Thousands of patients may be facing unnecessary leg amputations, owing to variations in practice around the UK. 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 are not 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.”
Carmichael 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.”
Duncan Ettles, consultant Radiologist Hull and East Yorkshire Hospitals NHS Trust, honorary clinical professor in Radiology University of Hull, and president of the British Society of Interventional Radiology (BSIR), recently told Interventional News that there was “a bit of a post code lottery when it comes to critical limb ischaemia”.
“It is incredibly important that we continue to push minimally invasive intervention, particularly for patients who present with critical limb ischaemia, where we can make a big impact in trying to reduce amputation rates.Looking across the UK, there is evidence to confirm that services are not uniform. One important contributor to this problem is that patients may be referred too late from primary care at a stage when the window of opportunity for endovascular treatment may have been missed. We still have a lot to do to educate the wider medical body and publicise the important role that interventional radiology has in potentially reducing rates of amputation,” Ettles added.
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 peripheral arterial disease. 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.
In 2012–2013, there were almost 12,000 lower limb amputations in England. The vast bulk of these lost limbs were related to peripheral arterial disease and diabetic foot disease.
A major driver of high amputation rates is the lack of a specific patient pathway for dealing with peripheral arterial disease patients. The data from the 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.
A further driver of high amputation rates is the lack of multidisciplinary 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 such teams are essential to ensure high standards of patient care, 30% of trusts handling vascular and diabetes patients lacked multidisciplinary teams for diabetes. Twenty eight per cent of Trusts lacked multidisciplinary teams for peripheral arterial disease.
Studies have shown that rapid treatment within 24 hours can reduce the risk of critical limb ischaemia, the most aggressive manifestation of peripheral arterial disease, leading to major limb amputation.
There are no national guidelines for the speed of referral for a patient suspected of critical limb ischaemia, despite the accepted orthodoxy among clinical experts that once admitted, a patient must be seen by a multidisciplinary 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. 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.
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 multidisciplinary teams for peripheral arterial disease 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 multidisciplinary teams in case of emergencies.
6. All commissioners should have a sub-24 hour policy to refer patients with suspected critical limb ischaemia to a multidisciplinary teams. Time is of the essence with this condition, and every hour that delays treatment increases the risk of amputation.
7. 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 general practitioner’s practises, and up to provider hospitals. They should also have a policy for referral to a multidisciplinary teams with clear links to secondary care. Too many Clinical Commissioning Groups reported having no policy on either.
8: 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.
9. 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.
10: 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.
11: 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.