The impact of diabetes on mortality rates after lower extremity amputation

OBJECTIVE

To assess the impact of diabetes, amputation level, sex and age on mortality rates after lower extremity amputation (LEA) in Belgium, and to assess temporal trends in one-year survival rates from 2009 to 2018.

METHODS

Nationwide data on individuals who underwent minor and major LEA from 2009 to 2018 were collected. Kaplan-Meier survival curves were constructed. A Cox regression model with time-varying coefficients was used to estimate the likelihood of mortality after LEA in individuals with or without diabetes. Matched amputation-free individuals with or without diabetes were used for comparison. Time trends were analysed.

RESULTS

Amputations 41,304 were performed: 13,247 major and 28,057 minor. Five-year mortality rates in individuals with diabetes were 52% and 69% after minor and major LEA, respectively (individuals without diabetes: 45% and 63%, respectively). In the first six postoperative months, no differences in mortality rates were found between individuals with or without diabetes. Later, hazard ratios (HRs) for mortality in individuals with diabetes (compared with no diabetes) after minor LEA ranged from 1.38 to 1.52, and after major LEA from 1.35 to 1.46 (all p ≤ 0.005). Among individuals without LEA, HRs for mortality in diabetes (versus no diabetes) were systematically higher compared to the HRs for mortality in diabetes (versus no diabetes) after minor and major LEA. One-year survival rates did not change for individuals with diabetes.

CONCLUSIONS

In the first six postoperative months, mortality rates after LEA were not different between individuals with or without diabetes; later, diabetes was significantly associated with increased mortality. However, as HRs for mortality were higher in amputation-free individuals, diabetes impacts mortality less in the minor and major amputation groups relative to the comparison group of individuals without LEA.

Impact of diabetes on medical costs in the pre- and postoperative year of lower extremity amputations in Belgium

AIMS

To compare the medical costs of individuals undergoing lower extremity amputation (LEA) in Belgium with those of amputation-free individuals.

METHODS

Belgian citizens undergoing LEAs in 2014 were identified. The median costs per capita in euros for the 12 months preceding and following minor and major LEAs were compared with those of matched amputation-free individuals.

RESULTS

A total of 3324 Belgian citizens underwent LEAs (2295 minor, 1029 major), 2130 of them had diabetes. The comparison group included 31,716 individuals. Amputation was associated with high medical costs (individuals with diabetes: major LEA €49,735, minor LEA €24,243, no LEA €2,877 in the year preceding amputation; €45,740, €21,445 and €2,284, respectively, in the post-amputation year). Significantly higher costs were observed in the individuals with (versus without) diabetes in all groups. This difference diminished with higher amputation levels. Individuals undergoing multiple LEAs generated higher costs (individuals with diabetes: €39,313-€89,563 when LEAs preceded index amputation; €46,629-€92,877 when LEAs followed index amputation). Individuals dying in the year after a major LEA generated remarkably lower costs.

CONCLUSIONS

LEA-related medical costs were high. Diabetes significantly impacted costs, but differences in costs diminished with higher amputation levels. Individuals with multiple amputations generated the highest costs.

Predictors of nursing home admission in the older population in Belgium: a longitudinal follow-up of health interview survey participants

Background

This study examines predictors of nursing home admission (NHA) in Belgium in order to contribute to a better planning of the future demand for nursing home (NH) services and health care resources.

Methods

Data derived from the Belgian 2013 health interview survey were linked at individual level with health insurance data (2012 tot 2018). Only community dwelling participants, aged ≥65 years at the time of the survey were included in this study (n = 1930). Participants were followed until NHA, death or end of study period, i.e., December 31, 2018. The risk of NHA was calculated using a competing risk analysis.

