Geospatial mapping and data linkage uncovers variability in outcomes of foot disease according to multiple deprivation: a population cohort study of people with diabetes

Epidemiology of major amputation following diabetic foot ulcer: Insights from recent nationwide data in the french national health registry (SNDS)

OBJECTIVE

The out-of-hospital care pathways of people with DFU have been little studied. We used the French National Health Data System (SNDS) to collect refund and care pathway data for all French residents. The aim of this study was to determine the incidence of major lower limb amputation (MA) and associated risk factors in a population with an incident DFU.

RESEARCH DESIGN AND METHODS

We included any person living with diabetes and incident DFU. The primary endpoint was the occurrence of MA within one year. We considered the course and consumption of care one year before and one year after the initial event.

RESULTS

In 2018, 133,791 people were included, and during the follow-up, MA was performed in 4,733 (3.5 %). Among these people with MAs, 16.4 % were included via the out-of-hospital part of the protocol, and their first contact with the hospital led to MA. Factors associated (hazard ratio, HR [95 % confidence interval, CI]) with MA were: being male (1.92 [1.78;2.08]), arteriopathy of the lower limb (10.16 [9.36;11.03]), psychiatric disease (1.10 [1.01;1.20]) and end-stage renal disease (2.12 [1.93;2.33]). Regarding the care pathway, associations (HR [95 %CI]) were observed between lower MA rates and people with more general practitioner (0.83 [0.75-0.91]), private nurse (0.88 [0.81-0.95]) and diabetologist (0.88 [0.81-0.95]) visits. Living in the most disadvantaged municipalities was associated (HR [95 %CI]) with a higher MA rate (1.17[1.06-1.29]).

CONCLUSION

This is the first national study of the care pathways followed by people with DFU. Failures in the care pathway, precariousness and several comorbidities were identified, with an impact on the MA risk.

Unravelling the cardio-renal-metabolic-foot connection in people with diabetes-related foot ulceration: a narrative review

Diabetes-related foot ulceration (DFU), a serious but preventable complication of diabetes, is a leading cause of hospitalisation, lower extremity amputation and disability worldwide. People with DFU have a greater burden of cardiovascular risk factors, heart failure and chronic kidney disease, resulting in over two-fold higher risk of cardiovascular death compared with people with diabetes without DFU. Here, we propose a "cardio-renal-metabolic-foot" connection in people with diabetes based on shared pathophysiological mechanisms linking DFU with cardiovascular and renal disease. Whilst these mechanistic links remain to be fully elucidated, systemic inflammation and infection in the context of DFU are postulated as key mediators in the development, and progression of, cardiovascular and renal disease. However, cardiovascular and renal disease are also implicated in the pathogenesis of DFU, highlighting the multi-directional interplay between conditions. The impact of screening, prevention, and early management of cardiovascular complications associated with DFU requires further research. Multi-modality cardiac imaging could play a role in unravelling disease mechanisms leading to novel therapeutic strategies, as well as facilitating personalised risk assessment and management. Recent clinical trials have transformed the therapeutic landscape for people with type 2 diabetes, by demonstrating that sodium glucose co-transporter 2 inhibitors, glucagon-like peptide-1 agonists and non-steroidal mineralocorticoid receptor antagonists improve cardiovascular and renal outcomes. Although dedicated research in people with DFU is warranted, these therapies could target multiple facets of the "cardio-renal-metabolic-foot" connection. The holistic, person-centred approach to managing DFU should incorporate new multidisciplinary models of care focusing on the prevention and management of cardiovascular and kidney disease.

The feasibility of a social media-based foot self-management education and support program for adults with diabetes: A partially randomized preference trial

Aim

To assess the feasibility of Diabetic Foot Care Group (DFCG), a social media-based self-management education and support intervention, for people with diabetes (PWD) empowerment in diabetes-related foot ulceration prevention.

Methods

A partially randomized preference trial was conducted among 32 PWD. DFCG was implemented through Facebook. Participants in the intervention group joined the DFCG in addition to their usual care, while the control group received usual care. Data were collected online using questionnaires on participants' DFCG acceptance, engagement and preliminary efficacy on nine diabetes foot care-related outcomes at baseline, one, and three months post-intervention.

Results

The participants' study intervention acceptability and engagement rates were 84.2% and 55.2%, respectively. DFCG efficacy rate compared to usual care was 88.9% to 22.2%. Three diabetes foot care-related outcomes increased significantly in the intervention group three-month post-intervention: foot self-care adherence (p = 0.001, ηp 2 = 0.35), preventive foot self-care practice (p = 0.002, ηp 2 = 0.33), and physical health status (p < 0.02, ηp 2 = 0.23).

Conclusion

DFCG is feasible and could effectively improve diabetes foot care-related outcomes.

Innovation

Social media is an innovative approach healthcare professionals could utilize to virtually support PWD in ongoing learning and engagement in optimal foot self-care activities.

