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About 3.7 million people (9.4%) had been diagnosed with diabetes in Canada as of 2020–2021, and at least 2% of adults are living with undiagnosed diabetes.Reference3 The overall number of people living with diabetes is growing over time due to an aging population and increasing incidence.Reference4

For those living with diabetes, the lifetime risk of developing a foot ulcer is about 15% to 25%.Reference5 This means that roughly 550,000 to 920,000 Canadians currently living with diabetes are predicted to experience some degree of foot complication, putting them in need of specialized services and at greater risk of a lower limb amputation if their care needs are not met.Reference5

Patients with lower limb amputations may experience loss of function, reduced quality of life, depression and high risk of premature death.Reference6 Reference7 For health systems, amputations are costly and signal that there are opportunities to improve service delivery and reduce the risk of diabetes-related complications.Reference8

Sources
Armstrong DG, et al. . Journal of Foot and Ankle Research. 2020.
Botros M, et al.; Wounds Canada. . In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada. 2017.
de Mestral, et al. . JAMA Network Open. 2022.
International Working Group on the Diabetic Foot (IWGDF). . 2023

Based on data from 2020–2021 to 2022–2023, there were about 7,720 lower limb amputations associated with diabetes annually, among those age 18 and older in Canada. 3,080 hospitalizations involved a leg (i.e., above-ankle or “major”) amputation, and 4,640 were for an ankle, foot or toe (i.e., ankle-and-below or “minor”) amputation without also involving a leg amputation. For this analysis, each hospitalization was assigned to only 1 outcome, based on severity.

Leg amputations are considered the more severe type of lower limb amputation and are used internationally and within Canada for health system reporting and monitoring of diabetes care quality.Reference9 Reference10 Reference11 Reference12 Reference13 It is widely cited that up to 85% of leg amputations are preventable.Reference2 Reference5

Ankle, foot and toe amputations associated with diabetes are also undesirable and preventable outcomes that reflect unmet health care needs; they often precede or accompany a leg amputation. In some provinces and territories, rates of ankle-and-below amputations have increased over time, which may reflect changing surgical practices and efforts to save limbs (i.e., carrying out a foot or toe amputation to prevent a leg amputation).Reference14 Reference15 Reference16

Among those receiving an amputation, 86% had a documented diagnosis of both diabetes and peripheral arterial disease (PAD). Having both PAD and diabetes increases the risk of amputation.Reference14 Reference15 Diabetes was also accompanied by hypertension (39% of amputations), chronic kidney disease (7%) and chronic obstructive pulmonary disease (4%). For more information on patient characteristics as well as crude and age-standardized rates, view the data tables on the Download the data page. 

Hospitalizations for ulcers, gangrene and infections that do not result in amputation are also undesirable outcomes for those living with diabetes. Examining these hospitalizations provides additional insight into the systemic and societal burden of unmet care needs for those with diabetes. Our analysis found that each year, there were about 23,500 hospitalizations for diabetes-associated ulcers, gangrene or infections (UGI) in the lower limbs, where an amputation procedure did not also occur. 

In this report, we collectively refer to diabetes-associated lower limb amputations and hospitalizations for UGI as diabetes-associated lower limb complications. 

Hospitalization costs exceed $750 million annually

Sources
Discharge Abstract Database, National Ambulatory Care Reporting System, Hospital Morbidity Database and Canadian MIS Database, 2020–2021 to 2022–2023; Case Mix Group+ Methodology, 2023; and Comprehensive Ambulatory Classification System, 2023, Canadian Institute for Health Information.

These cost estimates do not include physician compensation or account for the high proportion of patients who require further acute inpatient care, rehabilitation, home care services and mobility aids such as prosthetics and wheelchairs. They also do not account for emergency department visits or community-based care costs incurred leading up to hospitalization. For example, foot ulcers and other lower limb complications are treated in the community through primary care and footcare clinics.Reference17 Moreover, data from Ontario and Alberta suggests that for every 1 hospital stay for lower limb ulcers, gangrene and infections there are 2 to 3 emergency department visits.Reference18 These care encounters are not captured in the hospitalization rates and costs presented in this report.

Experiencing a lower limb amputation and being hospitalized for UGI are significant medical events from the patient’s and health system’s perspectives

• For leg amputation, the median length of stay was 19 days. 15% of these hospitalizations involved more than one amputation. Both the length of stay and complexity of care contribute to the high costs of hospitalization. 
• Close to one-third of hospitalizations for leg amputation led to the patient being discharged to their home. Most patients were transferred to other inpatient or rehabilitation care. 
• For both ankle, foot and toe amputations and hospitalizations for UGI, the median length of stay was about 8 days. Around 77% and 65% of patients, respectively, were discharged home. 
   

Many patients who are hospitalized for an ulcer or amputation undergo repeat hospitalizations related to lower limb complications. Of the 31,220 hospitalizations annually for diabetes-associated lower limb complications, about 19,100 were for unique patients. The remaining 12,120 were repeat visits within the year. 

Our analysis also shows that 19% of patients who received a leg amputation were readmitted for another amputation or for treatment for UGI within 12 months. For patients receiving ankle, foot or toe amputations and treatment for UGI, about 37% and 31%, respectively, were readmitted within 12 months for a diabetes-associated lower limb complication. 
 

As many as 8% of patients died in hospital within 30 days of a hospitalization for a leg amputation. This is more than 4 times the rate of 30-day in-hospital mortality following a major surgery.Reference19 The 30-day in-hospital mortality rates for ankle, foot or toe amputations and for hospitalizations for UGI are 3% and 8%, respectively. 

The risk of death is high for patients receiving an amputation or treatment for UGI due to the risk of stroke, heart attack and other cardiovascular or renal complications that are also associated with diabetes.Reference7 Reference20

For all 3 complications, mortality rates increase with age. Our analysis found that 5% of patients younger than 65 died within 30 days of a leg amputation, increasing to 15% for patients age 85 and older. 
 

About 43% of amputations occurred among people with diabetes age 40 to 64. For individuals with type 1 diabetes, about 63% of amputations occurred in this age group. For hospitalizations for UGI, about 35% and 53% were for people age 40 to 64 with type 2 and type 1 diabetes, respectively. 

For individuals in the workforce, the time required to address foot care needs and to recover from an amputation may result in loss of income, lost employment opportunities and other non-monetary losses.Reference6