Evidence map›Paper›PMID 33109531›Full record

ArticleCMAJ open

Regional health care services and rates of lower extremity amputation related to diabetes and peripheral artery disease: an ecological study.

Charles de Mestral, Mohamad A Hussain, Peter C Austin, Thomas L Forbes, Atul Sivaswamy, Ahmed Kayssi, Konrad Salata, Harindra C Wijeysundera, Subodh Verma, Mohammed Al-Omran

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Article in CMAJ open. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Cited by 6 papers.

0numbers the graph read from it

0cells of the map it votes in

6citing papers in PubMed

1.0field-weighted citation impact, top 22% of its field

1 · What the graph read from it

What it found

Each row is one number read from the abstract, on the scale the paper reported it, with its interval. Left of the dashed line favours the treatment, right favours the comparator. Under each row is the sentence it came from. New to these charts? A ten-minute tutorial.

The abstract states no effect estimate the extractor could read, or names no intervention and outcome on the map, so this paper lights no cell and moves no belief. It is still indexed, cited and linked below.

2 · The registry

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Neither the registry nor the abstract names a trial number. If this is a trial report, that itself is worth knowing.

3 · Its place in the literature

Who cites it

6 citing papers in PubMed, 20 citations in OpenAlex.

Barriers to Accessing Vascular Surgery in Northern, Rural, and Remote Canadian Communities.CJC open · 2026
Review
Social determinants of health and risk of lower extremity amputation in patients with peripheral artery disease in Canada: protocol for a systematic review and meta-analysis.BMJ open · 2026
Article
Developing an interprofessional decision support tool for diabetic foot ulcers management in primary care within the family medicine group model: a Delphi study in Canada.BMC primary care · 2024
Article
A novel Canadian multidisciplinary acute care pathway for people hospitalised with a diabetic foot ulcer.International wound journal · 2023
Article
A Population-Based Analysis of Diabetes-Related Care Measures, Foot Complications, and Amputation During the COVID-19 Pandemic in Ontario, Canada.JAMA network open · 2022
Article
Identifying barriers to preventive care among First Nations people at risk of lower extremity amputation: a qualitative study.CMAJ open
Article

4 · The record

Corrections and comments

PubMed lists nothing against this paper. Absence here is not a guarantee, only a check that was made.

5 · Who and what money

Authors and funding

10 authors at 6 institutions in 2 countries.

Charles de MestralLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont. Charles.deMestral@unityhealth.to.

Mohamad A HussainLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Peter C AustinLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Thomas L ForbesLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Atul SivaswamyLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Ahmed KayssiLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Konrad SalataLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Harindra C WijeysunderaLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Subodh VermaLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Mohammed Al-OmranLi Ka Shing Knowledge Institute (de Mestral, Hussain, Salata, Verma, Al-Omran), St. Michael's Hospital; ICES Central (de Mestral, Austin, Sivaswamy, Salata); Department of Surgery (de Mestral, Hussain, Forbes, Kayssi, Salata, Verma, Al-Omran), Faculty of Medicine, University of Toronto; Sunnybrook Research Institute (Austin, Kayssi, Wijeysundera), Sunnybrook Health Sciences Centre; Peter Munk Cardiac Centre (Austin, Forbes), University Health Network; Department of Medicine (Wijeysundera), Faculty of Medicine, University of Toronto; Diabetes Action Canada (de Mestral, Forbes, Kayssi, Al-Omran), Toronto, Ont.

Sunnybrook Health Science Centre · CASunnybrook Research InstituteHealth Sciences Centre · CASt. Michael's Hospital · CAUniversity Health Network · CAUniversity of Toronto · CA

Funding

No grant is acknowledged in the PubMed record.

6 · The paper itself

Abstract

backgroundThe care necessary to prevent amputation from diabetes and peripheral artery disease (PAD) remains disjointed in many jurisdictions. To help inform integrated regional care, this study explores the correlation between regional health care services and rates of lower extremity amputation.

methodsThis ecological study included 14 administrative health regions in Ontario, Canada. All diabetes- or PAD-related major (above ankle) amputations (Apr. 1, 2007, to Mar. 31, 2017) were identified among residents 40 years of age and older. For each region, age-and sex-adjusted amputation rates were calculated as well as per capita counts of key health providers (podiatrists and chiropodists, as well as surgeons) and health care utilization among study patients in the year before the first major amputation (physician visits, publicly funded podiatry visits, emergency department visits, hospital admissions, home care nursing, minor amputation, limb revascularization).

resultsA total of 11 658 patients with major amputation were identified (of whom 79.2% had diabetes and 96.5% had PAD). There was wide regional variation in amputation rates: 2.53 to 11.77 per 100 000 person-quarters. At a regional level, the proportion of study patients who received revascularization showed the strongest negative correlation with amputation rates. The regional proportion of study patients who saw a vascular surgeon showed the strongest negative correlation with amputation rates, relative to other health provider visits. Other measures of health care utilization among patients correlated poorly with regional amputation rates, as did the regional provider counts. The results were similar when we restricted the analysis to diabetes-related amputations.

interpretationAmputation rates related to diabetes and PAD vary widely across Ontario. Access to vascular assessment and revascularization must be integrated into regional amputation prevention efforts.

Indexed as

AdultAgedAged, 80 and overAmputation, SurgicalData Interpretation, StatisticalDiabetes Mellitus, Type 2Diabetic AngiopathiesEcologyFemaleHumansLegMaleMiddle AgedOntarioPatient Acceptance of Health CarePeripheral Arterial Disease

Identifiers

PMID33109531

DOI10.9778/cmajo.20200048

PMCPMC7595755

OpenAlexW3096519807

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Read under generation 80e0d062 · epoch 390. Bibliography from PubMed, PubMed Central and OpenAlex; grants from NIH RePORTER; trial links from ClinicalTrials.gov; estimates, votes and beliefs from the OpenQuestion graph.