Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months

Zhang, Yuqi; Cramb, Susanna; McPhail, Steven; Pacella, Rosana; Netten, Jaap J. van; Cheng, Qinglu; Derhy, Patrick H; Kinnear, Ewan M; Lazzarini, Peter A

doi:10.1016/j.diabres.2022.109239

Cited by 14 publications

(25 citation statements)

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“…[2][3][4] DFUs usually take months to heal and require intensive treatments to try and prevent hospitalisation, amputation and even death. 2,[5][6][7][8][9] Offloading treatment is essential to heal DFUs 6,10 by reducing the high plantar pressure that causes the development of DFUs in the first place. 11 Non-removable knee-high offloading devices, such as total contact cast (TCC), and removable knee-high offloading devices, such as removable cast walkers (RCWs), have been shown to be the most effective offloading treatments at reducing plantar pressure, reducing around 90% of plantar pressure.…”

Section: Introductionmentioning

confidence: 99%

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Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

Ababneh

Finlayson

Edwards

et al. 2023

Therapeutic Advances in Endocrinology

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Aims: Patients’ adherence to using knee-high offloading treatment is critical to effective healing of diabetes-related foot ulcers (DFUs). Previous studies have found that patients generally have low adherence to using removable knee-high offloading treatments, yet no study has investigated whether their adherence differs during daytime and nighttime. This study aimed to investigate the levels and factors associated with adherence to using knee-high removable cast walker (RCW) treatment during daytime and nighttime weight-bearing activities in people with DFUs. Methods: This was a secondary analysis of data collected from a multi-centre cross-sectional study investigating adherence to using knee-high RCWs among 57 participants with DFUs. All participants had multiple socio-demographic, physiological and psychosocial factors collected, before having their adherence to using RCWs during weight-bearing activity monitored over a 1-week period using the dual activity monitor method. Adherence data were categorised into daytime (06:00–18:00) and nighttime (18:00–06:00) periods and calculated separately. Multiple linear regression was used to identify factors associated with daytime and nighttime adherence. Results: Mean adherence to using RCW during weight-bearing activities in people with DFUs was higher during daytime compared with nighttime [39.9% (SD = 18.9) versus 20.4% (SD = 16.7), p < 0.001]. Factors independently associated with lower adherence during daytime were being male, longer diabetes duration, not having peripheral artery disease (PAD), and higher perceived RCW heaviness. Factors associated with lower adherence during nighttime were higher mean daytime steps, not having retinopathy and having dyslipidaemia. Conclusions: Adherence to using RCWs during weight-bearing activities reduced significantly at nighttime compared with daytime among people with DFUs, and this was associated with different factors. Interventions to improve adherence, in research and clinical practice, should incorporate methods to target daytime or nighttime adherence specifically.

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Section: Introductionmentioning

confidence: 99%

“…2–4 DFUs usually take months to heal and require intensive treatments to try and prevent hospitalisation, amputation and even death. 2,5–9…”

Section: Introductionmentioning

confidence: 99%

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

Ababneh

Finlayson

Edwards

et al. 2023

Therapeutic Advances in Endocrinology

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“…Although outpatient DFU care costs were higher with the increasing proportion of guideline‐based care, these costs were offset by the reduced costs associated with DFU‐related hospitalisation as well as minor and major amputation procedures. The parameters underpinning these lower rates of hospitalisations and amputations arose from our time‐to‐event analysis of a large, multi‐site, real‐world dataset that has previously highlighted that guideline‐based care factors for DFU was associated with shorter time‐to‐healing, and lower hospitalisation and amputation rates 14 . Patients having received guideline‐based prevention when their DFU healed, which included regular follow‐up monitoring in the clinic and having appropriate footwear, were also associated with lower recurrence rates.…”