Trial registration

ClinicalTrials.gov, Identifier: NCT04395521.

Degree of sulfation of freeze-dried calcium alginate sulfate scaffolds dramatically influence healing rate of full-thickness diabetic wounds

Diabetic foot ulcer (DFU) is a chronic and non-healing wound in all age categories with a high prevalence and mortality in the world. An ideal wound dressing for DFU should possess the ability of adsorbing high contents of exudate and actively promote wound healing. Here, we introduced the calcium alginate sulfate as a new biomaterial appropriate for use in wound dressing to promote the healing of full-thickness ulcers in a diabetic mouse model. In this regard, alginate sulfate (Alg-S) solutions with different degrees of substitution (DS) of 0.2, 0.5, and 0.9 were synthesized, freeze-dried, crosslinked by calcium cations, purified by washing and refreeze-dried. Primary analyses including swelling ratio, porosity content and mechanical properties revealed that all Alg-S scaffolds possess necessities for use as a wound dressing. After confirming the cytocompatibility of both alginate and alginate sulfate-based scaffolds by MTT assay, they were used as wound dressing for healing of full-thickness ulcers in diabetic mice. The results of wound healing process confirmed that calcium alginate sulfate scaffolds can heal the wounds faster than both alginate-treated and non-treated wounds. Furthermore, the histological analyses of healed tissues reveled normal regeneration of the skin tissue layers and collagen deposition similar to the healthy tissue.

Geographic Variation in First Lower Extremity Amputations Related to Diabetes and/or Peripheral Arterial Disease

BACKGROUND

To assess trends of first cases of lower extremity amputation (LEA) related to diabetes and/or peripheral arterial disease (PAD), according to areas of residency and neighbourhood material and social deprivation quintiles, in the province of Quebec, Canada.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we calculated crude and age-standardized annual incidence rates of first LEA (total, minor, and major) among adults 40 years of age and older with diabetes and/or PAD in fiscal years 2006 and 2019. Area of residency was compiled in 3 categories: (1) Montreal and other census metropolitan areas; (2) midsize agglomerations (10,000-100,000 inhabitants); and (3) small towns and rural areas (< 10,000 inhabitants). We also stratified according to neighbourhood material and social deprivation quintiles. One-year and 5-year all-cause mortality after first LEA were compared according to area of residency.

RESULTS

Among the 10,275 individuals who had a first LEA, age-standardized LEA rates remained stable between 2006 and 2019, whereas major LEA rates declined in all geographical areas and minor LEA rates increased (31.6%) in small towns and rural areas. In 2019, age-standardized LEA rates were higher in midsize agglomerations and small towns and rural areas compared with census metropolitan areas. Age-standardized LEA rates in 2019 were higher among the most deprived quintile compared with the most privileged quintile for material and social deprivation. No difference was observed in mortality after first LEA according to area of residency.

CONCLUSIONS

There are health disparities in the burden of diabetes and PAD related to first LEA in the province of Quebec. To improve preventive care and reduce the burden of LEA, targeted actions should be taken among the most deprived groups and rural settings.

The impact of social deprivation on development and progression of diabetic kidney disease

Introduction

Diabetes is one of the leading causes of chronic kidney disease. Social deprivation is recognised as a risk factor for complications of diabetes, including diabetic kidney disease. The effect of deprivation on rate of decline in renal function has not been explored in the Irish Health System to date. The objective of this study is to explore the association between social deprivation and the development/progression of diabetic kidney disease in a cohort of adults living with diabetes in Ireland.

Methods

This is a retrospective cohort study using an existing dataset of people living with diabetes who attended the diabetes centre at University Hospital Galway from 2012 to 2016. The variables included in this dataset include demographic variables, type and duration of diabetes, clinical variables such as medication use, blood pressure and BMI and laboratory data including creatinine, urine albumin to creatinine to ratio, haemoglobin A1c and lipids. This dataset will be updated with laboratory data until January 2023. Individual's addresses will be used to calculate deprivation indices using the Pobal Haase Pratschke (HP) deprivation index. Rate of renal function decline will be calculated using linear mixed-effect models. The relationship between deprivation and renal function will be assessed using linear regression (absolute and relative rate of renal function decline based on eGFR) and logistic regression models (rapid vs. non-rapid decline).

