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Two million people in Germany have diabetes, without knowing it – and there are almost 1,000 new cases every day. Around the World Diabetes Day on 14 November, 2016 the campaign “Germany measures!” The diabetes online community and diabetes DE – German diabetes help counteract this frightening trend – with targeted education and local counseling services all over Germany (Appendix A – E1).

The national diabetes is creepy. An elevated blood glucose level initially does not have clear symptoms; the affected persons do not notice anything of the incipient illness for a long time. However, a permanently increased blood glucose risk is a significant risk for late effects: diabetes increases the risk of a stroke by three people, causes about 2,000 blinds per year and 40,000 amputations and costs the German health care system more than 35 billion euros per year. On average, people with diabetes die five to ten years earlier – usually due to a too late diagnosis. The absolute number of amputations per year in Germany rose slightly from 55 689 in 2005 to 57 637 (+3.5%) in 2014. The percentage of major amputations that took place in patients with diabetes mellitus as the main diagnosis or a side diagnosis declined from 70.2% to 63.7%.

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On the other hand, diabetic foot care has been recognized as a relevant problem and a lot of local strategies have been implemented in the recent decade. Especially, in Germany diabetic foot networks have developed and built effective support. Diabetes nurses play a role in the education of prevention of diabetic foot ulcers, foot care and prevention of foot injury. Such specialist nurses are called podologists in Germany. In contrast to the podiatrists, podologists are not doctors and they are not allowed to use a scalpel or other instruments for active debridement of bleeding tissue. They care for the diabetic foot disease outside the normal medical setting. If a patient has diabetes mellitus and is at a high risk of developing a foot lesion, his or her doctors can prescribe diabetic foot care performed by podologists. The health insurance providers are required to pay the reimbursement costs for this service. In the 5 years between 2007 and 2011, expenses for podologic foot care (PFC) have clearly increased. Thus, an unknown but probably high number of patients with diabetes presenting with an at-risk foot are effectively treated before any surgical procedures become necessary. We analysed whether there is an association between the decrease in major amputations and the number of PFC visits prescribed in Germany (Appendix A – E1).

The 16 German Federal States are different in number of inhabitants, average age and prevalence rates of persons with diabetes. Unfortunately there are no valid population-based data regarding the differences in diabetic population demographics. We compared the total number of hospitalized cases per year with diabetes mellitus documented as an additional diagnosis provided by the Federal Statistical Office to adjust for the variations in diabetes in each county.

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