Results

Over the follow-up period (median 5.29 years), 226 individuals were admitted to a NH and 268 died without admission to a NH. The overall cumulative risk of NHA was 1.4, 5.7 and 13.1% at respectively 1 year, 3 years and end of follow-up period. After multivariable adjustment, higher age, low educational attainment, living alone and use of home care services were significantly associated with a higher risk of NHA. A number of need factors (e.g., history of falls, suffering from urinary incontinence, depression or Alzheimer’s disease) were also significantly associated with a higher risk of NHA. On the contrary, being female, having multimorbidity and increased contacts with health care providers were significantly associated with a decreased risk of NHA. Perceived health and limitations were both significant determinants of NHA, but perceived health was an effect modifier on limitations and vice versa.

Conclusions

Our findings pinpoint important predictors of NHA in older adults, and offer possibilities of prevention to avoid or delay NHA for this population. Practical implications include prevention of falls, management of urinary incontinence at home and appropriate and timely management of limitations, depression and Alzheimer’s disease. Focus should also be on people living alone to provide more timely contacts with health care providers. Further investigation of predictors of NHA should include contextual factors such as the availability of nursing-home beds, hospital beds, physicians and waiting lists for NHA.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-03496-4.

Temporal trends in major, minor and recurrent lower extremity amputations in people with and without diabetes in Belgium from 2009 to 2018

AIMS

This study assessed temporal trends in the incidence of lower extremity amputations (LEA) in Belgium from 2009 to 2018, and subsequent secondary amputation rates.

METHODS

Nationwide data on LEA were collected. Sex- and age-adjusted annual incidence rates were calculated. Time trends were analysed in negative binomial models. The incidence of secondary interventions, defined as either any ipsilateral reamputation or any contralateral amputation, was studied with death as competing risk.

RESULTS

41 304 amputations were performed (13 247 major, 28 057 minor). In individuals with diabetes, the amputation rate (first amputation per patient per year) decreased from 143.6/100.000 person-years to 109.7 (IRR 0.97 per year, 95 %CI 0.96-0.98, p < 0.001). The incidence of major LEAs decreased from 56.2 to 30.7 (IRR 0.93, 95 %CI 0.91-0.94, p < 0.001); the incidence of minor amputations showed a non-significant declining trend in women (54.3 to 45.0/100 000 person years, IRR 0.97 per year, 95 %CI 0.96-0.99), while this remained stable in men with diabetes (149.2 to 135.3/100 000 person years, IRR 1.00 per year, 95 %CI 0.98-1.01). In individuals without diabetes, the incidence of major amputation didn't change significantly, whereas minor amputation incidence increased (8.0 to 10.6, IRR 1.04, 95 %CI 1.03-1.05, p < 0.001). In individuals with diabetes, one-year secondary intervention rates were high (31.3% after minor, 18.4% after major LEA); the incidence of secondary amputations didn't change.

CONCLUSIONS

A significant decline in the incidence rate of major LEA was observed in people with diabetes. This decline was not accompanied by a significant rise in minor LEA. The incidence of secondary interventions remained stable.

Assessing polypharmacy in the older population: Comparison of a self-reported and prescription based method

PURPOSE

To explore differences in the prevalence and determinants of polypharmacy in the older general population in Belgium between self-reported and prescription based estimates and assess the relative merits of each data source.

METHODS

Data were used from participants aged ≥65 years of the Belgian national health survey 2013 (n = 1950). Detailed information was asked on the use of medicines in the past 24 h and linked with prescription data from the Belgian compulsory health insurance (BCHI). Agreement between polypharmacy (use or prescription ≥5 medicines) and excessive polypharmacy (≥10 medicines) between both sources was assessed with kappa statistics. Multinomial logistic regression was used to study determinants of moderate (5-9 medicines) and excessive polypharmacy (≥10 medicines) and over- and underestimation of prescription based compared to self-reported polypharmacy.

RESULTS

Self-reported and prescription based polypharmacy prevalence estimates were respectively 27% and 32%. Overall agreement was moderate, but better in men (kappa 0.60) than in women (0.45). Determinants of moderate polypharmacy did not vary substantially by source of outcome indicator, but restrictions in activities of daily living (ADL), living in an institution and a history of a hospital admission was associated with self-reported based excessive polypharmacy only.