Prospective Evaluation of Vitamin C, Vitamin D, and Zinc Deficiencies in Patients with Active Foot Ulceration

Objective: This prospective cohort study aimed to determine the relationship between serum vitamin C, D, and zinc on foot wound healing and compare time to healing in individuals who are deficient versus those who have adequate levels. Approach: One hundred adults with foot wounds were recruited from Blacktown high-risk foot service with a follow-up period of 12 months. Serum vitamin C, D, and zinc as well as routine baseline blood testing was undertaken. Wounds were measured using a three-dimensional wound camera and classified using the Wound Ischemia and Foot Infection system at regular intervals. Results: Vitamin C deficiency was present in 75% of participants, 50% had vitamin D deficiency, and 38% had zinc deficiency. Diabetes was present in 91% of participants, and 50% had a history of previous amputation. Wound chronicity (p = 0.03) and toe pressures (p = 0.04) were predictive of wound healing. Serum vitamin C, D, and zinc were not associated with significant differences in wound healing or time to wound healing. Innovation: Deficiencies in vitamin C, D, and zinc were highly prevalent in participants with active foot ulceration. Wound chronicity was predictive of healing outcomes, highlighting the importance of rapid access to best practice care. Conclusion: This cohort had high deficiency rates of vitamin C, D, and zinc consistent with previous literature; however, there was no relationship between these deficiencies and wound healing or time to heal. Large randomized controlled trials are required to comprehensively determine if adequate levels of these nutrients improve wound healing outcomes.

Neutrophil Extracellular Traps (NETs) Are Associated with Type 2 Diabetes and Diabetic Foot Ulcer Related Amputation: A Prospective Cohort Study

INTRODUCTION

The prevalence of diabetes mellitus and its sequelae has been on the rise, and diabetic foot ulcer (DFU) is the leading cause of non-traumatic lower limb amputation globally. The rising occurrence and financial burden associated with DFU necessitate improved clinical assessment and treatment. Diabetes has been found to enhance the formation of neutrophil extracellular traps (NETs) by neutrophils, and excessive NETs have been implicated in tissue damage and impaired wound healing. However, there is as yet insufficient evidence to clarify the value of NETs in assessing and predicting outcomes of DFU.

METHODS

We designed this prospective study with three cohorts formed from type 2 diabetes mellitus (T2DM) patients with DFU (n = 200), newly diagnosed T2DM patients (n = 42), and healthy donors (n = 38). Serum levels of NETs were detected for all groups, and the prognostic value for DFU-related amputation was analyzed.

RESULTS

The results showed that serum NET levels of the DFU group were significantly higher than in the T2DM group (P < 0.05), which also had significantly elevated serum NET levels compared to healthy donors (P < 0.05). Multivariate Cox regression showed that serum NET levels, diabetic foot surgical history, and Wagner grade were the risk factors for amputation (P < 0.05), and these three variables also exhibited the highest coefficient values in additional Lasso Cox regression. For patients with DFU, Kaplan-Meier curves showed that high serum NET levels associated with higher amputation probability (HR = 0.19, P < 0.01) and ROC curve based on NET value showed good validity for amputation (AUC: 0.727, CI 0.651-0.803).

CONCLUSION

Elevated serum NET levels serve as an easily accessible serological prognostic marker for assessing the risk of DFU-related amputation, thereby offering evaluation metrics for healthcare providers. Further investigations are necessary to understand the mechanisms driving this relationship.

The Development of the Municipal Registry of People with Diabetes in Porto Alegre, Brazil

Background/Objective: Diabetes registries that enhance surveillance and improve medical care are uncommon in low- and middle-income countries, where most of the diabetes burden lies. We aimed to describe the methodological and technical aspects adopted in the development of a municipal registry of people with diabetes using local and national Brazilian National Health System databases. Methods: We obtained data between July 2018 and June 2021 based on eight databases covering primary care, specialty and emergency consultations, medication dispensing, outpatient exam management, hospitalizations, and deaths. We identified diabetes using the International Classification of Disease (ICD), International Classification of Primary Care (ICPC), medications for diabetes, hospital codes for the treatment of diabetes complications, and exams for diabetes management. Results: After data processing and database merging using deterministic and probabilistic linkage, we identified 73,185 people with diabetes. Considering that 1.33 million people live in Porto Alegre, the registry captured 5.5% of the population. Conclusions: With additional data processing, the registry can reveal information on the treatment and outcomes of people with diabetes who are receiving publicly financed care in Porto Alegre. It will provide metrics for epidemiologic surveillance, such as the incidence, prevalence, rates, and trends of complications and causes of mortality; identify inadequacies; and provide information. It will enable healthcare providers to monitor the quality of care, identify inadequacies, and provide feedback as needed.

Social deprivation and diabetic kidney disease: A European view

There is a large body of literature demonstrating a social gradient in health and increasing evidence of an association between social deprivation and diabetes complications. Diabetic kidney disease (DKD) increases mortality in people with diabetes. Socioeconomic deprivation is increasingly recognized as a modifier of risk factors for kidney disease but also an independent risk factor itself for kidney disease. This may not be truly appreciated by clinicians and warrants further attention and exploration. In this review we explore the literature to date from Europe on the relationship between social deprivation and DKD. The majority of the studies showed at least an association with microalbuminuria, an early marker of DKD, while many showed an association with overt nephropathy. This was seen across many countries in Europe using a variety of different measures of deprivation. We reviewed and considered the mechanisms by which deprivation may lead to DKD. Health related behaviors such as smoking and suboptimal control of risk factors such as hypertension, hyperglycemia and elevated body mass index (BMI) accounts for some but not all of the association. Poorer access to healthcare, health literacy, and stress are also discussed as potential mediators of the association. Addressing deprivation is difficult but starting points include targeted interventions for people living in deprived circumstances, equitable roll out of diabetes technology, and flexible outpatient clinic arrangements including virtual and community-based care.

