Deficiencies in foot care of diabetic patients on renal replacement therapy

Opportunities To Improve Diabetes Care in the Hemodialysis Unit: A Cohort Study in Ontario, Canada

Background

Patients with diabetes receiving chronic, in-center hemodialysis face healthcare challenges. We examined the prevalence of gaps in their diabetes care, explored regional differences, and determined predictors of care gaps.

Methods

We conducted a population-based, retrospective study between January 1, 2016 and January 1, 2018 in Ontario, Canada. We included adults with prevalent diabetes mellitus receiving in-center hemodialysis as of January 1, 2018 and examined the proportion with (1) insufficient or excessive glycemic monitoring, (2) suboptimal screening for diabetes-related complications (retinopathy and cardiovascular screening), (3) hospital encounters for hypo- or hyperglycemia, and (4) hospital encounters for hypertension in the 2 years prior (January 1, 2016 to January 1, 2018). We then identified patient, provider, and health-system factors associated with more than one care gap and used multivariable logistic regression to determine predictors. Further, we used geographic information systems to explore spatial variation in gaps.

Results

There were 4173 patients with diabetes receiving in-center hemodialysis; the mean age was 67 years, 39% were women, and the majority were of lower socioeconomic status. Approximately 42% of patients had more than one diabetes care gap, the most common being suboptimal retinopathy screening (53%). Significant predictors of more than one gap included younger age, female sex, shorter duration of diabetes, dementia, fewer specialist visits, and not seeing a physician for diabetes. There was evidence of spatial variation in care gaps across our region.

Conclusions

There are opportunities to improve diabetes care in patients receiving in-center hemodialysis, particularly screening for retinopathy. Focused efforts to bring diabetes support to high-risk individuals might improve their care and outcomes.

The Health and Health Care of Adults With Type 1 And 2 Diabetes Across the Spectrum of Estimated Glomerular Filtration Rates

OBJECTIVES

Little is known about the health and health-care patterns of patients with diabetes according to their estimated glomerular filtration rates, especially within a publicly funded health-care system.

METHODS

Using linked health-care databases in Ontario, Canada, we performed a population-based study of adults 50 years of age and older (mean age, 68 years) with prevalent diabetes on January 1, 2014. We categorized patients according to their levels of kidney function (estimated glomerular filtration rate ≥90, 60 to 89, 30 to 59, 15 to 29 or <15 mL/min/1.73 m², or the receipt of ongoing maintenance dialysis). We then followed patients for 2 years to determine: 1) their level of contact with health-care providers (i.e. visits to family doctors, specialists); 2) their use and repeated use of acute medical services (i.e. hospitalizations and emergency department encounters; 3) diabetes-related monitoring and screening (i.e. glycated hemoglobin and cholesterol tests, vision screening); 4) glycemic and lipid control; and 5) diabetes-related outcomes.

RESULTS

There were 569,384 patients in our study. Most had estimated glomerular filtration rates between 60 and 89 mL/min/1.73 m². At baseline, patients with lower kidney function had longer durations of diabetes and more comorbidities. Over 2 years of follow up, they had higher burdens of medical care, excessive diabetes monitoring and were underscreened for diabetes-related complications. Although metabolic control was reasonable across groups, patients with low kidney function had more hospital encounters and more diabetes-related complications.

CONCLUSIONS

Patients with diabetes and low kidney function are a vulnerable population that faces health system challenges and care gaps. Suggestions for policy and practice are discussed.

Risk factors for foot ulceration in adults with end-stage renal disease on dialysis: study protocol for a prospective observational cohort study

BACKGROUND

Adults with end-stage renal disease treated with dialysis experience a high burden of foot ulceration and lower extremity amputation. However, the risk factors for foot ulceration in the dialysis population are incompletely understood due to the lack of high-quality prospective evidence. This article outlines the design of a prospective observational cohort study, which aims to investigate the risk factors for foot ulceration in adults on dialysis.

METHODS/DESIGN

This study will recruit 430 participants with end-stage renal disease on dialysis from satellite and home-therapy dialysis units across multiple health organisations in Melbourne, Victoria, Australia. Data collection at baseline will include a participant interview, medical record review, completion of a health-status questionnaire and a non-invasive foot assessment. Twenty participants will also be recruited to a reliability study to evaluate the reproducibility of testing procedures. Primary outcome data includes: new foot ulcer(s). Secondary outcome data includes: number of new foot ulcers, time to onset of new foot ulcer(s), new lower extremity amputation(s), episodes of infection of the foot or lower extremity, episodes of osteomyelitis, foot-related hospitalisations, revascularisation procedure(s) of the lower extremity, new podiatry interventions, kidney transplantation, and mortality. Participants will be assessed at baseline, and at 12 months they will be evaluated for the primary and secondary outcomes. Multivariate Cox proportional hazards models will be used to assess predictors of new foot ulceration and time to event secondary outcomes. Logistic regression will be used for binary outcomes including prevalence of foot ulcerations.

DISCUSSION

This is the first multi-centre prospective observational cohort study to investigate risk factors for foot ulceration in adults with end-stage renal disease on dialysis. This study will improve on prior studies by using prospective methods, multi-centre recruitment, statistical methods to control for confounding variables, and a pre-specified sample size estimation. The findings can inform the design of future trials evaluating the effectiveness of clinical interventions, which may lead to improved patient outcomes in the dialysis setting.