Socioeconomic and ethnic disparities in major lower limb amputation related to peripheral arterial disease in England

Background

Amputation is a treatment of last resort for peripheral arterial disease. This study examined associations between socioeconomic deprivation, ethnicity, above-knee amputation (AKA) and below-knee amputation (BKA) rates, and post-amputation survival in England.

Methods

Hospital Episode Statistics data identified patients aged ≥25 years who underwent an AKA or BKA related to peripheral arterial disease in 2006-2018. Data on ethnicity, comorbidity and socioeconomic deprivation was recorded. An ecological study design, based on population-level data, analysed amputation rates (Poisson regression), and a cohort study design investigated mortality subsequent to amputation (Cox regression).

Results

Within a population of 35.7 million people aged ≥25 years, 47 249 patients underwent peripheral arterial disease-related major amputation over 12 years (94.1% White, 1.9% Black, and 1.6% Asian ethnicity). AKA : BKA ratios were 1.03, 0.73, and 0.80 for White, Black, and Asian ethnicities respectively. Amputation rates increased with increasing socioeconomic deprivation. The amputation rate ratio for the most relative to the least deprived category varied with age, ranging from 4.94 (95% confidence interval 4.24 to 5.75) for age 45–54 years to 1.35 (1.21 to 1.49) for age ≥85 years for AKA, and from 3.88 (3.44 to 4.37) to 1.12 (0.97 to 1.29) for BKA. Post-amputation mortality hazard ratios also increased with increasing socioeconomic deprivation, ranging from 1.26 (1.04 to 1.53) for age 25–54 years to 1.11 (1.03 to 1.19) for age ≥75 years for AKA, and from 1.25 (1.08 to 1.46) to 1.17 (1.08 to 1.27) for BKA. Over 12 years, amputation rates decreased in all socioeconomic categories in the population aged ≥65 years, but there was little change in the population aged 25–64 years. Black ethnicity was associated with lower adjusted AKA and BKA rate ratios relative to White ethnicity in those aged 25–64 years, and similar AKA but higher BKA rate ratios in those aged ≥65 years. Black ethnicity was also associated with lower post-amputation mortality, except in those aged 25–54 years within 90 days of BKA. Asian ethnicity was associated with lower AKA and BKA rate ratios relative to White ethnicity, but similar post-amputation mortality with some exceptions.

Conclusion

The main policy and practice implications relate to socioeconomic inequalities. Greater efforts are needed in disadvantaged areas to prevent and manage peripheral arterial disease and reduce amputation.