CONCLUSIONS

Surveys and prescription data measure polypharmacy from a different perspective, but overall conclusions in terms of prevalence and determinants of polypharmacy do not differ substantially by data source. Linking survey data with prescription data can combine the strengths of both data sources resulting in a better tool to explore polypharmacy at population level.

Low incidence of anti-osteoporosis treatment after hip fracture

BACKGROUND

Following hip fracture, pharmacologic treatment can reduce the rate of subsequent fragility fractures. The objective of the present study was to assess the proportion of patients who are managed with bisphosphonates or selective estrogen-receptor modulators after hip fracture and to evaluate, among those managed with alendronate, the twelve-month compliance and persistence with treatment.

METHODS

Data were gathered from health insurance companies and were collected by AIM (Agence Intermutualiste) for the Belgian National Social Security Institute (INAMI). We selected all postmenopausal women who had been hospitalized for a hip fracture between April 2001 and June 2004 and had not been previously managed with bisphosphonates. Patients who had received alendronate treatment after the hip fracture were categorized according to their formulation use during the follow-up study (daily, weekly, daily followed by weekly, or weekly followed by weekly). Compliance at twelve months was quantified with use of the medication possession ratio (i.e., the number of days of alendronate supplied during the first year of treatment, divided by 365). Persistence with prescribed treatment was calculated as the number of days from the initial prescription to a lapse of more than five weeks after completion of the previous prescription refill. The cumulative treatment persistence rate was determined with use of Kaplan-Meier survival curves.

RESULTS

A total of 23,146 patients who had sustained a hip fracture were identified. Of these patients, 6% received treatment during the study period: 4.6% received alendronate, 0.7% received risedronate, and 0.7% received raloxifene. Bisphosphonate treatment was dispensed to 2.6% and 3.6% of the patients within six months and one year after the occurrence of the hip fracture, respectively. Among women who received alendronate daily (n = 124) or weekly (n = 182) and were followed for at least one year after the hip fracture, the twelve-month mean medication possession ratio was 67% (65.9% in the daily group and 67.7% in the weekly group). The analysis of persistence with treatment included a total of 726 patients (142 in the daily group, 261 in the weekly group, and 323 in the switch group). At twelve months, the rate of persistence was 41% and the median duration of persistence was 40.3 weeks.

CONCLUSIONS

The vast majority of patients who experience a hip fracture do not take anti-osteoporotic therapy after the fracture. Furthermore, among patients who begin alendronate treatment after the fracture, the adherence to treatment decreases over time and remains suboptimal.

Adherence to bisphosphonates therapy and hip fracture risk in osteoporotic women

Adherence is now one of the major issues in the management of osteoporosis and several papers have suggested that vertebral fractures might be increased in patients who do not follow appropriately their prescriptions. This paper relates the strong relationship existing between adherence to anti-osteoporosis treatment and the risk of subsequent hip fracture.

INTRODUCTION

A study was performed to investigate adherence to bisphosphonate (BP) therapy and the impact of adherence on the risk of hip fracture (Fx).

METHODS

An exhaustive search of the Belgian national social security database was conducted. Patients enrolled in the study were postmenopausal women, naive to BP, who received a first prescription of alendronate. Compliance at 12 months was quantified using the medication possession ratio (MPR). Persistence was calculated as the number of days from the initial prescription to a gap of more than 5 weeks after completion of the previous refill. A logistic regression model was used to estimate the impact of compliance on the risk of hip fracture. The impact of persistence on hip fracture risk was analysed using the Cox proportional hazards model.

