Incidence and trends of limb amputation in first nations and general population in Saskatchewan, 2006-2019

Patient-reported outcomes in diabetes-related foot conditions: Is patient experience influenced by ethnicity? A mixed-methods systematic review

AIMS

Research in diabetes-related foot conditions (DRFC) often focuses on ulcer-related care, whilst the patient experience and influence of sociodemographic factors are under-researched. This systematic review investigated patient-reported outcomes and experience in people with DRFC.

METHODS

Multiple databases were searched from inception to 16 August 2023. All original articles that assessed any patient-reported outcome or experience in DRFC and reported participant ethnicity were included. Data were synthesized using a sequential contingent approach. Study quality was assessed using study design-specific tools.

RESULTS

Twenty-three studies were included (11 qualitative, 11 quantitative and one mixed-methods). DRFC had a largely negative impact on various life dimensions, including social and daily life, work, emotional and psychological well-being, necessitating dependence on others in the form of emotional, social and/or religious support, which were experienced differently by different groups. Patient DRFC knowledge and self-care habits were typically suboptimal, and levels of hope and feeling of control over their condition varied between groups. Outcomes varied slightly between ethnicities across studies, with some ethnicity-specific themes identified such as beliefs about disease cause and footwear habits. Quantitative and qualitative findings were mostly congruent.

CONCLUSIONS

DRFC profoundly and negatively impacts patient-reported outcomes and experience, with limited evidence suggesting an influence of ethnicity.

Analysis of Oklahoma amputation trends and identification of risk factors to target areas for limb preservation interventions

OBJECTIVE

Annual trends of lower extremity amputation due to end-stage chronic disease are on the rise in the United States. These amputations are leading to massive expenses for patients and the medical system. In Oklahoma, we have a high-risk population because access to care is low, the number of uninsured is high, cardiovascular health is poor, and our overall health care performance is ranked 50th in the country. But we know little about Oklahomans and their risk of limb loss. It is, therefore, imperative to look closely at this population to discover contemporary rates, trends, and state-specific risk factors for amputation due to diabetes and/or peripheral arterial disease (PAD). We hypothesize that state-specific groups will be identified as having the highest risk for limb loss and that contemporary trends in amputations are rising. To create implementable solutions to limb preservation, a baseline must be set.

METHODS

We conducted a 12-consecutive-year observational study using Oklahoma's hospital discharge data. Discharges among patients 20 years or older with a primary or secondary diagnosis of diabetes and/or PAD were included. Diagnoses and amputation procedures were identified using International Classification of Disease-9 and -10 codes. Amputation rates were calculated per 1000 discharges. Trends in amputation rates were measured by annual percentage changes (APC). Prevalence ratios evaluated the differences in amputation rates across demographic groups.

RESULTS

Over 5,000,000 discharges were identified from 2008 to 2019. Twenty-four percent had a diagnosis of diabetes and/or PAD. The overall amputation rate was 12 per 1000 discharges for those with diabetes and/or PAD. Diabetes and/or PAD-related amputation rates increased from 8.1 to 16.2 (APC, 6.0; 95% confidence interval [CI], 4.7-7.3). Most amputations were minor (59.5%), and although minor, increased at a faster rate compared with major amputations (minor amputation APC, 8.1; 95% CI, 6.7-9.6 vs major amputation APC, 3.1; 95% CI, 1.5-4.7); major amputations were notable in that they were significantly increasing. Amputation rates were the highest among males (16.7), American Indians (19.2), uninsured (21.2), non-married patients (12.7), and patients between 45 and 49 years of age (18.8), and calculated prevalence ratios for each were significant (P = .001) when compared within their respective category.

CONCLUSIONS

Amputation rates in Oklahoma have nearly doubled in 12 years, with both major and minor amputations significantly increasing. This study describes a worsening trend, underscoring that amputations due to chronic disease is an urgent statewide health care problem. We also present imperative examples of amputation health care disparities. By defining these state-specific areas and populations at risk, we have identified areas to pursue and improve care. These distinctive risk factors will help to frame a statewide limb preservation intervention.

