Major Lower Limb Amputation and Revascularisation in England: A Retrospective Cohort Study скачать в хорошем качестве

Major Lower Limb Amputation and Revascularisation in England: A Retrospective Cohort Study

This study reviewed national hospital data to explore patterns of major lower limb amputation across England and their relationship to revascularisation, demographics, deprivation, and risk factors. The aim was to describe prevalence and regional variation, particularly whether higher amputation rates were linked to fewer revascularisations or differences in population risk. Methods Retrospective cohort analysis of Hospital Episode Statistics from April 2003 to March 2009, covering ~52 million encounters annually. The cohort included patients aged 50–84 years, the group most affected by PAD-related amputations. Patients under 50 and over 85 were excluded to reduce confounding. Amputation and revascularisation procedures were identified using OPCS 4.5 codes. Amputation was defined as X09 (leg, excluding feet). Revascularisation codes included open, endovascular, and diagnostic angiography for aorto-iliac and femoral-popliteal arteries. Demographics and risk factors were extracted from ICD-10 co-morbidity fields, including diabetes, hypertension, hyperlipidaemia, coronary disease, cerebrovascular disease, and smoking. Age-standardised prevalence was calculated using ONS population estimates and standardised to the England and Wales 2001 population. Regional data were grouped into North, Midlands, and South. Deprivation was measured by the Index of Multiple Deprivation 2010. Amputations were linked to revascularisations if both occurred within six years in the same patient and region, recognising that linkage did not confirm causal relationship or service quality. Logistic regression was used to explore predictors of amputation with or without revascularisation, adjusting for demographics and comorbidities. The Midlands served as reference due to rates approximating the national average. Results Over the study period there were 25,312 major amputations and 136,215 revascularisations. The age-standardised amputation rate was 26.3 per 100,000 and revascularisation rate 141.6 per 100,000. Men had double the rates of women for both amputation (37.0 vs 15.9) and revascularisation (197.4 vs 90.7). Amputees had a mean age of 70.6 years; 68.5 percent were men and 28.6 percent were from the most deprived areas. Diabetes (44 percent), hypertension (39 percent), and coronary heart disease (23 percent) were the leading comorbidities. Regional variation showed a clear North-South divide. Amputation rates per 100,000 were 31.7 in the North, 26.0 in the Midlands, and 23.1 in the South. Revascularisation rates were also highest in the North at 182.1, compared to 121.3 in the Midlands and 124.9 in the South. Amputation with revascularisation linkage: 7,543 amputations (29.8 percent) were linked to revascularisation. The odds of undergoing amputation with revascularisation were significantly higher in the North (OR 1.22) compared to the Midlands, persisting after adjustment. This excess was only partly explained by risk factor burden. Demographic adjustment had little effect; deprivation was not significant. Age, male sex, hypertension, hyperlipidaemia, coronary disease, and smoking increased the likelihood of amputation with revascularisation, while diabetics were more likely to undergo amputation without revascularisation. Risk factor profiles differed regionally: amputees in the North had more deprivation, coronary disease, and smoking, but lower recorded rates of diabetes, hypertension, and hyperlipidaemia. Strengths and limitations Strengths include use of a comprehensive national dataset and careful restriction to an age group most relevant for PAD. Limitations include reliance on coding accuracy, with under-recording of smoking and stroke compared to published data. Linkage methodology may have captured bilateral cases or amputations not directly related to PAD. The analysis could not prove whether revascularisation prevented amputation, since intention for limb salvage was unknown. Discussion The study demonstrated a persistent North-South divide in both amputation and revascularisation, with highest rates in Northern England. Higher odds of amputation with revascularisation in the North were not fully explained by deprivation or risk factors. The findings suggest differences in organisation or delivery of vascular services, with possible influences from PAD prevalence, referral patterns, and access to revascularisation pathways. Conclusion England shows significant regional inequality in major lower limb amputation, with excess burden in the North. While patient risk factors and deprivation contribute, they do not fully account for the disparity. Reducing this inequality remains a key challenge for PAD management and will require targeted improvements in healthcare organisation, early referral, and delivery of vascular services, especially in Northern regions.