Association between socioeconomic position and diabetic foot ulcer outcomes: a population-based cohort study in South Korea

The global and regional burden of diabetic peripheral neuropathy

Diabetic peripheral neuropathy (DPN) is length-dependent peripheral nerve damage arising as a complication of type 1 or type 2 diabetes in up to 50% of patients. DPN poses a substantial burden on patients, who can experience impaired gait and loss of balance, predisposing them to falls and fractures, and neuropathic pain, which is frequently difficult to treat and reduces quality of life. Advanced DPN can lead to diabetic foot ulcers and non-healing wounds that often necessitate lower-limb amputation. From a socioeconomic perspective, DPN increases both direct health-care costs and indirect costs from loss of productivity owing to neuropathy-related disability. In this Review, we highlight the importance of understanding country-specific and region-specific variations in DPN prevalence to inform public health policy and allocate resources appropriately. We also explore how identification of DPN risk factors can guide treatment and prevention strategies and aid the development of health-care infrastructure for populations at risk. We review evidence that metabolic factors beyond hyperglycaemia contribute to DPN development, necessitating a shift from pure glycaemic control to multi-targeted metabolic control, including weight loss and improvements in lipid profiles.

The Landscape of Products for Diabetic Peripheral Neuropathy: A Scientific and Patent Systematic Review

BACKGROUND

Diabetic peripheral neuropathy (DPN) is a complication of diabetes that occurs in 40 - 60 million individuals worldwide and is associated with other chronic diseases. However, there are no review studies that present the state-of- the- art and technologies developed to circumvent this important health problem.

MATERIALS AND METHODS

This review was conducted based on scientific papers and patents. The papers were retrieved from Lilacs, PubMed, and Web of Science databases, and the patents from INPI, ESPACENET, WIPO, and GOOGLE PATENTS. Thus, a sample consisting of 14 scientific articles and 667 patents was analyzed.

RESULTS

From the analysis of the data, we drew an overview of the development of biomedical technologies for DPN and detected the pioneering spirit of China, the USA, and Japan in the area, with a focus on the treatment of DPN. Based on this, we carried out a SWOT analysis to help direct future efforts in the area, which should focus primarily on developing technologies for prevention, early diagnosis, and, above all, cure of the disease to reduce the important impact of this disease in various sectors of society.

CONCLUSION

This study finds a concentration of diabetic peripheral neuropathy products, especially therapeutic drugs, in high-income countries. It highlights the need for global collaboration and strategic focus on therapeutic adherence and preventive strategies to effectively manage DPN.

Improved Diabetic Foot Ulcer Outcomes in Medicaid Beneficiaries with Podiatric Care Access

Objectives

This study aims to examine the association between state Medicaid coverage of podiatry services and the outcomes of beneficiaries with new diabetic foot ulcers (DFUs).

Methods

Medicaid beneficiaries who developed a DFU between 2010 and 2015 were identified using the PearlDiver claims database. The states were categorized into covered states (CS) and non-covered states (NCS) based on podiatric coverage during the study period. The outcomes included major amputation, minor amputation, and hospitalization due to foot infection within 12 months of index diagnosis. Logistic regression was used to assess the association of state coverage type and outcomes, controlling for age, sex, and the Charlson Comorbidity Index (CCI).

Results

Our study included 16,905 Medicaid beneficiaries who developed new DFUs: 14,748 in CS and 2157 in NCS. The overall major amputation rate was 2.6%. The risk of major amputation was 48% lower among Medicaid beneficiaries in CS (OR 0.52, 95% CI 0.31-0.90) than in NCS. The Medicaid beneficiaries in CS had a 24% lower risk of hospitalization for foot infection (OR 0.76, 95% CI 0.67-0.85) but had a 58% higher risk of minor amputation (OR 1.58, 95% CI 1.22-2.07) than in NCS.

Conclusions

Medicaid coverage of podiatry services might be associated with lower rates of major amputation and reduced risk of hospitalization for foot infection.

Association Between Atrial Fibrillation and Diabetes-Related Complications: A Nationwide Cohort Study

OBJECTIVE

This study aimed to investigate the associations between concurrent atrial fibrillation and diabetes-related complications among patients with diabetes.

