Pre-hospital delay in patients with diabetic foot problems

NewsBot · Dec 24, 2013

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Pre-hospital delay in patients with diabetic foot problems: influencing factors and subsequent quality of care
J. Yan, Y. Liu, B. Zhou, M. Sun
Diabetic Medicine; Accepted Article

Aims
To assess pre-hospital patient delay and its associated variables in patients with diabetic foot problems.
Methods
We classified 270 patients with diabetic foot problems retrospectively based on the distribution of pre-hospital delay. Clinical, demographic and socio-economic data were collected. Logistic regression analysis was performed to examine independent associations with patient delay.
Results
The median pre-hospital delay time was 46.49 days. Patients reported short (≤ 1 week; 77 patients, 28.5%), moderate (> 1 week and ≤ 1 month; 106 patients, 39.3%) and long delays (> 1 month; 87 patients, 32.2%). In a univariate analysis, nine variables were associated with a longer delay (P < 0.05): (1) no previous ulcer; (2) no health insurance; (3) poor housing conditions; (4) low income level; (5) low educational level; (6) infrequent foot inspection; (7) few follow-up medical visits; (8) absence of diabetic foot education; (9) lack of knowledge of foot lesion warning signals. A multivariate analysis showed that absence of diabetic foot education (odds ratio 2.70, 95% CI 1.03–7.06, P = 0.043) and lack of knowledge of foot lesion warning signals (odds ratio 2.14, 95% CI 1.16–3.94, P = 0.015) were independent predictors of long patient delay. Long delay increased the risk of amputation (odds ratio 2.22, 95% CI 1.36–3.64, P = 0.002) and mortality (odds ratio 2.69, 95% CI 1.35–5.33, P = 0.005).
Conclusions
A number of factors were involved in pre-hospital delay among patients with diabetic foot problems and contributed to poor outcomes. We recommend developing a community intervention programme that targets at-risk communities to encourage earlier multidisciplinary team assessment to reduce disparities and improve foot outcomes in patients with diabetes.
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Admin2 · Dec 24, 2013

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NewsBot · Dec 27, 2016

Delay between Onset of Symptoms and Seeking Physician Intervention Increases Risk of Diabetic Foot Complications: Results of a Cross-Sectional Population-Based Survey.
Gavan NA et al
J Diabetes Res. 2016;2016:1567405. doi: 10.1155/2016/1567405

We present a post hoc analysis of 17,530 questionnaires collected as part of the 2012 screening for neuropathy using Norfolk Quality of Life tool in patients with diabetes in Romania, to assess the impact on foot complications of time between the onset of symptoms of diabetes/its complications and the physician visit. Odds ratios (ORs) for self-reporting neuropathy increased from 1.16 (95% CI: 1.07-1.25) in those who sought medical care in 1-6 months from symptoms of diabetes/its complications onset to 2.27 in those who sought medical care >2 years after symptoms onset. The ORs for having a history of foot ulcers were 1.43 (95% CI: 1.26-1.63) in those who sought medical care in 1-6 months and increased to 3.08 (95% CI: 2.59-3.66) in those who sought medical care after >2 years from symptoms of diabetes/its complications onset. The highest ORs for a history of gangrene (2.49 [95% CI: 1.90-3.26]) and amputations (2.18 [95% CI: 1.60-2.97]) were observed in those who sought medical care after >2 years following symptoms onset. In conclusion, we showed that waiting for >1 month after symptoms onset dramatically increases the risk of diabetic foot complications. These results show the need for accessible educational programs on diabetes and its chronic complications and the need to avoid delays in reporting.
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NewsBot · Sep 7, 2017

FACTORS LEADING TO DELAYED PRESENTATION OF PATIENTS WITH DIABETIC FOOT SEPSIS AT REGIONAL HOSPITALS IN THE EKURHULENI METROPOLITAN MUNICIPALITY OF GAUTENG PROVINCE.
Mukendi I, Mundawarara S, Luvhengo T.
S Afr J Surg. 2017 Jun;55(2):68.

BACKGROUND:
Nearly 50% of all diabetes-related admissions are due to diabetic foot problems and diabetes mellitus is the commonest cause for non-traumatic amputation of the lower limb.
METHOD:
A prospective longitudinal observational study of all patients 18 years and older was conducted. Data collected included demographics, diabetic history and treatment type, comorbidities, prior treatment, clinical findings, treatment method and overall outcome. Data was entered into an Excel spreadsheet for analysis, and categorical data was expressed in percentages whereas continuous data in mean and 95% confidence interval. Incident risk ratio was calculated. Chi square and Student t-test were used when appropriate. Permission to conduct the study was received from HREC at Wits (M160759).
RESULTS:
68 patients were studied of which 61.8% (42/68) were males. The average age for males and females was 58.9 and 63.9 years respectively. 90.5% of males and 96.2% of females were known diabetic and 51.5% were on oral hypoglycaemics. 47.1% had prior diabetic education, 36.8% had home haemoglucotest and compliance was good in 39.7%. 71.4% of males and 80.8% of females presented more than two weeks after onset of foot sepsis. Prior use of herbal medication was reported by 16.7% of males compared to 26.9% in females. 69.1% were seen at a clinic and 71.4% were treated with antibiotics before referral. 53.8% of females and 59.5% of males were amputated and mortality was 15.4% and 4.8% for females and male, respectively.
CONCLUSION:
Majority of patients presenting with diabetic foot sepsis are known with diabetes and are on oral hypoglycaemics. Trial of antibiotic and herbal therapy is attempted for most patients before they are referred. More than 50% end with amputation and mortality is three times higher in females.
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NewsBot · Mar 7, 2018

Delayed referral of patients with diabetic foot ulcers across Europe: patterns between primary care and specialised units.
Manu C et al
J Wound Care. 2018 Mar 2;27(3):186-192. doi: 10.12968/jowc.2018.27.3.186.

