Improved Survival of Diabetic Foot Ulcer Patients 1995–2008

Abstract

OBJECTIVE -The purpose of this study was to determine whether a strategy of aggressive cardiovascular risk management reduced the mortality associated with diabetic foot ulceration. RESEARCH DESIGN AND METHODS-After an initial audit of outcomes demonstrating a high mortality rate in 404 diabetic foot ulcer patients with the first ulceration developing between 1995 and 1999, a new aggressive cardiovascular risk policy was introduced as standard practice at the Diabetic Foot Clinic, Royal Infirmary of Edinburgh, in 2001. In the first 3 years of this policy, 251 patients were screened and identified. The audit cycle was then closed by reauditing the 5-year mortality for this second group of foot ulcer patients in 2008.RESULTS -Overall 5-year mortality was reduced from 48.0% in cohort 1 to 26.8% in cohort 2 (P Ͻ 0.001). Improvement in survival was seen for both neuroischemic patients (5-year mortality of 58% reduced to 36%; relative reduction 38%) and neuropathic patients (36% reduction to 19%; relative reduction 47%) (both P Ͻ 0.001). Patients were more likely to die if they were older at the time of ulceration or had type 2 diabetes, renal impairment, or preexisting cardiovascular disease or were already taking aspirin. Prior statin use, current smoker or exsmoker status, blood pressure, A1C, and total cholesterol were not significantly different between survivors and those who died in the follow-up periods.CONCLUSIONS -Diabetic foot ulcer patients have a high risk of death. Survival has improved over the past 13 years. The adoption of an aggressive cardiovascular risk management policy in diabetic foot ulcer clinics is recommended for these patients. Diabetes Care 31:2143-2147, 2008L ower limb amputation in diabetic patients is associated with significant excess mortality (1). Foot ulceration is also believed to be associated with increased deaths due to related cardiovascular disease (2,3). In addition, patients with foot ulceration often have advanced diabetes complications (4). Cardiovascular risk reduction has, over the last 10 years, become a major part of diabetes care, particularly for type 2 diabetic patients. However, it has only been since 2004 that the U.K. General Medical Services contract has made the treatment of cardiovascular risk a renumerated part of diabetes management in primary care (5). This initiative is driven by target A1C, blood pressure, and cholesterol levels rather than absolute or calculated risk as in the past and has increased prescribing of therapies aimed to reduce cardiovascular risk (6). Patients without established risk factors might not receive adequate treatment if their values are not above the target.It is likely that the peripheral arterial disease and microvascular sclerosis associated with diabetic foot ulceration will reflect established arterial disease elsewhere in the body (3). Therefore, cardiovascular risk factor intervention might be expected to be effective in this setting. However, there are no studies of aggressive risk factor modification in patients with dia...

History of the team approach to amputation prevention: Pioneers and milestones

“…91 In Helsinski, Finland, the emphasis on active vascular intervention has resulted in a decrease in the incidence of major amputation both in nondiabetic and in diabetic patients, 92 and in Scotland, Matthew Young at the Edinburgh Diabetic Foot Clinic reported a decrease in mortality of diabetic foot patients after aggressive treatment of vascular risk factors. 93 Research has been a prominent feature of many diabetic foot clinics, with work presented at national and international meetings as well as at diabetic foot meetings, such as the Diabetic Foot Study Group, and the biennial Malvern Diabetic Foot meeting. William Jeffcoate and Fran Game set up a Foot Ulcer Trials Unit in Nottingham in 2002, and recently reported the outcomes of two studies coordinated from that center.…”

A systematic review and individual patient data meta-analysis of prognostic factors for foot ulceration in people with diabetes: the international research collaboration for the prediction of diabetic foot ulcerations (PODUS)

“…8 For those who experience diabetes-related amputations, the 5-year survival is poor, with mortality estimates of between 25% and 50% in 1985 in UK populations. 9,10 Changes in diabetes-related LEAs have been reported in parts of the UK. In common with some European countries and the USA, major LEA rates in Scotland have been reported to fall.…”

IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes

“…However, it would seem appropriate that these patients should be initially assessed in a similar manner to the patient with a non-ulcerated (intact) foot. Identification of the patient with PAD is essential to optimise management of the foot ulcer and in undertaking other measures to mitigate cardiovascular risk [20]. Patients should be informed that they have PAD and that it confers an increased risk to their foot.…”

“…antiplatelet agent, statin and antihypertensive medication when indicated) reduced 5-year mortality from 58% to 36% [20].…”