Diabetic foot complications among Indigenous peoples in Canada: a scoping review through the PROGRESS-PLUS equity lens

Introduction

Indigenous peoples in Canada face a disproportionate burden of diabetes-related foot complications (DRFC), such as foot ulcers, lower extremity amputations (LEA), and peripheral arterial disease. This scoping review aimed to provide a comprehensive understanding of DRFC among First Nations, Métis, and Inuit peoples in Canada, incorporating an equity lens.

Methods

A scoping review was conducted based on Arksey and O'Malley refined by the Joanna Briggs Institute. The PROGRESS-Plus framework was utilized to extract data and incorporate an equity lens. A critical appraisal was performed, and Indigenous stakeholders were consulted for feedback. We identified the incorporation of patient-oriented/centered research (POR).

Results

Of 5,323 records identified, 40 studies were included in the review. The majority of studies focused on First Nations (92%), while representation of the Inuit population was very limited populations (< 3% of studies). LEA was the most studied outcome (76%). Age, gender, ethnicity, and place of residence were the most commonly included variables. Patient-oriented/centered research was mainly included in recent studies (16%). The overall quality of the studies was average. Data synthesis showed a high burden of DRFC among Indigenous populations compared to non-Indigenous populations. Indigenous identity and rural/remote communities were associated with the worse outcomes, particularly major LEA.

Discussion

This study provides a comprehensive understanding of DRFC in Indigenous peoples in Canada of published studies in database. It not only incorporates an equity lens and patient-oriented/centered research but also demonstrates that we need to change our approach. More data is needed to fully understand the burden of DRFC among Indigenous peoples, particularly in the Northern region in Canada where no data are previously available. Western research methods are insufficient to understand the unique situation of Indigenous peoples and it is essential to promote culturally safe and quality healthcare.

Conclusion

Efforts have been made to manage DRFC, but continued attention and support are necessary to address this population's needs and ensure equitable prevention, access and care that embraces their ways of knowing, being and acting.

Systematic review registration

Open Science Framework https://osf.io/j9pu7, identifier j9pu7.

The impact of the demographic shift on limb amputation incidence in Saskatchewan, Canada, 2006-2019

BACKGROUND

Changing demographics in a population may have an inevitable influence on disease incidence including limb amputation. However, the extent to which these changes affect limb amputation (LA) is unknown. Understanding the impact of changing demographics on LA would provide the best opportunity to plan for the future. We assessed the impact of changes in age and sex on limb amputation in Saskatchewan between 2006 and 2019.

METHODS

Retrospective linked Saskatchewan's LA cases, and demographic characteristics and residents population from 2006-2019 was used. The amputation rate was calculated by dividing the total number of LA cases recorded each year by the annual Saskatchewan resident population and the results expressed per 100,000 populations. Furthermore, decomposition analysis was used to assess the impact of changes in age and sex on LA in a decade (2008-2017) and the Generalized Additive Model (GAM) was employed to examine the linear and non-linear effect of age.

RESULTS

We found that in the ten years (2008-2017), the absolute LA rate difference was 9.0 per 100,000 population. Changes in age structure alone contributed 7.7% to the LA rate increase and 92.3% to changes in age-specific LA rates. The decade witnessed a marginal population difference between males and females, but the LA rate was 2.1-2.2 times higher in males than in females. The GAM revealed a non-linear relationship between LA and age, and further indicates that the risk of LA significantly increased as age increases.

CONCLUSIONS

In a decade, we found that changes in age distribution and age-specific rate substantially impacted the increase in the LA rate observed in the province. This highlights the urgent need for strategized programs to respond to these changes as both the population and diabetes, which is age-dependent and a leading cause of LA, are expected to increase in the province by 2030. As changes in population and demographic factors are inevitable, this study provides data for policy makers on the need for continuous incorporation of the shift in population in the design of future health services.

