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All Party Parliamentary Group on Vascular Disease Condemns New Figures on Regional Variation in Amputation Rates

Thousands of patients may be facing unnecessary leg amputations, owing to variations in practice around the country. A new report from the All Party Parliamentary Group on Vascular Disease draws on new data from Freedom of Information requests to NHS Trusts and Clinical Commissioning Groups to draw attention to the variation around the country in amputation rates and implementation of the best clinical practice.

 

Neil Carmichael MP, Chair of the Group, said:

Too many patients aren't getting the treatment they need to avoid losing their legs. The figures for parts of the South-West of England are particularly alarming, and this needs to be tackled. The All Party Parliamentary Group on Vascular Disease, working with the country's top experts in this field, recommends that the Department of Health make reducing lower limb-loss a major priority. This is especially important given the country's ageing population.

Neil added:

The unacceptably high level of lower limb amputations among people with diabetes in certain areas is a real cause for alarm. There clearly is a serious problem if some regions of England have much higher amputation rates than others.

  • In 2012-2013, there were almost 12,000 lower limb amputations in England, a figure that remains stubbornly high year on year. The vast bulk of these lost limbs were related to Peripheral Arterial Disease and Diabetic Foot Disease.

Lost limb

2010-2011

2011-2012

2012-2013

Leg

5,061

4,701

4,669

Foot

785

980

1,040

Toe

5,512

6,021

5,951

Total

11,358

11,702

11,660

  • Amputations are dependent on where you live, which is dependent on the service provision policies of local health authorities Clinical Commissioning Groups and NHS Trusts. There is no nationally consistent policy on how to treat patients with PAD.
  • Amputation is twice as likely for patients in the South West as it is in London. Even patients in the second best performing region, the North West, have a 31% greater risk of amputation.

CCG region

Average number of amputations
per 1,000 adults with diabetes
(2009/10-2011/12)

Greater risk of amputation
compared to London

South West

3.88

100%

Yorkshire & Humber

2.79

44%

West Midlands

2.72

40%

Eastern

2.70

39%

South East

2.68

38%

East Midlands

2.66

37%

North East

2.66

37%

North West

2.55

31%

London

1.94

Click here to read the report in full, with a breakdown by region and by Trusts and Clinical Commissioning Groups

  • The Clinical Commissioning Group areas with the highest number of amputations per 1,000 patients with diabetes (2009-2012) were:

Clinical Commissioning Group

Region

Number of amputations
per 1000 adults with diabetes

1

Somerset

South West

4.7

2

Mansfield and Ashfield

East Midlands

4.6

3

Southend

Eastern

4.5

4

Hull

Yorkshire & Humber

4.4

5

Scarborough & Ryedale

Yorkshire & Humber

4.2

6

Vale of York

Yorkshire & Humber

4.1

7

South Devon and Torbay

South West

3.8

8

South Warwickshire

West Midlands

3.8

9

Thanet

South East

3.8

10

Kernow

South West

3.6

11

Newark and Sherwood

East Midlands

3.6

12

Corby

East Midlands

3.6

13

Darlington

North East

3.5

14

Bristol

South West

3.4

15

Knowsley

North West

3.4

16

Ashford

South East

3.4

17

Hardwick

East Midlands

3.4

18

Harrogate and Rural District

Yorkshire & Humber

3.4

19

Dartford, Gravesham and Swanley

South East

3.3

20

East Staffordshire

West Midlands

3.3

  • The Clinical Commissioning Groups with the highest total number of major amputations for patients with diabetes (2009-2012) were:

Clinical Commissioning Group

Region

Number of major amputations
over three years as a result of diabetes

1

Somerset

South West

108

2

Southern Derbyshire

East Midlands

93

3

Kernow

South West

90

4

Cambridgeshire and Peterborough

Eastern

89

5

Cumbria

North West

86

6

Sheffield

Yorkshire & Humber

81

7

Durham Dales, Easington and Sedgefield

North East

79

8

Birmingham Crosscity

West Midlands

78

9

Nene

East Midlands

63

10

North Durham

North East

60

11

Hull

Yorkshire & Humber

55

12

Stoke on Trent

West Midlands

53

13

Liverpool

North West

52

14

Bristol

South West

51

15

Lincolnshire East

East Midlands

49

16

Vale of York

Yorkshire & Humber

48

17

North Derbyshire

East Midlands

48

18

Oxfordshire

South East

47

19

South Devon and Torbay

South West

44

20

Bradford Districts

Yorkshire & Humber

44

  • The Clinical Commissioning Groups with the lowest number of amputations per 1,000 patients with diabetes (2009-2012) were:

Clinical Commissioning Group

Region

Number of amputations
per 1000 adults with diabetes

1

Brent

London

0.9

2

Bradford City

Yorkshire & Humber

1.2

3

Ealing

London

1.3

4

Waltham Forest

London

1.3

5

Redbridge

London

1.3

6

Leicester City

East Midlands

1.3

7

Nottingham West

East Midlands

1.4

8

Hillingdon

London

1.4

9

Airedale, Wharfedale & Craven

Yorkshire & Humber

1.6

10

Lambeth

London

1.6

  • A major driver of high amputation rates is the lack of a specific patient pathway for dealing with peripheral arterial disease patients. Our Freedom of Information request showed that from 2009 to 2012, Clinical Commissioning Group areas without a patient pathway had 11% more amputations on average than those with a patient pathway. (See Chapter 2 for a full list of the 35 CCGs without a patient pathway.)

