .03) and − 4.52 per 100,000 among subjects with diabetes (95% CI − 6.09 to − 2.94; p < .001). The coefficient of variation of major amputation rates between countries was fairly high (64%—in the total population, 67% among people with diabetes).


The study highlighted a clinically significant reduction of major amputations, in both the general population and among people with diabetes. The use of standardized definitions, while increasing the comparability of multinational data, highlighted remarkable differences between countries. These results can help identifying and sharing best practices effectively on a global scale.


Lower extremity amputations in diabetes Healthcare Quality Indicators Diabetes care Health systems performance assessment Generalized estimating equations 



The conduction of this study has been made possible through in kind support offered by the Italian Ministry of Health, represented by F. Carle, Director of Office VI, Directorate of Health Policy and Planning, in collaboration with the Italian Agency for Regional Health Services (AGENAS). The new OECD standardized definitions applied in this paper have been delivered with the active contribution of the following members of the EUBIROD network: Jana Lepiksone (Centre for Disease Control, Latvia); Karianne Fjeld Loovas (Noklus, Norway), Scott Cunningham, (University of Dundee, Scotland); Zeliko Metelko (CrodiabNet, University of Zagreb, Croatia); Tamara Poljicanin (National Institute of Public Health, Croatia); Joseph Azzopardi (University of Malta, Malta); Przemka Jarosz-Chobot (Medical University of Silesia, Poland); Iztok Stotl (University of Ljubljana, Slovenia). The following members of the HCQI Expert Group participated to the targeted OECD R&D Study: Deirdre Mulholland and Grainne Cosgrove (Department of Health, Ireland); Yael Applbaum and Ziona Haklai (Ministry of Health, Israel); Hanne Narvulbold (Directorate of Health, Norway) and Veena Raleigh (The King’s Fund, England). The authors are particularly grateful to Ian Brownwood and Nelly Biondi from the OECD Health Division, for their continuous assistance with issues related to the OECD data collection.

Author’s contribution

FC, LU, MMB and NSK conceived and designed this study. FC designed the statistical analysis and analysed the data. FC, LU, MMB and NSK interpreted the results. FC wrote the first draft of the manuscript. FC, LU, MMB and NSK contributed to the writing of the manuscript. FC, LU, MMB and NSK agreed with the results and conclusions of the manuscript. All authors have read and confirmed that they met ICMJE criteria for authorship. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis. FC is the guarantor. We attest that we have obtained appropriate permissions and paid any required fees for use of copyright protected materials.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interests.

Human and animal rights

This article does not contain any studies with human or animal subjects performed by the any of the authors.

Informed consent

All persons gave their informed consent prior to the inclusion in the study.

Supplementary material

592_2019_1423_MOESM1_ESM.docx (33 kb)
Supplementary material 1 (DOCX 32 kb)


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Copyright information

© Springer-Verlag Italia S.r.l., part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Statistical SciencesUniversity of BolognaBolognaItaly
  2. 2.National Agency for Regional Health Services (AGENAS)RomeItaly
  3. 3.Department of Systems MedicineUniversità Tor VergataRomeItaly
  4. 4.Hub for International Health ReSearch (HIRS)PerugiaItaly
  5. 5.Health DivisionOrganisation for Economic Co-operation and Development (OECD)ParisFrance
  6. 6.Academic Medical CentreUniversity of AmsterdamAmsterdamThe Netherlands

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