Incidence of Major Amputation for Diabetes in Scotland Sets a Target for Us All

In this issue, Kennon et al. (1) report the incidence of amputation in diabetes across Scotland. Their findings are expressed both in terms of the total population (which is primarily a measure of national disease burden and much influenced by the changing prevalence of diagnosed diabetes) and the population with diabetes: the “at risk” population. The advantage of expressing amputation in terms of those at risk is that the results can be used as an indication of the quality of disease management, even though the data require careful interpretation (2). Unfortunately, it is not possible to calculate incidence in the population at risk without reliable information on the prevalence of diabetes in the community or country being studied, and such information is rarely available. The study by Kennon et al. (1) is, therefore, a tribute to those who created the Scottish Care Information–Diabetes Collaboration (SCI-DC) (3). However, if a reliable national database of diabetes does not exist, other—potentially less reliable—approaches must be used, including 1 ) hospital discharge coding, which has traditionally been flawed by underrecording of diabetes but is improving with increased awareness of the contribution made by diabetes to the disease burden of all nations, and 2 ) the study of particular communities, with populations selected by health care provider or insurance/reimbursement scheme (Medicare, Veterans Health Administration [VHA], etc.) or by locality (4–7). By use of the SCI-DC database, Kennon et al. (1) report that the incidence of major amputation in people with known …