Number of Clinical Commissioning Groups without a patient pathway

West Midlands

8

East Midlands

8

Yorkshire & Humber

5

London

4

Eastern

3

North East

2

South West

2

South East

2

North West

1

  • A further driver of high amputation rates is the lack of Multi-Disciplinary Teams - core teams of clinicians who collaborate on how best to deal with patients with peripheral arterial disease or diabetes. In spite of strong evidence that MDTs are essential to high standards of patient care, 30% of Trusts handling vascular and diabetes patients (31) lacked MDTs for Diabetes. 28% of Trusts lacked MDTs for Peripheral Arterial Disease (29). (See Chapter 1 for a full list of the CCGs without MDTs.)

 

Number of Trusts lacking an MDT

North West

8

London

5

East Midlands

4

Yorkshire & Humber

4

South West

3

North East

3

South East

2

Eastern

1

West Midlands

1

  • Studies have shown that rapid treatment within 24 hours can reduce the risk of Critical Limb Ischaemia, the most aggressive manifestation of PAD, leading to major limb amputation.
  • There are no national guidelines for the speed of referral for a patient suspected of CLI, despite the accepted orthodoxy among clinical experts that once admitted, a patient must be seen by a Multi-Disciplinary Team within 24 hours.
  • Lower limb peripheral arterial disease represents one of the most visible manifestations of vascular disease. It is estimated to affect 9% of the population, and the incidence of it increases with age.[1] Population studies have found that about 20% of people aged over 60 years have some degree of peripheral arterial disease. Incidence is also high in people who smoke, people with diabetes and people with coronary artery disease. [2]

Click here to read the report in full, with a breakdown by region and by Trusts and Clinical Commissioning Groups

The All Party Parliamentary Group on Vascular Disease recommends:

1: To drive up the quality of services there needs to be a comparable set of simple outcome standards. An example would be what is seen in the intervention for aneurysms. Major amputation is currently the only main outcome, which is the result of a cultural problem, because it is still considered a successful treatment. Amputation should be considered a failure, and a functioning foot with minimal surgery should be the success.

2: The use of modern technology, such as video conferencing or telemedicine, should be used to link local or remote centre to ensure cases can be discussed and where appropriate care can be delivered locally to avoid unnecessary travelling.

3: Ensure that both MDTs for PAD and diabetic footcare teams with a strong track record are not disjointed, and should be used as a model of good practise for other centres which are struggling.

4: Establish pathway coordinators in hub centres with integrated clear pathways for the diabetic foot. This will help to identify high risk patients earlier and allow referral to expert opinions and treatment sooner which would reduce amputation rates.

5: Ensure that there is a named contact person in a hospital/community 24 hours a day who is a member of the MDT in case of emergencies.

6. All commissioners should have a sub-24 hour policy to refer patients with suspected CLI to a Multi-Disciplinary Team. Time is of the essence with this condition, and every hour that delays treatment increases the risk of amputation.

6. All commissioners and providers should have a clear pathway for patients suspected of Peripheral Arterial Disease and the diabetic foot. This pathway must be made standard practise, and the route that patients are referred to a hospital with Critical Limb Ischaemia should be rapid, clear, and properly understood by all healthcare workers from primary care up to specialist care. This should be channelled down to GP's practises, and up to provider hospitals. They should also have a policy for referral to a Multi-Disciplinary Team with clear links to secondary care. Too many CCGs reported having no policy on either.

7: The Quality Outcomes Framework needs to be improved so that all patients who are identified as high risk are referred for preventative podiatry and structured education. Preventative care is extremely important, as chances of lower limb amputation are massively increased if the situation develops to Critical Limb Ischaemia.

8. An established patient pathway must be established in all strategic health authorities, which in turn is made standard practise for all providers and commissioners. The route that patients are referred to a hospital with Critical Limb Ischaemia should be rapid, clear, and properly understood by all healthcare workers from primary care up to specialist care.

9: Commissioning structures need to balance centralisation of care for complex high-risk vascular procedures with the need to maintain equity of patient access for peripheral arterial disease.

10: Education for patients at risk should be made more widespread in the community. Guidance and support on smoking cessation and exercise, in particular for patients with diabetes, is one of the key areas which need attention.



[1] Circulation Foundation (2011). Campaign Toolkit. (Online). Available HERE

[2] Lower Limb Peripheral Arterial Disease: Diagnosis and Management,  NICE Clinical Guideline 147, 2012, p. 4.

 

 

 

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