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• W3048209215 abstract "Accumulating data on cardiovascular disease (CVD) development, morbidity, and mortality supports the concept of an East/West divide in Europe. In contrast to Western European countries (WECs), Central and Eastern European countries (CEECs) have a notably high burden of CVD.1Movsisyan N.K. Vinciguerra M. Medina-Inojosa J.R. Lopez-Jimenez F. Cardiovascular diseases in Central and Eastern Europe: a call for more surveillance and evidence-based health promotion.Ann Glob Health. 2020; 86: 21Crossref PubMed Scopus (13) Google Scholar There is broad consensus that the magnitude of the CVD epidemic in this region calls for action to strengthen the epidemiological knowledge base.1Movsisyan N.K. Vinciguerra M. Medina-Inojosa J.R. Lopez-Jimenez F. Cardiovascular diseases in Central and Eastern Europe: a call for more surveillance and evidence-based health promotion.Ann Glob Health. 2020; 86: 21Crossref PubMed Scopus (13) Google Scholar The CEECs include 11 ex-socialist countries (Bulgaria, Croatia, the Czech Republic, Estonia, Latvia, Lithuania, Hungary, Poland, Romania, Slovenia, and the Slovak Republic) that joined the European Union (EU) in the period 2004–2007. They represent 20% of the total EU population, emphasising the importance of this health issue. In the vascular surgery field, the incidence of lower limb major amputations is a central outcome indicator.2Rieß H.C. Debus E.S. Schwaneberg T. Hischke S. Maier J. Bublitz M. et al.Indicators of outcome quality in peripheral arterial disease revascularisations – a Delphi expert consensus.VASA. 2018; 47: 491-497Crossref PubMed Scopus (16) Google Scholar It is suitable to measure the performance of the whole healthcare system. It is essential to emphasise that this indicator reflects the consequences and quality of a complex chain of diverse events, primary healthcare measures, and interventions (or non-interventions), and, accordingly, it is not under the direct control of a single care provider.3Nicolucci A. Greenfield S. Mattke S. Selecting indicators for the quality of diabetes care at the health systems level in OECD countries.Int J Qual Health Care. 2006; 18: 26-30Crossref PubMed Scopus (74) Google Scholar In the last decade an abundance of big data and comprehensive analyses of amputation statistics have emerged from WECs; similar data from the CEECs are rarely available. The differences between the methodological approaches to how amputation rates are reported allow only a rough comparison of data. When approximating the average annual incidences of major lower limb amputations, CEECs show values close to, or above, 30 per 100 000 population. In contrast, in WECs, the major amputation incidence data show values below 20 per 100 000. This East/West divide is also discernible when comparing a unified Germany to the old Western and Eastern federal states.4Heyer K. Debus E.S. Mayerhoff L. Augustin M. Prevalence and regional distribution of lower limb amputations from 2006 to 2012 in Germany: a population based study.Eur J Vasc Endovasc Surg. 2015; 50: 761-766Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar In a report from the VASCUNET collaboration on incidences of major amputations in 12 countries, the highest incidence was reported in Hungary, followed by Slovakia.5Behrendt C.A. Sigvant B. Szeberin Z. Beiles B. Eldrup N. Thomson I. et al.International variations in amputation practice – a VASCUNET report.Eur J Vasc Endovasc Surg. 2018; 56: 391-399Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar Nonetheless, amputation rates are not systematically measured in healthcare systems. National and European regulators and the World Health Organization would be well advised to monitor this end point as a suitable performance indicator. Three urgent questions remain to be answered: (1) What are the main factors that account for this disparity? (2) How are healthcare systems, and specifically limb salvage teams, organised in WECs vs. CEECs? (3) Does this observation have any consequences for public health decision makers at EU level? The bulk of the publications presenting data on the population based incidence of amputations are simply descriptive. Analytical research, especially about the causes of the variation of amputation rates between and within countries, are rarely available. It can be assumed that differences in smoking habits, and how the epidemic of obesity and type 2 diabetes has affected different regions, are important background factors. The disparity in revascularisation activity may be one of the potential explanatory factors. There are some data from Hungary showing that revascularisation activity is markedly lower than in WECs.6Kolossvary E. Ferenci T. Kovats T. Kovacs L. Szeberin Z. Sotonyi P. et al.Lower limb amputations and revascularisation procedures in the Hungarian population: a 14 year retrospective cohort study.Eur J Vasc Endovasc Surg. 2020; 59: 447-456Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar However, observations suggest that, at a population level, the link between amputation rates and revascularisation is ambiguous, and this indicates that these two quality indicators represent complementary rather than overlapping domains.6Kolossvary E. Ferenci T. Kovats T. Kovacs L. Szeberin Z. Sotonyi P. et al.Lower limb amputations and revascularisation procedures in the Hungarian population: a 14 year retrospective cohort study.Eur J Vasc Endovasc Surg. 2020; 59: 447-456Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar,7Goodney P.P. Travis L.L. Brooke B.S. DeMartino R.R. Goodman D.C. Fisher E.S. et al.Relationship between regional spending on vascular care and amputation rate.JAMA Surg. 2014; 149: 34-42Crossref PubMed Scopus (35) Google Scholar In the broader sense, how limb salvage teams are organised in WECs and CEECs is of interest. All factors (physical or organisational) that may be considered as an access barrier to limb salvage services (distance from limb salvage or tertiary care centre, organisation of the limb salvage pathways) may contribute to the failure of care. The socio-economic status of the individual and the community may also be influential, which was revealed in an interesting observational study from Finland.8Forster T. Kentikelenis A. Bambra C. Health inequalities in Europe: setting the stage for progressive policy action.https://www.feps-europe.eu/attachments/publications/1845-6%20health%20inequalities%20inner-hr.pdfDate accessed: July 16, 2020Google Scholar The background of difference between WECs and CEECs in this regard is highly complex and can be attributed to the legacy of twentieth century European political divisions and healthcare policies in CEECs. According to this concept, differences in health systems (financing and coverage, human resources, barriers to access and utilisation, resilience in critical situations), and other social determinants of health (education, health behaviour, and health literacy), in addition to economic policy in a wider perspective, should be analysed to understand why people living in CEECs are more exposed to the risk of limb loss than living in WECs.9Venermo M. Manderbacka K. Ikonen T. Keskimäki I. Winell K. Sund R. Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study.BMJ Open. 2013; 3e002395Crossref PubMed Scopus (36) Google Scholar As for the remaining question, if this observation has any consequence for public health decision makers, the obvious answer is “yes”. Previous VASCUNET reports on bypass surgery and lower limb amputations have demonstrated that external factors related to the reimbursement system may have an impact on case selection and treatment. Union law underwent extensive reformations during the last decade. Against that backdrop, EU legislation bears responsibility not only for data protection and medical device regulation, but also for social and healthcare systems in need. The VASCUNET and extended international collaborations can help by harmonising healthcare and guiding EU and national health policies by using real world data from more than 26 clinical and administrative registries. Meanwhile, the Global Amputation Study, led by the World Federation of Vascular Societies, aims to address underlying factors for differences between countries, including healthcare expenditure and provision of vascular care on a global level. While the VASCUNET report had certain limitations, it generated important hypotheses that can be addressed by more detailed data collection using a more global perspective. After the ongoing conceptual phase, more countries will soon be invited to join these efforts, and the concept of data triangulation will be used to approximate to the complex relationship between physical or organisational factors and amputation rates." @default.
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• W3048209215 title "Lower Limb Major Amputation Data as a Signal of an East/West Health Divide Across Europe" @default.
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