Creating an interactive map visualising the geographic variations of the burden of diabetes to inform policymaking: An example from a cohort study in Tasmania, Australia

OBJECTIVES

To visualise the geographic variations of diabetes burden and identify areas where targeted interventions are needed.

METHODS

Using diagnostic criteria supported by hospital codes, 51,324 people with diabetes were identified from a population-based dataset during 2004-2017 in Tasmania, Australia. An interactive map visualising geographic distribution of diabetes prevalence, mortality rates, and healthcare costs in people with diabetes was generated. The cluster and outlier analysis was performed based on statistical area level 2 (SA2) to identify areas with high (hot spot) and low (cold spot) diabetes burden.

RESULTS

There were geographic variations in diabetes burden across Tasmania, with highest age-adjusted prevalence (6.1%), excess cost ($2627), and annual costs per person ($5982) in the West and Northwest. Among 98 SA2 areas, 16 hot spots and 25 cold spots for annual costs, and 10 hot spots and 10 cold spots for diabetes prevalence were identified (p<0.05). 15/16 (94%) and 6/10 (60%) hot spots identified were in the West and Northwest.

CONCLUSIONS

We have developed a method to graphically display important diabetes outcomes for different geographical areas.

IMPLICATIONS FOR PUBLIC HEALTH

The method presented in our study could be applied to any other diseases, regions, and countries where appropriate data are available to identify areas where interventions are needed to improve diabetes outcomes.

Independent association of history of diabetic foot with all-cause mortality in patients with type 2 diabetes: the Renal Insufficiency And Cardiovascular Events (RIACE) Italian Multicenter Study

BACKGROUND

Foot ulcers and/or infections are common long-term complications of diabetes and are associated with increased mortality, especially from cardiovascular disease, though only a few studies have investigated the independent contribution of these events to risk of death. This study aimed at assessing the association of history of diabetic foot with all-cause mortality in individuals with type 2 diabetes, independent of cardiovascular risk factors, other complications, and comorbidities.

METHODS

This prospective cohort study enrolled 15,773 Caucasian patients in 19 Italian centers in the years 2006-2008. Prior lower extremity, coronary, and cerebrovascular events and major comorbidities were ascertained by medical records, diabetic retinopathy by fundoscopy, diabetic kidney disease by albuminuria and estimated glomerular filtration rate, cardiovascular risk factors by standard methods. All-cause mortality was retrieved for 15,656 patients on 31 October 2015.

RESULTS

At baseline, 892 patients (5.7%) had a history of diabetic foot, including ulcer/gangrene and/or amputation (n = 565; 3.58%), with (n = 126; 0.80%) or without (n = 439; 2.78%) lower limb revascularization, and revascularization alone (n = 330; 2.09%). History of diabetic foot was associated with all-cause death over a 7.42-year follow-up (adjusted hazard ratio, 1.502 [95% confidence interval, 1.346-1.676], p < 0.0001), independent of confounders, among which age, male sex, smoking, hemoglobin A1c, current treatments, other complications, comorbidities and, inversely, physical activity level and total and HDL cholesterol were correlated independently with mortality. Both ulcer/gangrene and amputation alone were independently associated with death, with a higher strength of association for amputation than for ulcer/gangrene (1.874 [1.144-3.070], p = 0.013 vs. 1.567 [1.353-1.814], p < 0.0001). Both ulcer/gangrene/amputation and lower limb revascularization alone were independently associated with death; mortality risk was much higher for ulcer/gangrene/amputation than for revascularization (1.641 [1.420-1.895], p < 0.0001 vs. 1.229 [1.024-1.475], p = 0.018) and further increased only slightly for combined ulcer/gangrene/amputation and revascularization (1.733 [1.368-2.196], p < 0.0001).

CONCLUSIONS

In patients with type 2 diabetes, an history of diabetic foot event, including ulcer/gangrene, amputation, and lower limb revascularization, was associated with a ~ 50% increased risk of subsequent death, independent of cardiovascular risk factors, other complications and severe comorbidities, which were also significantly associated with mortality. The association with mortality was greatest for amputation, whereas that for revascularization alone was relatively modest.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT00715481, retrospectively registered 15 July, 2008.

