Missed opportunities for timely recognition of chronic limb-threatening ischaemia in patients undergoing a major amputation: a population-based cohort study utilising the United Kingdom’s Clinical Practice Research Datalink

Objectives

Opportunities for timely recognition of chronic limb-threatening ischaemia (CLTI) within primary care, such as performing cardiovascular assessment during clinical consultation, are possibly being missed. This study aims to investigate for potential ‘missed opportunities’ within primary care.

Methods

Population-based cohort study, utilising the UK’s Clinical Practice Research Datalink (CPRD). Patients undergoing a major amputation for CLTI between 01/01/2000-31/12/2016 were included. Primary care consultation and patient clinical data within the one-year period prior to amputation were extracted from the CPRD. Dates of last primary care consultation and cardiovascular assessment prior to amputation were evaluated. Timings of latest cardiovascular assessments were stratified into ‘recent’ (7-90 days before amputation) and ‘late’ (>91 days).

Results

3260 patients were included. In the year prior to amputation, patients attended a median of 19 [9-32] primary care consultations, however prescription of secondary preventative medications was poor (antiplatelet=49.7%, lipid lowering agent=40.7%). Overall, 2175 patients (66.7%) attended a primary care consultation 7-30 days before their amputation. However, only 416 (12.8%) underwent a cardiovascular assessment within this period, with 2073 (63.6%) undergoing no assessment within 90 days of their amputation. Of these 2073 patients, 1230 (59.3%) had a primary care consultation 7-30 days before their procedure. Patients undergoing ‘late’ assessment were younger (p=.003), with higher systolic (p=.008) and diastolic (p=.001) blood pressures than those undergoing ‘recent’ assessment. Differences were also observed between timings of assessment by deprivation (p=.003) and ethnicity (p=.006).

Conclusion

Missed opportunities for timely recognition potentially exist and may be related to age, deprivation and ethnicity. Further work is required to investigate these factors, as well as individual amputations to identify the causes precipitating amputation. Greater emphasis on the medical management of peripheral arterial disease and identifying cardiovascular risk factors in patients who may not fit the ‘at risk’ stereotype, are also required.