{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,18]],"date-time":"2026-06-18T21:32:47Z","timestamp":1781818367549,"version":"3.54.5"},"reference-count":29,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2022,4,11]],"date-time":"2022-04-11T00:00:00Z","timestamp":1649635200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Peripheral arterial disease (PAD) and acute limb ischemia (ALI) pose an increasing strain on health care systems. The objective of this study was to describe the German health care landscape and to assess hospital utilization with respect to PAD and ALI. Methods: Secondary data analysis of diagnosis-related group statistics data (2009\u20132018) provided by the German Federal Statistical Office. Inclusion of cases encoded by the International Classification of Diseases (ICD-10) codes for PAD and arterial embolism or thrombosis. Construction of line diagrams and choropleth maps to assess temporal trends and regional distributions. Results: A total of 2,589,511 cases (median age 72 years, 63% male) were included, of which 2,110,925 underwent surgical or interventional therapy. Overall amputation rate was 17%, with the highest rates of minor (28%) and major amputations (15%) in patients with tissue loss. In-hospital mortality (overall 4.1%) increased in accordance to Fontaine stages and was the highest in patients suffering arterial embolism or thrombosis (10%). Between 2009 and 2018, the annual number of PAD cases with tissue loss (Fontaine stage IV) increased from 97,092 to 111,268, whereby associated hospital utilization decreased from 2.2 million to 2.0 million hospital days. Hospital incidence and hospital utilization showed a clustering with the highest numbers in eastern Germany, while major amputation rate and mortality were highest in northern parts of Germany. Conclusions: Increased use of endovascular techniques was observed, while hospital utilization to treat PAD with tissue loss has decreased. This is despite an increased hospital incidence. Addressing socioeconomic inequalities and a more homogeneous distribution of dedicated vascular units might be advantageous in reducing the burden of disease associated with PAD and ALI.<\/jats:p>","DOI":"10.3390\/jcm11082116","type":"journal-article","created":{"date-parts":[[2022,4,12]],"date-time":"2022-04-12T00:23:11Z","timestamp":1649722991000},"page":"2116","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["Utilization and Regional Differences of In-Patient Services for Peripheral Arterial Disease and Acute Limb Ischemia in Germany: Secondary Analysis of Nationwide DRG Data"],"prefix":"10.3390","volume":"11","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7076-9526","authenticated-orcid":false,"given":"Matthias","family":"Trenner","sequence":"first","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"},{"name":"Division of Vascular Medicine, St.-Josefs Hospital, 65189 Wiesbaden, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christoph","family":"Knappich","sequence":"additional","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bianca","family":"Bohmann","sequence":"additional","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Simon","family":"Heuberger","sequence":"additional","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0743-1642","authenticated-orcid":false,"given":"Hans-Henning","family":"Eckstein","sequence":"additional","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Kuehnl","sequence":"additional","affiliation":[{"name":"Department for Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, 81675 Munich, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2022,4,11]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"2982","DOI":"10.1016\/j.jacc.2020.11.010","article-title":"Global Burden of Cardiovascular Diseases and Risk Factors, 1990\u20132019: Update From the GBD 2019 Study","volume":"76","author":"Roth","year":"2020","journal-title":"J. Am. Coll Cardiol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1329","DOI":"10.1016\/S0140-6736(13)61249-0","article-title":"Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: A systematic review and analysis","volume":"382","author":"Fowkes","year":"2013","journal-title":"Lancet"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1016\/j.jvs.2014.03.290","article-title":"Epidemiology of peripheral arterial disease and critical limb ischemia in an insured national population","volume":"60","author":"Nehler","year":"2014","journal-title":"J. Vasc. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"932","DOI":"10.1093\/eurheartj\/ehv006","article-title":"Peripheral arterial disease and critical limb ischaemia: Still poor outcomes and lack of guideline adherence","volume":"36","author":"Reinecke","year":"2015","journal-title":"Eur. Heart J."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1024\/0301-1526\/a000966","article-title":"The prospective GermanVasc cohort study","volume":"50","author":"Kotov","year":"2021","journal-title":"Vasa"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"558","DOI":"10.1016\/j.jvs.2017.06.102","article-title":"Estimated annual health care expenditures in individuals with peripheral arterial disease","volume":"67","author":"Scully","year":"2018","journal-title":"J. Vasc. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1016\/j.ejvs.2019.08.006","article-title":"Editor\u2019s Choice\u2014Comorbidity Patterns Among Patients with Peripheral Arterial Occlusive Disease in Germany: A Trend Analysis of Health Insurance Claims Data","volume":"59","author":"Kreutzburg","year":"2020","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e009724","DOI":"10.1161\/JAHA.118.009724","article-title":"Determinants of Long-Term Outcomes and Costs in the Management of Critical Limb Ischemia: A Population-Based Cohort Study","volume":"7","author":"Mustapha","year":"2018","journal-title":"J. Am. Heart Assoc."