Singapore has one of the highest rates of lower extremity amputation (LEA) in the world, with public hospitals here needing to conduct some four amputation procedures a day.
Researchers from the National Healthcare Group Health Services & Outcomes Research (HSOR) department conducted a 10-year retrospective study of 2,170 diabetes patients with LEA from Tan Tock Seng Hospital. Their average age was about 64 and some 22% died within one year. Mortality was due to multiple complications.
DIABETES AND LOWER EXTREMITY AMPUTATIONS IN SINGAPORE – A SUMMARY
- Definition: Lower extremity amputation (LEA) is defined as the surgical removal of the toe, foot or leg. (Major LEA refers to amputation of the leg, below or above the knee.)
- Early signs: A major complication of poorly controlled diabetes is arterial disease which affects blood vessels supplying multiple organs. High blood sugar causes a shutdown of the process which maintains and protects healthy blood vessels from damage, resulting in vessels hardening and narrowing. Depending on which blood vessels are affected, this can lead to heart disease, stroke, or peripheral arterial disease. In addition, diabetes can affect the peripheral nervous system, leading to neuropathy or loss of sensation. Long standing diabetes may also be associated with kidney disease, retinopathy and impaired vision.
- Diabetes is a multi-organ disease: The combination of these factors can lead to blindness, loss of feeling, foot ulcers, infection and gangrene. Without early and adequate treatment, this can progress to lower extremity amputation. About 20% of all diabetes patients will develop foot ulcers in their lifetime. In half of these cases, patients will also suffer from peripheral arterial disease. The importance of foot ulcers in the evolution to limb loss is underscored by the fact that some 85% of major amputations are preceded by foot ulcers.
- Major contributing factors to LEA:
– Late presentation: Ideally, patients with a foot lesion should visit the doctor as soon as possible. Delays of a few days or weeks drastically reduce chances of successful intervention to save limbs.
– Co-morbidities: About 80% of LEA patients have significant co-morbidities which include high blood pressure, and ischaemic heart disease.
– Lack of awareness/ poor control of diabetes: Patients are often unaware of the risks posed by untreated foot ulcers. Some have poorly controlled diabetes which can accelerate the spread of infection and result in an unsalvageable situation.
TIMELY INTERVENTIONS NEEDED
Patients who seek treatment early enough have the option of various intervention treatments to salvage limbs. These include treatment of infection (drainage of abscesses or debridement) and re-vascularisation (angioplasty or bypass). At TTSH, limb salvage therapies have led to a 20% reduction in LEA operations in 2015 compared to the year before.
MOVING FORWARD – INTEGRATED CARE
Patient education and screening in the community can lead to early interventions and potentially reduce the need for LEA. NHG is working towards more seamless integration between the acute hospital, primary care and community sectors to provide patients with a robust support network and promote wellness. “This is in line with the healthcare sector’s shift from episodic to sustainable integrated care, developing a model that emphasises closer relationships between the patients and the healthcare system,” said Professor Philip Choo, Group CEO of NHG.
“This is a major paradigm shift from illness care to wellness care. We need to move away from transactional medicine, where patients are told what to do. The new model of care aims to encourage patients to take greater ownership of their health, promote behavioural changes and better lifestyle habits, as well as early detection of diseases through appropriate health screening and case finding. It also integrates the healthcare system with social service providers in the community, enabling those with stable chronic conditions to be better managed at home.”