Section: Discussionmentioning

confidence: 99%

Cost‐effectiveness of guideline‐based care provision for patients with diabetes‐related foot ulcers: A modelled analysis using discrete event simulation

et al. 2022

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Aims:The provision of guideline-based care for patients with diabetes-related foot ulcers (DFU) in clinical practice is suboptimal. We estimated the cost-effectiveness of higher rates of guideline-based care, compared with current practice. Methods:The costs and quality-adjusted life-years (QALYs) associated with current practice (30% of patients receiving guideline-based care) were compared with seven hypothetical scenarios with increasing proportion of guideline-based care (40%, 50%, 60%, 70%, 80%, 90% and 100%). Comparisons were made using discrete event simulations reflecting the natural history of DFU over a 3-year time horizon from the Australian healthcare perspective. Incremental cost-effectiveness ratios were calculated for each scenario and compared to a willingness-to-pay of AUD 28,000 per QALY. Probabilistic sensitivity analyses were conducted to incorporate joint parameter uncertainty.Results: All seven scenarios with higher rates of guideline-based care were likely cheaper and more effective than current practice. Increased proportions compared with current practice resulted in between AUD 0.28 and 1.84 million in cost savings and 11-56 additional QALYs per 1000 patients. Probabilistic sensitivity analyses indicated that the finding is robust to parameter uncertainty.

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“…We encourage our colleagues, whether working in multidisciplinary diabetic foot clinics or in a solo practice, to consider developing some form of surveillance (e.g., registries, pathways) to monitor interventions and outcomes and attempt to improve their outcomes (e.g., through bench marking, best practice and research) for cohorts of persons with diabetes who have a foot ulcer. 17,18,60 12. We encourage our research colleagues to consider these key considerations and conduct well-designed studies according to published reporting standards 12 in areas of offloading in which we find gaps in the evidence base so to better inform the diabetic foot community in the future on effective offloading treatment for persons with diabetes and a foot ulcer.…”

Section: Many Rcts On Offloading Interventions Do Not Directly Mea-mentioning

confidence: 99%

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

Bus

Armstrong

Crews

et al. 2023

Diabetes Metabolism Res

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AimsOffloading mechanical tissue stress is arguably the most important of multiple interventions needed to heal diabetes‐related foot ulcers. This is the 2023 International Working Group on the Diabetic Foot (IWGDF) evidence‐based guideline on offloading interventions to promote healing of foot ulcers in persons with diabetes. It serves as an update of the 2019 IWGDF guideline.Materials and MethodsWe followed the GRADE approach by devising clinical questions and important outcomes in the PICO (Patient‐Intervention‐Control‐Outcome) format, undertaking a systematic review and meta‐analyses, developing summary of judgement tables and writing recommendations and rationales for each question. Each recommendation is based on the evidence found in the systematic review, expert opinion where evidence was not available, and a careful weighing of GRADE summary of judgement items including desirable and undesirable effects, certainty of evidence, patient values, resources required, cost effectiveness, equity, feasibility, and acceptability.ResultsFor healing a neuropathic plantar forefoot or midfoot ulcer in a person with diabetes, use a non‐removable knee‐high offloading device as the first‐choice offloading intervention. If contraindications or patient intolerance to non‐removable offloading exist, consider using a removable knee‐high or ankle‐high offloading device as the second‐choice offloading intervention. If no offloading devices are available, consider using appropriately fitting footwear combined with felted foam as the third‐choice offloading intervention. If such a non‐surgical offloading treatment fails to heal a plantar forefoot ulcer, consider an Achilles tendon lengthening, metatarsal head resection, joint arthroplasty, or metatarsal osteotomy. For healing a neuropathic plantar or apex lesser digit ulcer secondary to flexibile toe deformity, use digital flexor tendon tenotomy. For healing rearfoot, non‐plantar or ulcers complicated with infection or ischaemia, further recommendations have been outlined. All recommendations have been summarised in an offloading clinical pathway to help facilitate the implementation of this guideline into clinical practice.ConclusionThese offloading guideline recommendations should help healthcare professionals provide the best care and outcomes for persons with diabetes‐related foot ulcers and reduce the person's risk of infection, hospitalisation and amputation.

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Multiple factors predict longer and shorter time-to-ulcer-free in people with diabetes-related foot ulcers: Survival analyses of a large prospective cohort followed-up for 24-months

Cited by 14 publications

References 50 publications

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

Differences in adherence to using removable cast walker treatment during daytime and nighttime weight-bearing activities in people with diabetes-related foot ulcers

Cost‐effectiveness of guideline‐based care provision for patients with diabetes‐related foot ulcers: A modelled analysis using discrete event simulation

Guidelines on offloading foot ulcers in persons with diabetes (IWGDF 2023 update)

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