OBJECTIVE:
Diabetic foot ulceration (DFU) has the potential to deteriorate rapidly without prompt assessment and treatment. The aim of this study was to assess the referral patterns for DFU, from primary care to specialised diabetes foot care units.

METHOD:
A two-part, quantitative, online questionnaire was administered to GPs across four countries in Europe: France, the UK, Germany and Spain. The first part entailed a survey of GPs' perceptions of referrals for DFU. The second part of the questionnaire collected data on recently managed DFU cases.

RESULTS:
There were 600 questionnaires collected in the first part of the study (150 per country), and 1188 patient cases of DFU management were included in the second part. Up to 95% of patients had type 2 diabetes. Patients' complaints led to diagnosis, on average, 60% of the time, and the diagnosis was an incidental finding during a consultation 13-28% of the time. On average, only 40% of GPs completely agreed that they have clearly identified DFU clinical practitioners working in a hospital facility. In 55-66% of cases, the duration of DFU was unknown or DFU diagnosis was delayed more than three weeks from the onset of the wound. On average, 48% of patients were referred after an unknown duration or more than one month from the onset of DFU.

CONCLUSION:
Despite differences in health-care structures across Europe, delays in referral to specialist foot care teams seems to be a common theme. There is an ongoing need to educate GPs, nurses and patients to be more aware of the risk of DFU, and the need for prompt referral to specialist diabetic foot teams.
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NewsBot · Apr 26, 2021

Demographics and outcomes of inpatients with diabetic foot ulcers treated conservatively and surgically in a metropolitan hospital network
Luisa M Rosi et al
Diabetes Res Clin Pract. 2021 Apr 16

Aims: To describe the demographics of patients with diabetic foot ulcers (DFU) and their impact on inpatient management. Secondary outcomes identified relationships of treatment modality with mortality, length of hospital admission, readmissions and post-admission care.

Methods: Retrospective cohort study including patients with DFU admitted to a hospital network in Melbourne, Australia from 2016-2018. Medical records were manually reviewed for acute admission with DFU as a major presenting diagnosis; incidental ulcers and traumatic amputations were excluded. Amputations distal and proximal to the ankle were labelled 'minor' and 'major' respectively. Patients were followed until October 31, 2019.

Results: Of 338 patients, 21 and 148 had major and minor amputations, and 169 were managed conservatively. 94% had ≥1 microvascular and/or macrovascular complication. Conservative management (7 days) was associated with a shorter length of stay (major 18, minor 10 days, p<0.001). Readmission rates were not significantly different. Mortality was greatest (38%) and survival time shortest (999 d) after major amputation than after either other treatment. Other factors associated with mortality were age and a history of coronary artery disease.

Conclusions: Early identification and multi-disciplinary management of DFU is essential to reduce the significant morbidity and mortality associated with amputation in these complex patients.
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NewsBot · May 10, 2022

High-intensity Hospital Utilization Among Adults With Diabetic Foot Ulcers: A Population-based Study
Muzammil H Syed et al
Can J Diabetes. 2021 Oct 22;S1499-2671(21)00418-4

Background: Diabetic foot ulcers (DFUs) are common and disabling, necessitating lengthy hospitalizations. In this study we sought to identify potentially modifiable determinants of high-intensity hospital care use among adults with DFUs.

Methods: Three related case-control studies were conducted using Canada-wide cohorts of adults hospitalized with a DFU from 2011 to 2015. In study 1, cases comprised the top 10% with the highest cumulative 1-year acute care hospital costs; controls were randomly selected from those below the top 10%. Study 2 comprised cases/controls within/below the top 10% for cumulative acute care hospital length of stay (LOS). Study 3 included cases/controls within/below the top 10% for cumulative number of acute care hospitalizations. Using generalized linear models, predictor variables were tested between cases and controls, while adjusting for age and sex.

Results: In study 1, mean acute care costs among 8,971 cases and 3,174 controls were $71,757 and $13,687, respectively. Sepsis conferred the greatest excess cost (mean, $38,790; 95% confidence interval [CI], $34,597 to $43,508), followed by chronic kidney disease (mean, $30,607; 95% CI, $28,389 to $32,825) and major lower limb amputation (mean, $30,884; 95% CI, $28,613 to $33,155). In study 2, mean LOS was higher among 8,477 cases (69 days) than 3,467 controls (12 days). Lower limb amputation conferred the greatest adjusted excess in mean LOS (mean, 28 days; 95% CI, 27 to 28 days). In study 3, there was a mean of 3 hospitalizations among 10,341 cases and 1 among 5,509 controls. Peripheral artery disease conferred the greatest excess number of hospitalizations (1.3 more hospitalizations; 1.2 to 1.4).

Conclusions: Early aggressive treatment of chronic kidney disease and peripheral artery disease, alongside guideline-based amputation prevention strategies, may reduce high-intensity hospital care use among adults with DFU.
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