Amputation rates of the lower limb by amputation level – observational study using German national hospital discharge data from 2005 to 2015

Abstract

BackgroundIn international comparisons, rates of amputations of the lower limb are relatively high in Germany. This study aims to analyze trends in lower limb amputations over time, as well as outcomes of care concerning in-hospital mortality and reamputation rates during the same hospital stay which might indicate the quality of surgical and perioperative health care processes.MethodsThis work is an observational population-based study using complete national hospital discharge data (Diagnosis-Related Group Statistics (DRG Statistics)) from 2005 to 2015. All inpatient cases with lower limb amputation were identified and stratified by eight amputation levels. Time trends of case numbers and in-hospital mortality were studied age-sex standardized. For inpatient cases with reamputation during the same hospital stay, first and last amputation levels were cross tabulated.ResultsA total of 55,595 amputations of the lower limb in 2015 (52,096 in 2005) were identified. After age-sex standardization to the demographic structure of 2005, a relative decrease of − 11.1% was revealed (men − 2.6%, women − 25.0%). The stratified analysis by amputation levels showed that the decreases were induced by higher amputation levels, whereas the amputation levels of toe/foot ray after standardization still showed a relative increase of + 12.8%. In-hospital mortality of all cases with lower limb amputation fell from 19.8% in 2005 to 17.4% in 2015 (SMR 0.89 [95% CI 0.86; 0.92]). The percentage of reamputations during the same hospital stay declined from 13.2 to 10.2%.ConclusionsThe number of lower limb amputations declined in Germany, however distinctly stronger in women than in men. The observed decreases of in-hospital mortality as well as of reamputation rates point to improvements in perioperative health care. Despite these indications of improvements, the distinct increase in case numbers at the level of toe/foot ray calls for additional targeted prevention efforts, especially for patients with diabetes.Electronic supplementary materialThe online version of this article (10.1186/s12913-018-3759-5) contains supplementary material, which is available to authorized users.

Epidemiology of Major Lower Extremity Amputations in Individuals With Diabetes in Austria, 2014-2017: A Retrospective Analysis of Health Insurance Database

“…In our study, the overall and yearly age-standardized rate of major LEA was signi cantly higher in males than females. Similar to our results, the analysis of national data of Germany noted higher amputation rates in males compared to females between 2005 and 2015 [12]. Another study from Germany reported signi cantly higher rates of amputations in males with and without diabetes compared to females that were independent of healthcare-related factors [21].…”

“…The temporal trend of major LEA re ects the performance of the primary healthcare system regarding the long-term care of diabetes. As mentioned earlier, the reduction in the incidence of major LEA in individuals with diabetes has been witnessed worldwide [12,13], however, an interesting temporal trend for LEA has been observed in Austria as per OECD estimates. .…”

“…Therefore, a reduction in the incidence of major LEA is a major health priority and considered a core indicator of the long-term quality of diabetes care worldwide [10]. Data from national audits in many countries and the Organization for Economic Cooperation and Development (OECD) have demonstrated a signi cant reduction in the incidence of diabetes-related major LEA over years owing to diabetic foot ulcer prevention and care programs [9][10][11][12]. Nevertheless, studies have reported up to a 20-fold variation in the rate of major LEA among countries [13,14].…”

Cost-effectiveness and budget impact of the microprocessor-controlled knee C-Leg in transfemoral amputees with and without diabetes mellitus

“…In Germany, the proportion of age-adjusted major amputations (above-ankle to hemipelvectomy) with diagnosed diabetes mellitus declined by 30.9% within 9 years (2005-2014), whereas minor amputations in this cohort increased by 25.4%. [1] Another publication reported comparable trends for the period 2005-2015: − 43% for hip joint/femoral amputation and − 36.9% for knee and lower leg amputation [2].…”

“…We identified one German study that reported midterm survival of lower limb amputees [21]. Other German studies only reported in-hospital-mortality [2]. Icks et al [21] provided survival data for patients with and without DM up to 5 years after amputation.…”