Major lower limb amputations in Far North Queensland

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Prevalence and risk factors of peripheral artery disease in a population with chronic kidney disease in Australia: A systematic review and meta-analysis

There is a lack of clarity and guidance for screening peripheral artery disease (PAD) in persons with chronic kidney disease (CKD) and end stage kidney disease (ESKD) despite this group being at excess risk of cardiovascular disease (CVD). In this current study, we performed a systematic review and meta-analysis to examine the prevalence and risk factors for PAD in persons with CKD in Australian cohorts. We used the inverse variance heterogeneity meta-analysis with double arcsine transformation to summarize the prevalence of PAD (with 95% CIs). Nine studies and 18 reports from the Australia and New Zealand dialysis and transplant registry with 36 cohorts were included in the review. We found a substantially higher PAD prevalence in cohorts based on an ankle-brachial index (ABI) or toe systolic pressure (TBI) than cohorts based on self-reported history. Higher PAD prevalence was observed in ESKD persons than CKD persons without dialysis (PAD diagnosis based on ABI or TBI: 31% in ESKD persons and 23% in CKD persons, PAD diagnosis based on self-reported history: 17% in ESKD persons and 10% in CKD persons). Older age, Caucasian race, cerebrovascular disease and haemodialysis were associated with the presence of PAD in ESKD persons. Our findings indicated a considerable proportion of PAD in CKD and ESKD persons particularly in those with ESKD. To develop and provide an adequate plan to clinically manage CKD patients with PAD, evidence of cost-effectiveness and clinical benefit of early detection of PAD in persons with CKD in Australia is recommended for future studies.

Incidence of lower limb amputation in Central Australia

Objective The aims of this study were to review the demographic details of those who have undergone lower limb amputation (LLA) surgery in Central Australia and determine the region-specific age-adjusted incidence rate of LLA. Methods A retrospective audit of service users who underwent LLA in a Central Australian hospital from 2012 to 2017 was undertaken. Demographic, operative and postoperative outcomes data were collected. The age-adjusted incidence rate of LLA was determined using the direct method. Demographic data were analysed using descriptive parametric analysis. Results In the period 2012-17, 166 service users underwent a total of 291 amputations in 231 episodes of care (hospital admissions). The age-adjusted incidence rate of LLA was 87.4 per 100000 for females and 104.6 per 100000 for males in this region. In total, 84% (n=140) of those requiring amputation surgery identified as Aboriginal Australians (P<0.001), 54% (n=75) of whom were female. Aboriginal Australians who underwent LLA were, on average, 13 years younger and were more likely to have type 2 diabetes (P<0.001) and require renal dialysis (P<0.001) than the non-Aboriginal Australian cohort. Of the Aboriginal Australians who underwent LLA, 82% (n=103) lived very remotely (>100km from the central town's centre), compared with 23% of non-Aboriginal Australians (P<0.001). In addition, 46% (n=64) of Aboriginal Australians who underwent LLA required renal dialysis. Those requiring renal dialysis were more likely to require subsequent amputation (P=0.014) and had a higher mortality rate following amputation (P=0.031). Partial foot amputation was the most common level of amputation in Central Australia (38%). Conclusions Central Australia appears to have the highest incidence rate of LLA for any region in Australia, with Aboriginal Australians, particularly females and those undergoing renal dialysis, being disproportionately represented. Further studies should aim to determine targeted, culturally safe and successful methods of diabetic foot ulcer prevention, early detection and management with a view to reducing the high amputation rates for these cohorts. What is known about the topic? Large health inequalities between Aboriginal and non-Aboriginal Australians exist. Aboriginal Australians are currently fourfold as likely as non-Aboriginal Australians to have type 2 diabetes (T2D), increasing their risk of LLA. There is a geographical variance in the incidence of LLA in Australia; the Northern Territory is overrepresented, with rates two- to threefold higher than that of the national average. Regional incidence rates are not currently known. What does this paper add? This study showed that the age-adjusted incidence rate for LLA in Central Australia is significantly higher than in other regions in Australia. Most LLA surgeries undertaken in Central Australia were performed for Aboriginal Australians who have T2D, with a disproportionate representation of females and those requiring renal dialysis. What are the implications for practitioners? This study shows that there is a need for further research and preventative measures to address the high rates of LLA among Aboriginal Australians, particularly for females and those with renal impairment. These groups could benefit from targeted, culturally safe approaches to early identification, referral and management of lower limb ulceration by relevant service providers.