Diabetic Foot Admissions Rose as Major Amputations Fell

Key Takeaways

• In a 10-year single-center tertiary-care cohort of hospitalized diabetic foot disease in China, 39% of admissions involved Wagner grade 4-5 lesions, 42% osteomyelitis, 38% peripheral arterial disease, and 19% sepsis at presentation.
• Admissions rose significantly over time, while major amputations declined modestly and mortality did not show a significant sustained shift.
• Hospital burden remained substantial, with a median 9-day stay, intensive care unit use in 13%, 30-day readmission in 16%, and 1-year readmission in 27%.
• After adjustment, peripheral arterial disease was most strongly associated with major amputation, while sepsis was most strongly associated with short-term mortality.

Hospitalized diabetic foot disease often arrives as a late-presenting ischemic-infectious inpatient state marked by deep tissue loss, systemic illness, frequent surgery, prolonged stays, and recurrent admissions. In a single tertiary-care hospital cohort in China, that pattern reflects a non-North-American care setting in which referral timing, inpatient case mix, and access to limb-salvage services may differ from U.S. practice. A decade-long view of these admissions helps show how inpatient burden, limb loss, and short-term mortality evolved within one hospital system.

In the 10-year diabetic foot cohort in Frontiers in Public Health, investigators performed a retrospective observational review of electronic medical records from January 2015 through December 2024. They reviewed 700 records and included 500 adults with diabetes hospitalized for diabetic foot ulceration, infection, ischemic gangrene, or mixed diabetic foot disease, excluding traumatic non-diabetic foot ulcers, primary vascular pathologies not associated with diabetes, incomplete documentation, and ineligible duplicate or follow-up admissions. Ulcer severity was classified with Wagner or University of Texas systems, and the analysis tracked hospital burden, amputations, mortality, and multivariable predictors. Variables with less than 5% missingness were imputed, and sensitivity analyses were similar.

Advanced ulceration, infection, ischemia, and frequent procedures were common at presentation, suggesting late presentation in this inpatient cohort. Across the decade, admissions increased over time (β = 2.03 admissions/year, p = 0.004), major amputation rates declined (β = -1% per year, p = 0.031), and mortality remained statistically stable (β = -0% per year, p = 0.641). Major amputations fell across the observation period, but the overall inpatient phenotype remained severe.

In-hospital mortality was 7% and 30-day mortality was 9%, indicating a persistent early fatality burden. The multivariable diabetic foot risk analysis identified peripheral arterial disease (PAD) as the strongest independent predictor of major amputation (adjusted OR 4.15, 95% CI 2.10-8.10) and sepsis as the strongest independent predictor of mortality (adjusted OR 3.80, 95% CI 2.05-7.05). Wagner grade 3 or higher lesions and osteomyelitis were also associated with major amputation, while older age, chronic kidney disease, and PAD were associated with mortality; major amputation itself was not significant after adjustment.

The retrospective single-center design limits how directly these findings generalize beyond this tertiary-care hospital population, and the China-based setting should not be assumed to map directly onto North American inpatient care patterns. Mortality interpretation was bounded to in-hospital and 30-day outcomes, with incomplete follow-up beyond 1 year for some patients, and detailed PAD severity grading was unavailable for a subset of the cohort. Residual confounding remains possible despite adjustment, and no formal economic analysis was performed, so the resource burden described here is best read as clinical rather than cost-accounting evidence.

The authors concluded that diabetic foot hospitalization remained a persistent high-burden inpatient problem in this China-based tertiary-care setting, with rising admissions, modestly lower major amputation rates, and no clear change in short-term mortality. The overall pattern was one of sustained severity at presentation despite some improvement in major amputation rates.

Clinician Questions

Which diabetic foot admissions were included in this 10-year hospital cohort?

Adults aged 18 years or older with type 1 or type 2 diabetes were included if they were hospitalized for diabetic foot ulceration, diabetic infection, ischemic gangrene, or mixed diabetic foot disease; excluded admissions involved traumatic non-diabetic foot ulcers, primary vascular pathologies not associated with diabetes, incomplete documentation, and duplicate or follow-up hospitalizations that did not meet eligibility criteria.

How was major amputation defined in hospitalized diabetic foot disease in this analysis?

Major amputation in hospitalized diabetic foot disease was defined as below-knee or above-knee amputation, whereas minor amputation referred to toe, ray, or forefoot amputation.

How was peripheral arterial disease identified in the diabetic foot cohort?

Peripheral arterial disease was identified by objective evidence of lower-extremity arterial insufficiency, including an ankle-brachial index below 0.90, Doppler ultrasonography showing significant stenosis or occlusion, computed tomography angiography, digital subtraction angiography, or a vascular specialist's documented diagnosis; severity-stratified analysis was limited because detailed grading was unavailable for some patients.

What was linked to early versus later readmission after diabetic foot hospitalization?

After diabetic foot hospitalization, most 30-day readmissions were linked to infection or wound failure, whereas readmissions within 1 year were more often associated with recurrent infection or the development of new ulcers.