Call to action on diabetes care: reaching communities facing health inequalities, health inequities and deprivation

This article presents evidence and policy on the importance of reaching out into local communities with inclusive approaches to try to reduce and prevent inequities and inequalities in diabetes care. The global emergency diabetes is causing and the risks and disproportionately high ethnic disparities are investigated. The article includes some suggestions on changing approaches to reduce health inequalities to enable diabetes care to become more accessible for those who need it the most.

Diabetic Foot Ulcers: A Review

Importance

Approximately 18.6 million people worldwide are affected by a diabetic foot ulcer each year, including 1.6 million people in the United States. These ulcers precede 80% of lower extremity amputations among people diagnosed with diabetes and are associated with an increased risk of death.

Observations

Neurological, vascular, and biomechanical factors contribute to diabetic foot ulceration. Approximately 50% to 60% of ulcers become infected, and about 20% of moderate to severe infections lead to lower extremity amputations. The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation. The mortality rate for people with diabetic foot ulcers is 231 deaths per 1000 person-years, compared with 182 deaths per 1000 person-years in people with diabetes without foot ulcers. People who are Black, Hispanic, or Native American and people with low socioeconomic status have higher rates of diabetic foot ulcer and subsequent amputation compared with White people. Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify risk of limb-threatening disease. Several interventions reduce risk of ulcers compared with usual care, such as pressure-relieving footwear (13.3% vs 25.4%; relative risk, 0.49; 95% CI, 0.28-0.84), foot skin measurements with off-loading when hot spots (ie, greater than 2 °C difference between the affected foot and the unaffected foot) are found (18.7% vs 30.8%; relative risk, 0.51; 95% CI, 0.31-0.84), and treatment of preulcer signs. Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers. Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis. Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care (3.2% vs 4.4%; odds ratio, 0.40; 95% CI, 0.32-0.51). Approximately 30% to 40% of diabetic foot ulcers heal at 12 weeks, and recurrence after healing is estimated to be 42% at 1 year and 65% at 5 years.

Conclusions and Relevance

Diabetic foot ulcers affect approximately 18.6 million people worldwide each year and are associated with increased rates of amputation and death. Surgical debridement, reducing pressure from weight bearing, treating lower extremity ischemia and foot infection, and early referral for multidisciplinary care are first-line therapies for diabetic foot ulcers.

Hybrid gelatin-sulfated alginate scaffolds as dermal substitutes can dramatically accelerate healing of full-thickness diabetic wounds

Diabetic foot ulcers (DFUs) are defined as chronic and non-healing wounds that cause skin disorders. Here, we introduce a novel biodegradable gelatin/sulfated alginate hybrid scaffold as a dermal substitute to accelerate the healing of full-thickness diabetic ulcers in a diabetic mouse model. The hybrid scaffold possessing different weight ratios of sulfated alginate, from 10 % up to 50 %, were prepared through chemical crosslinking by carbodiimide chemistry and further freeze-drying. Based on the in vitro cytotoxicity experiments, the hybrid scaffolds not only showed no cytotoxicity, but the cell growth also dramatically increased by increasing the sulfated alginate content. Finally, the pathology of hybrid scaffolds as the dermal substitutes for healing of full-thickness diabetic wounds showed the more appropriate formation of epidermal layer, more homogeneous distribution of collagenous tissue and lower penetration of immune cells for the hybrid scaffolds-treated wounds.

Etiology, Epidemiology, and Disparities in the Burden of Diabetic Foot Ulcers

Diabetic foot ulcers (DFU) are a major source of preventable morbidity in adults with diabetes. Consequences of foot ulcers include decline in functional status, infection, hospitalization, lower-extremity amputation, and death. The lifetime risk of foot ulcer is 19% to 34%, and this number is rising with increased longevity and medical complexity of people with diabetes. Morbidity following incident ulceration is high, with recurrence rates of 65% at 3-5 years, lifetime lower-extremity amputation incidence of 20%, and 5-year mortality of 50-70%. New data suggest overall amputation incidence has increased by as much as 50% in some regions over the past several years after a long period of decline, especially in young and racial and ethnic minority populations. DFU are a common and highly morbid complication of diabetes. The pathway to ulceration, involving loss of sensation, ischemia, and minor trauma, is well established. Amputation and mortality after DFU represent late-stage complications and are strongly linked to poor diabetes management. Current efforts to improve care of patients with DFU have not resulted in consistently lower amputation rates, with evidence of widening disparities and implications for equity in diabetes care. Prevention and early detection of DFU through guideline-directed multidisciplinary care is critical to decrease the morbidity and disparities associated with DFU. This review describes the epidemiology, presentation, and sequelae of DFU, summarizes current evidence-based recommendations for screening and prevention, and highlights disparities in care and outcomes.

Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study

OBJECTIVE

Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population.

RESEARCH DESIGN AND METHODS

This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation.

RESULTS

A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03).

CONCLUSIONS

In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.

