Diabetes accounts for about two-thirds of lower limb amputations in Canada.Reference3 This report used pan-Canadian data from 2020–2021 to 2022–2023 to examine equity in diabetes care, with a focus on lower limb amputations (i.e., amputations of the leg, ankle, foot or toe).

Diabetes-associated lower limb amputations are largely preventable, and they have high health system and societal costs. Data on these procedures is readily available in CIHI’s comprehensive hospital data holdings for reporting at national, provincial and territorial levels. In this analysis, we included amputations for patients with a diabetes diagnosis, unless the amputation was associated with trauma or cancer, or the diagnosis was for gestational diabetes.

Lower limb amputations among those with diabetes are commonly preceded by foot ulcers or infected wounds. This analysis also examined hospitalizations that involved care for diabetes-associated ulcers, gangrene and infections in the lower limb but did not involve an amputation.

Evidence suggests that diabetes-associated amputations disproportionately affect equity-deserving populations.Reference4 Reference5 Reference6 This analysis focused on inequalities defined by age; recorded sex or gender (referred to here as “sex”); neighbourhood-level measures of income, high school completion and social deprivation; and rurality/remoteness, as derived using patients’ postal codes.

To compare populations, we primarily calculated age-standardized rates relative to the overall total population. To start to understand the impact of diabetes prevalence versus diabetes management on amputation rates, we also calculated rates relative to the number of people with diabetes (i.e., prevalence), using both administrative and survey data sources.

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• Each year from 2020–2021 to 2022–2023, there were about 7,720 hospitalizations for lower limb amputations associated with diabetes. 3,080 of these involved a leg amputation. There were also 23,500 diabetes-associated hospitalizations for treatment of ulcers, gangrene or infections.
• Together, these hospitalizations accounted for approximately $750 million annually; however, this reflects a fraction of the total system costs associated with diabetic foot ulcers and amputations.
• Patients who received a leg amputation spent about 19 days in hospital. These patients often require multiple procedures during their stay and have a high risk of readmission and in-hospital death. Costs for these hospitalizations were high at about $47,000 per stay.
• About 43% of amputations occurred among those age 40 to 64. 
• Males with diabetes were 2 to 3 times more likely than females to have an amputation or to be hospitalized with a lower limb complication. 
• Lower limb complications were also more common for those living in neighbourhoods with lower income, lower high school completion and higher social deprivation, as well as in rural and remote communities. 
• Inequalities among population groups and variation among the provinces and territories appear related to both diabetes prevention and management.

These findings shed light on the potential health system and societal benefits of preventing amputations and other diabetes complications, particularly among equity-deserving populations. ������ϱ� systems can use this information to support strategies that improve access to primary care and early intervention for patients at higher risk of diabetes complications. 

Wounds Canada’s Pathway for Preventing and Managing Diabetic Foot Complications outlines a risk-based approach for preventing ulcers and amputations. This approach begins with primary care services for early detection and screening, and extends to specialized services for foot and wound care.Reference7 Reference8 Stakeholders from across Canada, including Wounds Canada, have called for a strong focus on prevention, emphasizing early detection and education that is tailored to specific populations and that considers the social determinants of health and health equity. By ensuring care is both timely and effective, care pathways aim to reduce the incidence of diabetes-related complications and improve patient outcomes.  

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Approximately 80% of leg amputations related to diabetes are preventable with the right care at the right time. Regular foot screening prevents wounds and should include a foot exam, treating high-risk features such as removing calluses, making sure a person’s footwear is protective and talking about foot health when living with diabetes. If a foot wound arises, rapid access to care, ideally multidisciplinary, is limb-saving — Dr. Charles de Mestral, Surgeon, Unity ������ϱ� Toronto

������ϱ�and other national, provincial and territorial organizations and stakeholders are working to modernize and connect pan-Canadian health data. 

Data for equity stratification 

To enable more comprehensive analysis of health system inequalities, work is underway to embed socio-demographic data in health care data, or to link these 2 types of data. For example, as of April 2022, optional race-based and First Nations, Inuit and Métis identity data collection has been introduced for inpatient and ambulatory care data in Canada.Reference9 ������ϱ�is committed to working in collaboration with First Nations, Inuit and Métis Peoples, communities, governments and organizations on health, wellness and data priorities, as defined by them. Standardized and more comprehensive socio-demographic data collection is also an integral component of CIHI’s Connected Care initiative.

Data to examine access to effective health care

Addressing inequities in long-term diabetes complications, such as lower limb amputations, requires an understanding of where barriers and inequities occur along the trajectory of diabetes prevention and management. To do this, recent and disaggregated data is needed on the quality of primary care. For example, an identified gap is the lack of recent data on the proportion of those diagnosed with diabetes who receive regular foot checks.Reference10

Using data collected by the provinces and territories, the Public ������ϱ� Agency of Canada monitors the number of people living with diabetes in Canada through the Canadian Chronic Disease Surveillance System. Ongoing investments through the Framework for Diabetes in Canada will enhance diabetes monitoring and reporting. CIHI’s modernization of health workforce data will also allow analysis based on a provider’s area of practice (e.g., diabetes care, amputation care, foot care). 

• Measuring ������ϱ� Inequalities: A Toolkit
• First Nations, Inuit and Métis health 
• Race-based and Indigenous identity data
• Connected care
• What’s New With ������ϱ� Workforce Information at ������ϱ�(PDF)