RESULTS

The mean MPR at 12 months was significantly higher among patients receiving weekly (n = 15.021) compared to daily alendronate (n = 14,136) (daily = 58.6%; weekly = 70.5%; p < 0.001). At 12 months, the rate of persistence was 39.45%. For each decrease of the MPR by 1%, the risk of hip Fx increased by 0.4% (OR: 0.996; CI 95%: 0.994-0.998; p < 0.001). The relative risk reduction for hip Fx was 60% (HR: 0.404; CI 95%: 0.357-0.457; p < 0.0001) for persistent compared to non-persistent patients.

CONCLUSION

These results confirm that adherence to current therapeutic regimens remains suboptimal.

[Euthanasia and other medical decisions concerning the end of life in Belgium: epidemiologic studies]

BACKGROUND

The study presented here is the first replica of the Dutch death certificate study on end of life decisions (ELDs). The main objective was to assess the incidence of euthanasia (the administration of drugs with the explicit intention to shorten the patient's life at the explicit request of the patient), physician assisted suicide (PAS), and other ELDs in medical practice in Belgium (Flanders).

METHODS

A 20% random sample of 3,999 deaths was selected from all death certificates between January 1 and April 30, 1998. The physicians who signed the death certificates received one mail questionnaire per death case.

FINDINGS

The response rate of the physicians was 52%. The results were corrected for the non response bias, and extrapolated to estimated annual incidences after seasonal adjustment for causes of death. It was estimated that 1.3% (1.0-1.6%, CI: 95) of all deaths resulted from euthanasia or PAS. In 3.2% (2.7-3.8%, CI: 95) of all cases, the physician ended the patient's life with lethal drugs without the explicit request of the patient. Alleviation of pain and symptoms with opioids in doses with a potential life shortening effect preceded death in 18.5% (17.3-19.7%, CI: 95) of cases and nontreatment decisions in 16.4% (15.3-17.5%, CI: 95) of cases, of which 5.8% (5.1-6.5%, CI: 95) with the explicit intention of ending the patient's life.

INTERPRETATION

ELDs are prominent in medical practice in Belgium (Flanders). The incidence of deaths preceded by an ELD is similar to the Netherlands, but greater than in Australia. However, in Belgium (Flanders) the incidence of ending of patient's life without the patient's explicit request (3.2%, 2.7-3.8% CI: 95) is similar to Australia (3.5%, 2.7-4.3% CI: 95), but significantly higher than in the Netherlands (0.7%, 0.5-0.9% CI: 95).

End-of-life decisions in medical practice in Flanders, Belgium: a nationwide survey

BACKGROUND

Our study is a repeat of the Dutch death-certificate study on end-of-life decisions (ELDs). The main objective was to estimate the frequency of euthanasia (the administration of lethal drugs with the explicit intention of shortening the patient's life at the patient's explicit request), physician-assisted suicide (PAS), and other ELDs in medical practice in Flanders, Belgium.

METHODS

A 20% random sample of 3999 deaths was selected from all deaths recorded between Jan 1 and April 30, 1998. The physicians who signed the corresponding death certificates received one questionnaire by post per death.

FINDINGS

The physicians' response rate was 1355 (52%). 1925 deaths were described. The results were corrected for non-response bias, and extrapolated to estimated annual rates after seasonal adjustment for death causes, and we estimate that 705 (1.3%, 95% CI 1.0-1.6) deaths resulted from euthanasia or PAS. In 1796 (3.2%, 2.7-3.8) cases, lethal drugs were given without the explicit request of the patient. Alleviation of pain and symptoms with opioids in doses with a potential life-shortening effect preceded death in 10,416 (18.5%, 17.3-19.7) cases and non-treatment decisions in 9218 (16.4%, 15.3-17.5) cases, of which 3261 (5.8%, 5.1-6.5) with the explicit intention of ending the patient's life.

INTERPRETATION

ELDs are prominent in medical practice in Flanders. The frequency of deaths preceded by an ELD is similar to that in the Netherlands, but lower than that in Australia. However, in Flanders the rate of administration of lethal drugs to patients without their explicit request is similar to Australia, and significantly higher than that in the Netherlands.