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

Abstract

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.

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“…Our data suggest that the need for hospitalisation identifies CLTI patients at very high risk for mortality. We believe that this indicates that CLTI patients need to be identified and treated early to avoid urgent hospitalisation as supported by primary-care data showing that early detection of ulcers and prompt referral improve amputation-free survival [19]. Note that ulcers were present for 138/187 days.…”

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“…hypertension ( 39 ) to more complex investigation carried out in real time e.g. amputation free survival ( 48 ). In this way, people with a moderate complication e.g.…”