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Lo ZJ, Tan E, Chandrasekar S, Ooi D, Liew H, Ang G, Yong E, Hong Q, Chew T, Muhammad Farhan MF, Zhu X, Ang P, Law C, Raman N, Park D, Tavintharan S, Hoi WH, Lin J, Koo HY, Choo J, Low KQ, Low R, Venkataraman K, Car J, Chew DEK. Diabetic foot in primary and tertiary (
DEFINITE
) Care: A health services innovation in coordination of diabetic foot ulcer (
DFU
) Care within a healthcare cluster ‐ 18‐month results from an observational population health cohort study. Int Wound J 2022; 20:1609-1621. [PMID: 36372913 PMCID: PMC10088846 DOI: 10.1111/iwj.14016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 10/25/2022] [Accepted: 10/26/2022] [Indexed: 11/15/2022] Open
Abstract
Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.
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Affiliation(s)
- Zhiwen Joseph Lo
- Vascular Surgery Service, Department of Surgery Woodlands Health Singapore Singapore
- Centre for Population Health Sciences. Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore
| | - Elaine Tan
- Toa Payoh Polyclinic National Healthcare Group Polyclinics Singapore Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Desmond Ooi
- Vascular Surgery Service, Department of General Surgery Khoo Teck Puat Hospital Singapore Singapore
| | - Huiling Liew
- Department of Endocrinology Tan Tock Seng Hospital Singapore Singapore
| | - Gary Ang
- Health Services and Outcomes Research National Healthcare Group Singapore Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery Tan Tock Seng Hospital Singapore Singapore
| | - Tiffany Chew
- Department of Podiatry Tan Tock Seng Hospital Singapore Singapore
| | | | - Xiaoli Zhu
- Nursing Service National Healthcare Group Polyclinics Singapore Singapore
| | - Pauline Ang
- Podiatry Service National Healthcare Group Polyclinics Singapore Singapore
| | - Chelsea Law
- Department of Podiatry Khoo Teck Puat Hospital Singapore Singapore
| | - Nadiah Raman
- Department of Podiatry Khoo Teck Puat Hospital Singapore Singapore
| | - Derek Park
- Department of Orthopaedics Khoo Teck Puat Hospital Singapore Singapore
| | | | - Wai Han Hoi
- Department of Endocrinology Woodlands Health Singapore Singapore
| | - Jaime Lin
- Department of Endocrinology Woodlands Health Singapore Singapore
| | - Hui Yan Koo
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Julia Choo
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Kai Qiang Low
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Rose Low
- Group Integrated Care National Healthcare Group Singapore Singapore
| | - Kavita Venkataraman
- Saw Swee Hock School of Public Health National University of Singapore Singapore Singapore
| | - Josip Car
- Centre for Population Health Sciences. Lee Kong Chian School of Medicine Nanyang Technological University Singapore Singapore
- School of Public Health Imperial College London London UK
| | - Daniel EK Chew
- Department of Endocrinology Tan Tock Seng Hospital Singapore Singapore
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Schmitt VH, Hobohm L, Vosseler M, Brochhausen C, Münzel T, Espinola‐Klein C, Keller K. Temporal trends in patients with peripheral artery disease influenced by diabetes mellitus in Germany. J Diabetes 2022; 14:670-684. [PMID: 36146952 PMCID: PMC9574718 DOI: 10.1111/1753-0407.13316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 08/16/2022] [Accepted: 09/06/2022] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION In patients with peripheral artery disease (PAD) the presence of diabetes mellitus (DM) is associated with higher morbidity and mortality. Because huge efforts are made to improve medical care of patients with DM including chronic disease programs, the aim of the present study was to investigate temporal trends regarding the clinical burden of DM on PAD patients within a 15-year observational period. METHODS We analyzed all patients hospitalized because of PAD between 2005 and 2019 in Germany stratified regarding DM. RESULTS Overall, 2 654 871 hospitalizations of PAD patients (865 823 with DM) were included. Hospitalizations based on PAD inclined from 142 778 in 2005 to 190 135 in 2019 (β 3956 per year; 95% confidence interval [CI] 3034-4878, p < .001) with simultaneous increase of hospitalizations of PAD patients with DM (2005: 41609 (29.1%) versus 2019: 65 302 (34.3%); β 2019 per year [95% CI 1593-2446], p < .001). Amputation rates (β -0.42 [95% CI -0.44 to -0.40]; p < .001) as well as in-hospital case-fatality rate (2005: 4.7%, 2019: 2.8%; β -0.64 [95% CI -0.69 to -0.59]; p < .001) decreased in diabetic PAD patients during the observational time. In spite of improved morbidity and mortality in the last years of the observational period, patients with DM still suffered from an increased risk for morbidity and mortality during the observational period compared to nondiabetic PAD patients. CONCLUSIONS Despite the progress in DM treatments, DM still was associated with an unfavorable clinical patient profile and remained a substantial risk factor for morbidity and mortality in hospitalized patients with PAD and DM in Germany between 2005 and 2019.