Social Deprivation, Healthcare Access and Diabetic Foot Ulcer: A Narrative Review

The diabetic foot ulcer (DFU) is a common and serious complication of diabetes. There is also a strong relationship between the environment of the person living with a DFU and the prognosis of the wound. Financial insecurity seems to have a major impact, but this effect can be moderated by social protection systems. Socioeconomic and socio-educational deprivations seem to have a more complex relationship with DFU risk and prognosis. The area of residence is a common scale of analysis for DFU as it highlights the effect of access to care. Yet it is important to understand other levels of analysis because some may lead to over-interpretation of the dynamics between social deprivation and DFU. Social deprivation and DFU are both complex and multifactorial notions. Thus, the strength and characteristics of the correlation between the risk and prognosis of DFU and social deprivation greatly depend not only on the way social deprivation is calculated, but also on the way questions about the social deprivation−DFU relationship are framed. This review examines this complex relationship between DFU and social deprivation at the individual level by considering the social context in which the person lives and his or her access to healthcare.

Adherence to General Diabetes and Foot Care Processes, with Prompt Referral, Are Associated with Amputation-Free Survival in People with Type 2 Diabetes and Foot Ulcers: A Scottish National Registry Analysis

Aims

To compare different packages of care across care providers in Scotland on foot-related outcomes.

Methods

A retrospective cohort study with primary and secondary care electronic health records from the Scottish Diabetes Registry, including 6,845 people with type 2 diabetes and a first foot ulcer occurring between 2013 and 2017. We assessed the association between exposure to care processes and major lower extremity amputation and death. Proportional hazards were used for time-to-event univariate and multivariate analyses, adjusting for case-mix characteristics and care processes. Results were expressed in terms of hazard ratios with 95% confidence intervals.

Results

2,243 (32.7%) subjects had a major amputation or death. Exposure to all nine care processes at all ages (HR = 0.63; 95% CI: 0.58-0.69; p < .001) and higher foot care attendance in people aged >70 years (HR = 0.88; 0.78-0.99; p = .03) were associated with longer major amputation-free survival. Waiting time ≥ 12 weeks between ulceration and clinic attendance was associated with worse outcomes (HR = 1.59; 1.37-1.84; p < .001). In people > 70 years, minor amputations were associated with improved major amputation-free survival (HR = 0.69; 0.52-0.92; p = .01).

Conclusions

Strict adherence to a standardised package of general diabetes care before foot ulceration, timely foot care after ulceration, and specific treatment pathways were associated with longer major amputation-free survival among a large cohort of people with type 2 diabetes in Scotland, with a larger impact on older age groups.

Effects of social deprivation and healthcare access on major amputation following a diabetic foot ulcer in a French administrative area: Analysis using the French claim data

AIM

The link between social deprivation and the development of diabetic foot ulcer (DFU) is still widely debated. The study objective was to evaluate the relationship between lower limb amputation, social deprivation level, and inequalities in access to care service among people with DFU. This regional pilot study was conducted at the living area level and based on the French National Health Data System (SNDS).

METHODS

We conducted a retrospective cohort study using hospital and primary care claim data in the Languedoc-Roussillon region. DFUs were determined using an original algorithm of care consumption or hospital diagnosis. The primary end point was amputation at 1 year. Secondary end points were mortality at 1 year and impact of potential access to care on amputation.

RESULTS

We included 15,507 people from 2015 to 2017. Amputation and mortality rates were 17.5 and 117 per 1000 person-years. The least precarious living areas showed better prognoses (relative risk = 0.46; 95% CI 0.27-0.66). Territorial accessibility to a private-practice nurse, unlike physician accessibility, was associated with better results on major outcomes (p = 0.004).

CONCLUSION

This is the first study using SNDS to study the care pathway of DFU management within and outside the hospital. High social deprivation in a living areas seems to be associated with more major amputations after a DFU.

Incidence, hospitalization and mortality and their changes over time in people with a first ever diabetic foot ulcer

AIMS

A diabetic foot ulcer (DFU) is a severe condition associated with morbidity and mortality. Population-based studies are rare and limited by access to reliable data. Without this data, efforts in primary prevention cannot be evaluated. Therefore, we examined the incidence and changes over time for the first DFU in people with diabetes. We also examined hospitalization and all-cause mortality and their changes over time.

METHODS

From the UK primary care CPRD GOLD database (2007-2017), we identified 129,624 people with diabetes by a prescription for insulin or a non-insulin anti-diabetic drug. DFUs were identified using Read codes and expressed as incidence rates (IRs). Changes over time were described using Poisson and logistic regression and expressed as incidence rate ratios (IRRs) and odds ratios (ORs) respectively.

RESULTS

The mean IR of first registered DFUs was 2.5 [95% CI: 2.1-2.9] per 1000 person-years for people with type 2 diabetes and 1.6 [1.3-1.9] per 1000 person-years for people with type 1. The IRs declined for people with type 2 diabetes (IRR per year: 0.97 [0.96-0.99]), while no changes were observed for people with type 1 diabetes (IRR per year: 0.96 [0.89-1.04]). Average hospitalization and 1-year mortality risk for people with type 2 diabetes were 8.2% [SD: 4.7] and 11.7% [SD: 2.2] respectively. Both declined over time (OR: 0.89 [0.84, 0.94] and 0.94 [0.89, 0.99]).