Trends of limb amputation considering type, level, sex and age in Saskatchewan, Canada 2006-2019: an in-depth assessment

BACKGROUND

Most epidemiologic reports focus on lower extremity amputation (LEA) caused specifically by diabetes mellitus. However, narrowing scope disregards the impact of other causes and types of limb amputation (LA) diminishing the true incidence and societal burden. We explored the rates of LEA and upper extremity amputation (UEA) by level of amputation, sex and age over 14 years in Saskatchewan, Canada.

METHODS

We calculated the differential impact of amputation type (LEA or UEA) and level (major or minor) of LA using retrospective linked hospital discharge data and demographic characteristics of all LA performed in Saskatchewan and resident population between 2006 and 2019. Rates were calculated from total yearly cases per yearly Saskatchewan resident population. Joinpoint regression was employed to quantify annual percentage change (APC) and average annual percent change (AAPC). Negative binomial regression was performed to determine if LA rates differed over time based on sex and age.

RESULTS

Incidence of LEA (31.86 ± 2.85 per 100,000) predominated over UEA (5.84 ± 0.49 per 100,000) over the 14-year study period. The overall LEA rate did not change over the study period (AAPC -0.5 [95% CI - 3.8 to 3.0]) but fluctuations were identified. From 2008 to 2017 LEA rates increased (APC 3.15 [95% CI 1.1 to 5.2]) countered by two statistically insignificant periods of decline (2006-2008 and 2017-2019). From 2006 to 2019 the rate of minor LEA steadily increased (AAPC 3.9 [95% CI 2.4 to 5.4]) while major LEA decreased (AAPC -0.6 [95% CI - 2.1 to 5.4]). Fluctuations in the overall LEA rate nearly corresponded with fluctuations in major LEA with one period of rising rates from 2010 to 2017 (APC 4.2 [95% CI 0.9 to 7.6]) countered by two periods of decline 2006-2010 (APC -11.14 [95% CI - 16.4 to - 5.6]) and 2017-2019 (APC -19.49 [95% CI - 33.5 to - 2.5]). Overall UEA and minor UEA rates remained stable from 2006 to 2019 with too few major UEA performed for in-depth analysis. Males were twice as likely to undergo LA than females (RR = 2.2 [95% CI 1.99-2.51]) with no change in rate over the study period. Persons aged 50-74 years and 75+ years were respectively 5.9 (RR = 5.92 [95% Cl 5.39-6.51]) and 10.6 (RR = 10.58 [95% Cl 9.26-12.08]) times more likely to undergo LA than those aged 0-49 years. LA rate increased with increasing age over the study period.

CONCLUSION

The rise in the rate of minor LEA with simultaneous decline in the rate of major LEA concomitant with the rise in age of patients experiencing LA may reflect a paradigm shift in the management of diseases that lead to LEA. Further, this shift may alter demand for orthotic versus prosthetic intervention. A more granular look into the data is warranted to determine if performing minor LA diminishes the need for major LA.

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006-2019: a population-based study

Background

Understanding trends in limb amputation (LA) can provide insight into the prevention and optimization of health care delivery. We examine the influence of primary (first report) and subsequent (multiple reports) limb amputation on the overall (all reports) rate of limb amputation in Saskatchewan considering amputation level.

Methods

Hospital discharged data associated with LA from 2006 to 2019 and population estimates in Saskatchewan were used. LA cases were grouped based on overall, primary, and subsequent LA and further divided by level into major (through/above the ankle/wrist) and minor (below the ankle/wrist). Incidence rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial were used to analyze the trends. In addition, the top three amputation predisposing factors (APF) were described by LA groups.