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Affiliation(s)
- Volker H. Schmitt
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- German Center for Cardiovascular sdfsResearch (DZHK)Partner Site Rhine MainMainzGermany
| | - Lukas Hobohm
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Markus Vosseler
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | | | - Thomas Münzel
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- German Center for Cardiovascular sdfsResearch (DZHK)Partner Site Rhine MainMainzGermany
| | - Christine Espinola‐Klein
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
| | - Karsten Keller
- Department of CardiologyUniversity Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Center for Thrombosis and Hemostasis (CTH)University Medical Center Mainz (Johannes Gutenberg‐University Mainz)MainzGermany
- Medical Clinic VII, Department of Sports MedicineUniversity Hospital HeidelbergHeidelbergGermany
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3
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Mariadoss AVA, Sivakumar AS, Lee CH, Kim SJ. Diabetes mellitus and diabetic foot ulcer: Etiology, biochemical and molecular based treatment strategies via gene and nanotherapy. Biomed Pharmacother 2022; 151:113134. [PMID: 35617802 DOI: 10.1016/j.biopha.2022.113134] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 05/05/2022] [Accepted: 05/15/2022] [Indexed: 12/06/2022] Open
Abstract
Diabetes mellitus (DM) is a collection of metabolic and pathophysiological disorders manifested with high glucose levels in the blood due to the inability of β-pancreatic cells to secrete an adequate amount of insulin or insensitivity of insulin towards receptor to oxidize blood glucose. Nevertheless, the preceding definition is only applicable to people who do not have inherited or metabolic disorders. Suppose a person who has been diagnosed with Type 1 or Type 2DM sustains an injury and the treatment of the damage is complicated and prolonged. In that case, the injury is referred to as a diabetic foot ulcer (DFU). In the presence of many proliferating macrophages in the injury site for an extended period causes the damage to worsen and become a diabetic wound. In this review, the scientific information and therapeutic management of DM/DFU with nanomedicine, and other related data were collected (Web of Science and PubMed) from January 2000 to January 2022. Most of the articles revealed that standard drugs are usually prescribed along with hypoglycaemic medications. Conversely, such drugs stabilize the glucose transporters and homeostasis for a limited period, resulting in side effects such as kidney damage/failure, absorption/gastrointestinal problems, and hypoglycemic issues. In this paper, we review the current basic and clinical evidence about the potential of medicinal plants, gene therapy, chemical/green synthesized nanoparticles to improving the metabolic profile, and facilitating the DM and DFU associated complications. Preclinical studies also reported lower plasma glucose with molecular targets in DM and DFU. Research is underway to explore chemical/green synthesized nanoparticle-based medications to avoid such side effects. Hence, the present review is intended to address the current challenges, recently recognized factors responsible for DM and DFU, their pathophysiology, insulin receptors associated with DM, medications in trend, and related complications.
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Affiliation(s)
- Arokia Vijaya Anand Mariadoss
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University, College of Medicine, Hwaseong, Republic of Korea
| | - Allur Subramaniyan Sivakumar
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University, College of Medicine, Hwaseong, Republic of Korea
| | - Chang-Hun Lee
- Department of New Biology, Daegu Gyeongbuk Institute of Science and Technology, Daegu, Republic of Korea
| | - Sung Jae Kim
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hallym University, College of Medicine, Hwaseong, Republic of Korea.
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Lo ZJ, Chandrasekar S, Yong E, Hong Q, Zhang L, Chong LRC, Tan G, Chan YM, Koo HY, Chew T, Sani NF, Cheong KY, Cheng LRQ, Tan AHM, Muthuveerappa S, Lai TP, Goh CC, Ang GY, Zhu Z, Hoi WH, Lin JHX, Chew DEK, Lim B, Yeo PS, Liew H. Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study. Int Wound J 2021; 19:765-773. [PMID: 34363329 PMCID: PMC9013583 DOI: 10.1111/iwj.13672] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 07/28/2021] [Accepted: 07/28/2021] [Indexed: 12/28/2022] Open
Abstract
Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case‐control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow‐up (33% vs 76%, P < .001), decrease in 1‐year minor amputation rate (14% vs 3%, P = .007), and decrease in 1‐year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.
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Affiliation(s)
- Zhiwen Joseph Lo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore.,Lee Kong Chian School of Medicine Centre for Population Health Sciences, Nayang Technological University, Singapore.,Skin Research Institute of Singapore, Agency for Science, Technology and Research, Singapore
| | - Sadhana Chandrasekar
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Enming Yong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Qiantai Hong
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Li Zhang
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | | | - Glenn Tan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Yam Meng Chan
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Hui Yan Koo
- Vascular Surgery Service, Department of General Surgery, Tan Tock Seng Hospital, Singapore
| | - Tiffany Chew
- Department of Podiatry, Tan Tock Seng Hospital, Singapore
| | | | | | | | - Audrey Hui Min Tan
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | | | - Tina Peiting Lai
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | - Cheng Cheng Goh
- Wound and Stoma Care, Nursing Specialty, Tan Tock Seng Hospital, Singapore
| | - Gary Y Ang
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Zhecheng Zhu
- Health Services and Outcomes Research, National Healthcare Group, Singapore
| | - Wai Han Hoi
- Department of Endocrinology, Woodlands Health Campus, Singapore
| | - Jaime H X Lin
- Department of Endocrinology, Woodlands Health Campus, Singapore
| | - Daniel E K Chew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Brenda Lim
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Pei Shan Yeo
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
| | - Huiling Liew
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore
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