CONCLUSION

The decline in all IRs, hospitalizations and mortality in people with type 2 diabetes suggests that prevention and care of the first DFU has improved for this group in primary care in the UK.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

Foot Ulcer and Risk of Lower Limb Amputation or Death in People With Diabetes: A National Population-Based Retrospective Cohort Study

OBJECTIVE

To describe incidence of foot ulceration and amputation-free survival associated with foot ulceration status in a national population-based cohort study of people with diabetes.

RESEARCH DESIGN AND METHODS

The study population included 233,459 people with diabetes who were alive in Scotland on 1 January 2012 identified from the national population-based register (national prevalence 4.9%). Characteristics of patients identified from linked hospital and mortality records during follow-up to the end of November 2017 were compared by outcome. Cox regression was used to assess the association between history of foot ulcer and amputation-free survival.

RESULTS

The population included 23,395 people with type 1 diabetes and 210,064 people with type 2 diabetes. In total there were 13,093 (5.6%) people who had a previous foot ulceration, 9,023 people who developed a first ulcer, 48,995 who died, and 2,866 who underwent minor or major amputation during follow-up. Overall incidence of first-time foot ulcers was 7.8 per 1,000 person-years (95% CI7.6-7.9) and 11.2 (11.0-11.4) for any ulcer. Risk factors for reduced amputation-free survival included social deprivation, mental illness, and being underweight in addition to conventional cardiovascular risk factors. Adjusted hazard ratios (95% CI) were 2.09 (1.89-2.31) for type 1 diabetes and 1.65 (1.60-1.70) for type 2 diabetes.

CONCLUSIONS

The overall incidence of foot ulceration in a population-based study of people with diabetes was 11.2 per 1,000 person-years. Foot ulceration is associated with lower amputation-free survival rate, a potential measure of effectiveness of care among people with diabetes. Mental illness and social deprivation are also highlighted as risk factors.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

Development of a prediction model for foot ulcer recurrence in people with diabetes using easy-to-obtain clinical variables

INTRODUCTION

We aimed to develop a prediction model for foot ulcer recurrence in people with diabetes using easy-to-obtain clinical variables and to validate its predictive performance in order to help risk assessment in this high-risk group.

RESEARCH DESIGN AND METHODS

We used data from a prospective analysis of 304 people with foot ulcer history who had 18-month follow-up for ulcer outcome. Demographic, disease-related and organization-of-care variables were included as potential predictors. Two logistic regression prediction models were created: model 1 for all recurrent foot ulcers (n=126 events) and model 2 for recurrent plantar foot ulcers (n=70 events). We used 10-fold cross-validation, each including five multiple imputation sets for internal validation. Performance was assessed in terms of discrimination using area under the receiver operating characteristic curve (AUC) (0-1, 1=perfect discrimination), and calibration with the Brier Score (0-1, 0=complete concordance predicted vs observed values) and calibration graphs.

RESULTS

Predictors in model 1 were: a younger age, more severe peripheral sensory neuropathy, fewer months since healing of previous ulcer, presence of a minor lesion, use of a walking aid and not monitoring foot temperatures at home. Mean AUC for model 1 was 0.69 (2SD 0.040) and mean Brier Score was 0.22 (2SD 0.011). Predictors in model 2 were: a younger age, plantar location of previous ulcer, fewer months since healing of previous ulcer, presence of a minor lesion, consumption of alcohol, use of a walking aid, and foot care received in a university medical center. Mean AUC for model 2 was 0.66 (2SD 0.023) and mean Brier Score was 0.16 (2SD 0.0048).

CONCLUSIONS

These internally validated prediction models predict with reasonable to good calibration and fair discrimination who is at highest risk of ulcer recurrence. The people at highest risk should be monitored more carefully and treated more intensively than others.

TRIAL REGISTRATION NUMBER

NTR5403.

Social Deprivation and Incident Diabetes-Related Foot Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study

OBJECTIVE

To investigate the relationship between social deprivation and incident diabetes-related foot disease (DFD) in newly diagnosed patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A population-based open retrospective cohort study using The Health Improvement Network (1 January 2005 to 31 December 2019) was conducted. Patients with type 2 diabetes free of DFD at baseline were stratified by Townsend deprivation index, and risk of developing DFD was calculated. DFD was defined as a composite of foot ulcer (FU), Charcot arthropathy, lower-limb amputation (LLA), peripheral neuropathy (PN), peripheral vascular disease (PVD), and gangrene.