Results

The rate of overall LA and primary LA remained stable (AAPC − 0.9 [95% CI − 3.9 to 2.3]) and (AAPC −1.9 [95% CI −4.2 to 0.4]) respectively, while the rate of subsequent LA increased 3.2% (AAPC 3.2 [95% CI 3.1 to 9.9]) over the 14-year study period. The rate of overall major LA declined 4.6% (AAPC − 4.6 [95% CI −7.3 to −1.7]) and was largely driven by the 5.9% decline in the rate of primary major LA (AAPC − 5.9 [95% CI − 11.3 to –0.2]). Subsequent major LA remained stable over the study period (AAPC −0.4 [95% CI − 6.8 to 6.5]). In contrast, the overall rate of minor LA increased 2.0% (AAPC 2.0 [95% CI 1.0 to 2.9]) over the study period which was largely driven by a 9.6% increase in the rate of subsequent minor LA (AAPC 9.6 [95% CI 4.9 to 14.4]). Primary minor LA rates remained stable over the study period (AAPC 0.6 [95% CI − 0.2 to 1.5]). The study cohorts were 1.3-fold greater risk of minor LA than major LA. Diabetes mellitus (DM) was the leading APF representing 72.8% of the cohort followed by peripheral vascular disease (PVD) and trauma with 17.1 and 10.1% respectively. Most (86.7%) of subsequent LA were performed on people with DM.

Conclusions

Overall LA rates remained stable over the study period with declining rates of major LA countered by rising rates of minor LA. Minor LA exceeded major LA with the largest rate increase identified in subsequent minor LA. Diabetes was the greatest APF for all LA groups. This rising rate of more frequent and repeated minor LA may reflect changing intervention strategies implemented to maintain limb function. The importance of long-term surveillance to understand rates of major and minor LA considering primary and subsequent intervention is an important step to evaluate and initiate prevention and limb loss management programs.

Factors associated with prolonged post-operative acute care length of stay in limb amputation patients in Saskatchewan, Canada

BACKGROUND

The effect of predisposing factors on post-operative acute care length of stay (POALOS) after lower extremity amputation (LEA) has been sparsely studied with reports largely focused on major (through/proximal to the ankle) LEA specifically due to diabetes mellitus (DM). Although valuable, the narrow focus disregards the impact of other causes and minor levels (distal to the ankle) of LEA. To address this gap, this study aimed to identify predisposing factors associated with prolonged POALOS after index LEA stratified by amputation level in Saskatchewan.

METHODS

The study used Saskatchewan's provincial linked administrative health data and demographic factors between 2006 and 2019. Amputation levels, identified as major or minor, were derived from the amputation procedure codes. POALOS was calculated by subtracting patients' intervention date from discharge date, recorded in days, and categorized as short (< 7 days) or prolonged (> 7 days). Multivariable logistic regression was performed to identify predictors associated with prolonged POALOS.

RESULTS

Of the 3123 LEA cases 1421 (45.5%) had prolonged POALOS. The median POALOS for the entire cohort was 7 days (IQR 3 to 16 days); 5 days (IQR 1 to 10 days) for minor LEA and 11 days (IQR 5 to 23 days) for major LEA. Predictors of prolonged POALOS after minor LEA were diabetes (AOR = 2.47, 95% CI: 1.87-3.27) and general surgeon (AOR = 1.52, 95% CI: 1.21-1.91). Minor LEA performed by orthopedic surgeons were half (AOR = 0.49, 95% CI: 0.35-0.70) as likely to experience prolonged POALOS. Predictors of prolonged POALOS after major LEA were diabetes (AOR = 1.34, 95% CI: 1.04-1.71), general surgeon (AOR = 1.91, 95% CI: 1.45-2.49), urban residence (AOR = 1.58, 95% CI: 1.25-1.99), Resident Indian (RI) status (AOR = 1.57, 95% CI: 1.15-2.15), and age with the likelihood of prolonged POALOS after LEA attenuating with increasing age: 35-54 years (AOR = 2.73, 95% CI: 1.56-4.76); 55-69 years (AOR = 2.65, 95% CI: 1.54-4.58); and 70+ years (AOR = 1.81, 95% CI: 1.05-3.11).

CONCLUSION

This study identified only diabetes and surgical specialty predicted prolonged POALOS after both major and minor LEA in Saskatchewan while residence, RI status, and age were predictors of POALOS after major LEA. These findings shed light on the need for further research to identify confounding factors. It is not clear if general surgeons care for more unplanned, emergent cases with poor entry-level health while specialty surgeons perform more scheduled procedures.