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"764","DOI":"10.1136\/bmj.320.7237.764","article-title":"ABC of arterial and venous disease: Acute limb ischaemia","volume":"320","author":"Callum","year":"2000","journal-title":"BMJ"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1016\/j.ejvs.2019.09.006","article-title":"Editor\u2019s Choice\u2014European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia","volume":"59","author":"Bjorck","year":"2020","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1016\/j.ejvs.2021.10.044","article-title":"Epidemiology and Prognostic Factors in Acute Lower Limb Ischaemia: A Population Based Study","volume":"63","author":"Kulezic","year":"2022","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_12","first-page":"391","article-title":"Incidence, Treatment and Mortality in Patients with Abdominal Aortic Aneurysms","volume":"114","author":"Kuhnl","year":"2017","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"411","DOI":"10.1097\/SLA.0000000000002248","article-title":"Effect of Hospital Volume on In-hospital Morbidity and Mortality Following Pancreatic Surgery in Germany","volume":"267","author":"Krautz","year":"2018","journal-title":"Ann. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1082","DOI":"10.1097\/SLA.0000000000001693","article-title":"Nationwide In-hospital Mortality Following Pancreatic Surgery in Germany is Higher than Anticipated","volume":"264","author":"Nimptsch","year":"2016","journal-title":"Ann. Surg."},{"key":"ref_15","first-page":"885","article-title":"Trends in acute inpatient stroke care in Germany--an observational study using administrative hospital data from 2005-2010","volume":"109","author":"Nimptsch","year":"2012","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"379","DOI":"10.1002\/bjs.10714","article-title":"Nationwide analysis of risk factors for in-hospital mortality in patients undergoing abdominal aortic aneurysm repair","volume":"105","author":"Trenner","year":"2018","journal-title":"Br. J. Surg."},{"key":"ref_17","first-page":"120","article-title":"Good Practice of Secondary Data Analysis (GPS): Guidelines and recommendations","volume":"77","author":"Swart","year":"2015","journal-title":"Gesundheitswesen"},{"key":"ref_18","first-page":"e161","article-title":"A Consensus German Reporting Standard for Secondary Data Analyses, Version 2 (STROSA-STandardisierte BerichtsROutine fur SekundardatenAnalysen)","volume":"78","author":"Swart","year":"2016","journal-title":"Gesundheitswesen"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"189","DOI":"10.1111\/j.1538-4632.1992.tb00261.x","article-title":"The Analysis of Spatial Association by Use of Distance Statistics","volume":"24","author":"Getis","year":"1992","journal-title":"Geogr. Anal."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1111\/j.1538-4632.1995.tb00912.x","article-title":"Local Spatial Autocorrelation Statistics: Distributional Issues and an Application","volume":"27","author":"Ord","year":"1995","journal-title":"Geogr. Anal."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1818","DOI":"10.1161\/CIRCRESAHA.121.318535","article-title":"Epidemiology of Peripheral Artery Disease and Polyvascular Disease","volume":"128","author":"Aday","year":"2021","journal-title":"Circ. Res."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"1021","DOI":"10.1001\/jama.2015.10029","article-title":"Prevalence of and Trends in Diabetes Among Adults in the United States, 1988\u20132012","volume":"314","author":"Menke","year":"2015","journal-title":"JAMA"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"391","DOI":"10.1016\/j.ejvs.2018.04.017","article-title":"International Variations in Amputation Practice: A VASCUNET Report","volume":"56","author":"Behrendt","year":"2018","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"852","DOI":"10.1016\/j.ejvs.2018.02.024","article-title":"Spatial Analysis of Hospital Incidence and in Hospital Mortality of Abdominal Aortic Aneurysms in Germany: Secondary Data Analysis of Nationwide Hospital Episode (DRG) Data","volume":"55","author":"Kuehnl","year":"2018","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_25","first-page":"519","article-title":"Regional frequency variation of revascularization procedures for carotid stenosis in Germany. Secondary data analysis of DRG data from 2012 to 2014. Gefasschirurgie: Zeitschrift fur vaskulare und endovaskulare Chirurgie: Organ der Deutschen und der Osterreichischen Gesellschaft fur Gefasschirurgie unter Mitarbeit der Schweizerischen Gesellschaft fur Gefasschirurgie","volume":"23","author":"Kuhnl","year":"2018","journal-title":"Gef\u00e4sschirurgie"},{"key":"ref_26","unstructured":"Deutsche Herzstiftung (2022, March 10). Deutscher Herzbericht 2020. Available online: https:\/\/www.herzstiftung.de\/system\/files\/2021-06\/Deutscher-Herzbericht-2020.pdf."},{"key":"ref_27","first-page":"704","article-title":"Regional Differences in the Prevalence of Cardiovascular Disease","volume":"113","author":"Dornquast","year":"2016","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_28","first-page":"235","article-title":"The Use of Tobacco, E-Cigarettes, and Methods to Quit Smoking in Germany","volume":"115","author":"Kotz","year":"2018","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_29","unstructured":"Hans B\u00f6ckler Stiftung (2022, March 10). WSI Verteilungsmonitor\u2014Verf\u00fcgbare Pro-Kopf-Einkommen, Regional. Available online: https:\/\/www.boeckler.de\/pdf\/wsi_vm_verfuegbare_einkommen.pdf."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/8\/2116\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T22:51:33Z","timestamp":1760136693000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/11\/8\/2116"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2022,4,11]]},"references-count":29,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2022,4]]}},"alternative-id":["jcm11082116"],"URL":"https:\/\/doi.org\/10.3390\/jcm11082116","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2022,4,11]]}}}