RESEARCH DESIGN AND METHODS

This nationwide observational cohort study used the health checkup database from the Korean National Health Insurance Service. Patients diagnosed with diabetes who underwent health checkups between 2009 and 2012 were investigated. The patients with atrial fibrillation were matched in a 1:5 ratio with those without atrial fibrillation using propensity scores. Study outcomes included macrovascular, microvascular (diabetic retinopathy and diabetic nephropathy), and diabetic foot complications. The risks of clinical outcomes were measured using hazard ratios (HRs) with 95% CIs.

RESULTS

A total of 65,760 patients with diabetes were analyzed (54,800 without atrial fibrillation and 10,960 with atrial fibrillation). After well-balanced propensity score matching, atrial fibrillation was associated with significantly higher risks of macrovascular complications (HR 1.12, 95% CI 1.09-1.16), diabetic nephropathy (HR 1.23, 95% CI 1.16-1.30), and diabetic foot complications (HR 1.13, 95% CI 1.09-1.17) compared with no atrial fibrillation, while the risk of diabetic retinopathy was comparable (HR 0.99, 95% CI 0.96-1.03). Patients with atrial fibrillation had a significantly higher risk of diabetic foot amputation (HR 4.12, 95% CI 1.98-8.56).

CONCLUSIONS

Among patients with diabetes, concurrent atrial fibrillation was associated with increased risks for diabetes-related macrovascular complications, diabetic nephropathy, and diabetic foot. Such patients require holistic management to reduce the risk of adverse outcomes.

Visit to Visit Hemoglobin A1c Variation and Long-term Risk of Major Adverse Limb Events in Patients With Type 2 Diabetes

CONTEXT

Glycemic variation had been demonstrated to be associated with several complications of diabetes.

OBJECTIVE

Investigation of the association between visit to visit hemoglobin A1c (HbA1c) variation and the long-term risk of major adverse limb events (MALEs).

METHODS

Retrospective database study. Average real variability was used to represent glycemic variations with all the HbA1c measurements during the 4 following years after the initial diagnosis of type 2 diabetes. Participants were followed from the beginning of the fifth year until death or the end of the follow-up. The association between HbA1c variations and MALEs was evaluated after adjusting for mean HbA1c and baseline characteristics. Included were 56 872 patients at the referral center with a first diagnosis of type 2 diabetes, no lower extremity arterial disease, and at least 1 HbA1c measurement in each of the 4 following years were identified from a multicenter database. The main outcome measure was incidence of a MALE, which was defined as the composite of revascularization, foot ulcers, and lower limb amputations.

RESULTS

The average number of HbA1c measurements was 12.6. The mean follow-up time was 6.1 years. The cumulative incidence of MALEs was 9.25 per 1000 person-years. Visit to visit HbA1c variations were significantly associated with MALEs and lower limb amputation after multivariate adjustment. People in the highest quartile of variations had increased risks for MALEs (HR 1.25, 95% CI 1.10-1.41) and lower limb amputation (HR 3.05, 95% CI 1.97-4.74).

CONCLUSION

HbA1c variation was independently associated with a long-term risk of MALEs and lower limb amputations in patients with type 2 diabetes.

Low Household Income Status and Death from Pneumonia in People with Type 2 Diabetes Mellitus: A Nationwide Study

BACKGRUOUND

We explored the risk of death from pneumonia according to cumulative duration in low household income state (LHIS) among adults with type 2 diabetes mellitus (T2DM).

METHODS

Using Korean National Health Insurance Service data (2002 to 2018), the hazards of mortality from pneumonia were analyzed according to duration in LHIS (being registered to Medical Aid) during the 5 years before baseline (0, 1-4, and 5 years) among adults with T2DM who underwent health examinations between 2009 and 2012 (n=2,503,581). Hazards of outcomes were also compared in six groups categorized by insulin use and duration in LHIS.

RESULTS

During a median 7.18 years, 12,245 deaths from pneumonia occurred. Individuals who had been exposed to LHIS had higher hazards of death from pneumonia in a dose-response manner (hazard ratio [HR], 1.726; 95% confidence interval [CI], 1.568 to 1.899 and HR, 4.686; 95% CI, 3.948 to 5.562 in those exposed for 1-4 and 5 years, respectively) compared to the non-exposed reference. Insulin users exposed for 5 years to LHIS exhibited the highest outcome hazard among six groups categorized by insulin use and duration in LHIS.