RESULTS

A total of 176,359 patients were eligible (56% men; mean age 62.9 [SD 13.1] years). After excluding 26,094 patients with DFD before/within 15 months of type 2 diabetes diagnosis, DFD incidentally developed in 12.1% of the study population over 3.27 years (interquartile range 1.41-5.96). Patients in the most deprived Townsend quintile had increased risk of DFD compared with those in the least deprived (adjusted hazard ratio [aHR] 1.22; 95% CI 1.16-1.29) after adjusting for sex, age at type 2 diabetes diagnosis, ethnicity, smoking, BMI, HbA_1c, cardiovascular disease, hypertension, retinopathy, estimated glomerular filtration rate, insulin, glucose/lipid-lowering medication, and baseline foot risk. Patients in the most deprived Townsend quintile had higher risk of PN (aHR 1.18; 95% CI 1.11-1.25), FU (aHR 1.44; 95% CI 1.17-1.77), PVD (aHR 1.40; 95% CI 1.28-1.53), LLA (aHR 1.75; 95% CI 1.08-2.83), and gangrene (aHR 8.49; 95% CI 1.01-71.58) compared with those in the least.

CONCLUSIONS

Social deprivation is an independent risk factor for the development of DFD, PN, FU, PVD, LLA, and gangrene in newly diagnosed patients with type 2 diabetes. Considering the high individual and economic burdens of DFD, strategies targeting patients in socially deprived areas are needed to reduce health inequalities.

Association of peripheral artery disease and chronic limb-threatening ischemia with socioeconomic deprivation in people with diabetes: A population data-linkage and geospatial analysis

The association between the prevalence and geographical distribution of peripheral artery disease (PAD) and chronic limb-threatening ischemia (CLTI) in patients with diabetes in the context of socioeconomic deprivation is not well understood. We undertook a retrospective cohort study of 76,307 people with diabetes admitted as a hospital inpatient in a large Scottish health administrative area. Utilising linked health records, we identified diagnoses of PAD and/or CLTI and their distribution using small area cartography techniques according to multiple deprivation maps. Spatial autocorrelation techniques were applied to examine PAD and CLTI patterning. Association between crude inpatient prevalence-adjusted outcome rates and exposure to social deprivation were determined. We found crude prevalence-adjusted rates of 8.05% for PAD and 1.10% for CLTI with a five- to sevenfold difference from the least to most deprived regions. Statistically significant hot spots were found for PAD (p < 0.001) and CLTI (p < 0.001) in the most deprived areas, and cold spots for PAD (p < 0.001) but not CLTI (p = 0.72) in the least deprived areas. Major health disparities in PAD/CLTI diagnoses in people with diabetes is driven by socioeconomic deprivation.

Geographical clustering and socioeconomic factors associated with hypoglycemic events requiring emergency assistance in Andalusia (Spain)

INTRODUCTION

The geographical distribution of hypoglycemic events requiring emergency assistance was explored in Andalusia (Spain), and potentially associated societal factors were determined.

RESEARCH DESIGN AND METHODS

This was a database analysis of hypoglycemia requiring prehospital emergency assistance from the Public Company for Health Emergencies (Empresa Pública de Emergencias Sanitarias (EPES)) in Andalusia during 2012, which served 8 393 159 people. Databases of the National Statistics Institute, Basic Spatial Data of Andalusia and System of Multiterritorial Information of Andalusia were used to retrieve spatial data and population characteristics. Geographic Information System software (QGIS and GeoDA) was used for analysis and linkage across databases. Spatial analyses of geographical location influence in hypoglycemic events were assessed using Moran's I statistics, and linear regressions were used to determine their association with population characteristics.

RESULTS

The EPES attended 1 137 738 calls requesting medical assistance, with a mean hypoglycemia incidence of 95.0±61.6 cases per 100 000 inhabitants. There were significant differences in hypoglycemia incidence between basic healthcare zones attributable to their geographical location in the overall population (Moran's I index 0.122, z-score 7.870, p=0.001), women (Moran's I index 0.088, z-score 6.285, p=0.001), men (Moran's I index 0.076, z-score 4.914, p=0.001) and aged >64 years (Moran's I index 0.147, z-score 9.753, p=0.001). Hypoglycemia incidence was higher within unemployed individuals (β=0.003, p=0.001) and unemployed women (β=0.005, p=0.001), while lower within individuals aged <16 years (β=-0.004, p=0.040), higher academic level (secondary studies) (β=-0.003, p=0.004) and women with secondary studies (β=-0.005, p<0.001). In subjects aged >64 years, lower rate of hypoglycemia was associated with more single-person homes (β=-0.008, p=0.022) and sports facilities (β=-0.342, p=0.012).

CONCLUSIONS

This analysis supports the geographical distribution of hypoglycemia in the overall population, both genders and subjects aged >64 years, which was affected by societal factors such as unemployment, literacy/education, housing and sports facilities. These data can be useful to design specific prevention programs.