OBJECTIVE: The out-of-hospital care pathways of people with DFU have been little studied. We used the French National Health Data System (SNDS) to collect refund and care pathway data for all French residents. The aim of this study was to determine the incidence of major lower limb amputation (MA) and associated risk factors in a population with an incident DFU. RESEARCH DESIGN AND METHODS: We included any person living with diabetes and incident DFU. The primary endpoint was the occurrence of MA within one year. We considered the course and consumption of care one year before and one year after the initial event. RESULTS: In 2018, 133,791 people were included, and during the follow-up, MA was performed in 4,733 (3.5 %). Among these people with MAs, 16.4 % were included via the out-of-hospital part of the protocol, and their first contact with the hospital led to MA. Factors associated (hazard ratio, HR [95 % confidence interval, CI]) with MA were: being male (1.92 [1.78
2.08]), arteriopathy of the lower limb (10.16 [9.36
11.03]), psychiatric disease (1.10 [1.01
1.20]) and end-stage renal disease (2.12 [1.93
2.33]). Regarding the care pathway, associations (HR [95 %CI]) were observed between lower MA rates and people with more general practitioner (0.83 [0.75-0.91]), private nurse (0.88 [0.81-0.95]) and diabetologist (0.88 [0.81-0.95]) visits. Living in the most disadvantaged municipalities was associated (HR [95 %CI]) with a higher MA rate (1.17[1.06-1.29]). CONCLUSION: This is the first national study of the care pathways followed by people with DFU. Failures in the care pathway, precariousness and several comorbidities were identified, with an impact on the MA risk.