CONCLUSION

Among adults with T2DM, cumulative duration in LHIS may predict increased risks of mortality from pneumonia in a graded dose-response manner. Insulin users with the longest duration in LHIS might be the group most vulnerable to death from pneumonia among adults with T2DM.

Global mortality of diabetic foot ulcer: A systematic review and meta-analysis of observational studies

AIM

To estimate the long-term mortality and risk factors in patients with diabetic foot ulcer (DFU).

METHODS

We systematically searched Medline (PubMed), Embase, Scopus, Web of Science, Cochrane Library, China Science and Technology Journal Database (CQVIP), China National Knowledge Infrastructure, the Chinese Biomedical Literature Database (SinoMed) and Wanfang Data from 1 January 2011 to 31 July 2022. All observational studies that reported long-term mortality of patients with DFU were included. Random effect models were used to pool the reconstructed participant data from Kaplan-Meier curves. The primary outcome was the long-term survival of patients with DFU. An aggregate data meta-analysis was also performed.

RESULTS

We identified 34 studies, with 124 376 participants representing 16 countries, among whom there were 51 386 deaths. Of these, 27 studies with 21 171 patients were included in the Kaplan-Meier-based meta-analysis. The estimated Kaplan-Meier-based survival rates were 86.9% (95% confidence interval [CI] 82.6%-91.5%) at 1 year, 66.9% (95% CI 59.3%-75.6%) at 3 years, 50.9% (95% CI 42.0%-61.7%) at 5 years and 23.1% (95% CI 15.2%-34.9%) at 10 years. The results of the aggregate data-based meta-analysis were similar. Cardiovascular disease and infection were the most common causes of death, accounting for 46.6% (95% CI 33.5%-59.7%) and 24.8% (95% CI 16.0%-33.5%), respectively. Patients with older age (per 1 year, hazard ratio [HR] 1.054, 95% CI 1.045-1.063), peripheral artery disease (HR 1.882, 95% CI 1.592-2.225), chronic kidney disease (HR 1.535, 95% CI 1.227-1.919), end-stage renal disease (HR 3.586, 95% CI 1.333-9.643), amputation (HR 2.415, 95% CI 1.323-4.408) and history of cardiovascular disease (HR 1.449, 95% CI 1.276-1.645) had higher mortality risk.

CONCLUSIONS

This meta-analysis found that the overall mortality of DFU was high, with nearly 50% mortality within 5 years. Cardiovascular disease and infection were the two leading causes of death.

Tendência temporal das complicações do pé diabético e da cobertura da Atenção Primária à Saúde nas capitais brasileiras, 2008–2018

Introdução: Complicações diabéticas são condições preveníveis em sua maioria, sendo o pé diabético uma das mais comuns. O manejo adequado do pé diabético mitiga eventos incapacitantes e maiores gastos ao sistema de saúde. As intervenções efetivas na Atenção Primária à Saúde (APS) possibilitam prevenir as complicações diabéticas. Objetivo: Analisar a tendência das complicações do pé diabético e sua relação com a cobertura da APS nas capitais brasileiras, entre 2008 e 2018. Métodos: Estudo ecológico de séries temporais das incidências acumuladas de complicações do pé diabético nas 27 capitais utilizando dados do Sistema de Informação sobre Hipertensos e Diabéticos. As variáveis independentes foram ano, cobertura da APS e da Estratégia Saúde da Família. Empregou-se modelo de regressão de Prais-Winsten. Resultados: No Brasil, ocorreram 45.095 casos de complicações do pé diabético no período, com média de 0,57 casos/100.000 habitantes (p<0,001) — estável em 14 capitais (p>0,05) e crescente em 13 capitais (p<0,05). Há associação entre elevação do nível de cobertura da APS e estabilidade na evolução das complicações diabéticas (p<0,05). Conclusões: Evidencia-se aumento da ocorrência das complicações do pé diabético, contudo, nas capitais com crescimento da cobertura da APS, houve controle da progressão.