Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Abstract

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA.HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

Experiences and impact of a rural Australian high‐risk foot service: A multiple‐methods study

“…The benefits of multidisciplinary specialised care are well known and it is generally accepted that specialised coordinated care is both economical and effective in reducing complications associated with DFD 41–44 . Despite this evidence, not all Australians have access to this care, which is partly responsible for the higher rates of DFD‐related amputation seen in individuals who live greater distances from care 6 …”

“…The Australian Institute of Health and Welfare statistics demonstrate a 50% higher likelihood of lower limb amputation for people who reside in rural areas, 23 with similar findings demonstrated by other local studies. 6,24,25 However, the cause of poorer health outcomes in rural areas is complex. Poor health is multifactorial and is often driven by social determinants.…”

“…5 Recent research conducted in regional New South Wales demonstrated that individuals with DFD living greater distances from an HRFS are more likely to undergo amputation. 6 The Hunter New England Local Health District (HNELHD) has one of the largest geographic footprints of all health districts in New South Wales, covering 131 375 km 2 and servicing 920 370 people 7 (Figure 1). The Tamworth HRFS was established in 2018 in Kamilaroi/Gamilaroi/Gomeroi country and was one of the first HRFSs established outside of a metropolitan coastal area in New South Wales.…”

Factors influencing diabetes‐related foot ulcer healing in Australian adults: A prospective cohort study

“…However, where possible, automated measures were used to reduce the risk of measurement error. Geographical distance from participant residence to their high‐risk foot service was not accounted for and should be considered a limitation, as previous studies have demonstrated that increased geographical distance from specialised care is associated with an increased likelihood of amputation 73 . Similarly, the number of clinical appointments attended from baseline throughout the study period was not included and this should also be considered a limitation.…”

How far has diabetes‐related foot disease research progressed in Australia? A bibliometric review (1970–2023)

“…Australia has been reported to have higher DFD‐related hospitalisation and amputation rates than similar countries [ 7 , 8 , 9 ]. However, substantial variation exists between different geographical areas within Australia and also within indigenous populations [ 10 , 11 , 12 ]. It is estimated that on any given day in Australia, 50,000 people have DFD, 1000 are in hospital due to DFD, 12 will undergo a DFD‐related amputation and four people will die due to DFD [ 13 , 14 ].…”