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It is interesting to read that Meffen A, et al. (2020) will study the incidence, prevalence and number of major-lower limb amputations in the UK, amongst their objectives. They plan to investigate the reasons for significant variation in the reporting of epidemiology of major lower extremity amputation (LEA). Prevalence of LEA has been evaluated, on numerous occasions in many epidemiological studies (1-14).
There has been a recent study that has followed similar methods and objectives to Meffen A, et al. (2020), to determine the methodological differences that create the variation of prevalence of LEAs (1). There are also studies that have used robust methodology to report on incidence, prevalence and number of LEAs, which include age standardised, gender, ethnic minority, and regional specific data analysis (6, 13, 14).
The same systematic searches of peer reviewed journals using PRISMA guidelines, have already been carried out from a comprehensive range of databases: PubMed, Cumulative index to Nursing and Allied Health Literature (CINAHL), ExperptaMedica Database (EMBASE), Medical Literature Analysis and Retrieval Online (MEDLINE), Cochrane database, NHS Digital, Diabetes UK and Healthcare Quality Improvement Partnership (HQIP), of all LEA studies performed in England, over a 30 year period (1988- 2018) (1).
The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7...
The variation in prevalence of major LEAs, reported by Davies M, Burdett L, Bowling F, et al. (2019) range from 0.7 to 332.4 per 100,000 in the diabetic population and 3.0 to 76.1 per 100,000 in the general population (1). A reliable conclusion has been reached as to why there is significant variation in the studies. There is absence in the application of standardised epidemiological principles when calculating and reporting on (LEA rates (1). Methodology used in most studies does not facilitate comparison across populations and time. The inconsistent nature of reporting LEAs make drawing conclusions on temporal and population change difficult, which is evidenced comprehensively in Table 1 and Table 2 of Davies M, Burdett L, Bowling F, et al. (2019) study.
Ahmad et al, (6, 13, 14) have successfully published regional and subgroup differences relating to LEA prevalence, using robust methodology, which Meffen A, et al. (2020) plan to study. They reported that above to below knee amputation ratio (a potential marker of poor care) is higher in Northern regions of England (North 1.3:1, Midlands 1.2:1, South 0.9:1) and that amputation rates are three times higher in men compared with women. They have also reported that LEAs are 70% higher in black than white populations, and half of amputations are in people that do not have diabetes.
Collecting and analysing NHS data for LEA patients that do not have diabetes, but have peripheral arterial disease, is difficult due to lack of specific coding. This is despite this patient group making up at least forty percent of all LEAs (14). Hopefully, studies such as Meffen A, et al. (2020) will initiate the urgently needed implementation of national NHS coding for non-diabetic amputations (other than caused by cancer and trauma) as a result of their investigation of healthcare data sources, by evidencing such limitations in their findings.
Meffen A, et al. confirms that in England there are fewer major LEAs than minor, however minor amputations will be excluded from their study. Minor LEAs have significant variation in rates, which relate to similar issues as major LEAs. It is important that accurate data exists for both minor and major LEAs, to allow public health professionals to implement preventative strategies, and plan their services on a local, regional and national level.
Future studies will need to describe and present basic numerator and denominator population characteristics e.g. number, age and gender, and use standardised definitions and coding for the type of LEA, to achieve accurate data reporting. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines ought to considered to become requisite for authors conducting and publishing observational studies, in order to publish standardised high-quality presentation of epidemiology studies (15).
It is without doubt that public health specialists, vascular surgeons, diabetologists, podiatric surgeons, podiatrists, and all other lower limb specialists will find future studies that deliver accurate number and prevalence rates of LEAs, extremely valuable. Standardised methodology when carrying such studies in this subject is long- awaited.
Competing interests: No competing interests
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