‘Death is a greater risk’ than amputation after diabetic foot ulcer
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People with diabetes and a history of foot ulcer are more likely to die than undergo amputation during 6 years of follow-up, a potential measure of effectiveness of diabetes care, registry data from Scotland show.
In an analysis of real-world data comparing people with diabetes with and without foot ulcer, researchers also found amputation or death occurred for approximately one in two of those with a prior foot ulcer and one in five with no previous foot ulcer, with greater risk for people living in socially deprived areas or with mental illness.
“Even for people with previous ulcers, death was a much more common outcome than amputation, especially for people with type 2 diabetes,” Graham Leese, MD, FRCP, an NHS consultant and honorary professor at Ninewells Hospital and the University of Dundee, Scotland, told Healio. “Classic vascular and metabolic risk factors were associated with poor outcomes, but this study also emphasizes the emerging evidence of the association between mental illness and social deprivation with poor outcomes for people with diabetes and foot ulcers.”
Leese and colleagues analyzed data from 23,395 people with type 1 diabetes and 210,064 people with type 2 diabetes who were alive in Scotland on Jan. 1, 2012, identified via the Scottish Care Information – Diabetes database, a disease-specific electronic patient record. Researchers linked the data with Scottish registry data on hospital admissions, death records and the Scottish Renal Registry, following the cohort through November 2017. Primary outcomes were incidence of ulcers during follow-up, lower-limb amputation and death. Researchers used Cox regression analyses to assess the association between history of foot ulcer and amputation-free survival.
Within the cohort, 13,093 people (5.6%) had a previous foot ulceration, 9,023 developed a first ulcer, 48,995 died and 2,866 underwent minor or major amputation during follow-up.
Researchers found incidence of first-time foot ulcers was 7.8 per 1,000 person-years (95% CI, 7.6-7.9) and 11.2 per 1,000 person-years (95% CI, 11-11.4) for incidence of a new or recurrent ulcer.
Overall, 21.7% of the cohort had an amputation or died during follow-up, including 10.7% of those with type 1 diabetes and 22.9% of those with type 2 diabetes.
Risk factors for reduced amputation-free survival included social deprivation, mental illness and being underweight. Previous myocardial infarction, stroke, and peripheral vascular disease and chronic kidney disease were also associated with higher risks for death and amputation. Adjusted HRs for risk for amputation or death with ulcer were 2.09 (95% CI, 1.89-2.31) for type 1 diabetes and 1.65 (95% CI, 1.6-1.7) for type 2 diabetes.
Overall survival during follow-up for those with a history of ulcer was 71% for those with type 1 diabetes and 53% for those with type 2 diabetes, according to researchers.
“After adjustments for all risk factors, history of an ulcer was associated with a 3.4- and 2.4-fold increased risk for death or amputation, respectively, for people with type 1 and type 2 diabetes,” Leese told Healio. “The incidence data will help health care planning and workforce planning. People with diabetes and a history of foot ulcer need to be aware that death is a greater risk for them than amputation, and management of cardiovascular risk factors is vitally important.”
Leese said intervention studies are needed to demonstrate targeted inputs for people with diabetes and previous ulcers can be beneficial, particularly for those living in a socially deprived area or who have mental illness.
For more information:
Graham Leese, MD, FRCP, can be reached at graham.leese2@nhs.scot.
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