Risk stratification systems for diabetic foot ulcers: a systematic review

Abstract

Aims/hypothesis Several risk stratification systems have been proposed for predicting development of diabetic foot ulcer. However, little has been published that assesses their similarities and disparities, diagnostic accuracy and evidence level. Consequently, we conducted a systematic review of the existing stratification systems. Methods We searched the MEDLINE database for studies (published until April 2010) describing the creation and validation of risk stratification systems for prediction of diabetic foot ulcer development. Results We included 13 studies describing or evaluating the following different risk degree stratification systems: University of Texas; International Working Group on Diabetic Foot; Scottish Intercollegiate Guideline Network (SIGN); American Diabetes Association; and Boyko and colleagues. We confirmed that five variables were included in almost all the systems: diabetic neuropathy, peripheral vascular disease, foot deformity, and previous foot ulcer and amputation. The number of variables included ranged from four to eight and the number of risk groups from two to six. Only four studies reported or allowed the calculation of diagnostic accuracy measures. The SIGN system showed some higher diagnostic accuracy values, particularly positive likelihood ratio, while predictive ability was confirmed through external validation only in the system of Boyko et al. Conclusions/interpretation Foot ulcer risk stratification systems are a much needed tool for screening patients with diabetes. The core variables of various systems are very similar, but the number of included variables in each model and risk groups varied greatly. Overall, the quality of evidence for these systems is low, as little validation of their predictive ability has been done.

Can plantar soft tissue mechanics enhance prognosis of diabetic foot ulcer?

“…Visual acuity 76 (poor vision) score [10] and VPT score [12] (measure of neu-77 ropathy level) were reported to be associated with DFU. monly used predicting the risk of ulceration [14]. Recently 86 another systematic review and meta-analysis, reported that 87 insensitivity to a 10-g monofilament or one absent pedal 88 pulse will identify patients with moderate or intermediate 89 risk of foot ulceration [15].…”

Stratification of foot risk predicts the incidence of new foot disease, but do we yet know that the adoption of routine screening reduces it?

“…In this issue of Diabetologia, Dr Monteiro-Soares et al [1] have produced a timely systematic review of systems that have been described for classifying the relative risk of future ulceration of the foot in diabetic individuals. Disease of the foot represents a considerable threat-a threat to both the well-being and survival of the individual [2]-as well as posing an enormous burden on heathcare services.…”

“…The formal studies cited by Monteiro-Soares et al [1] used a variety of methods to determine both neuropathy (loss of protective sensation) and peripheral arterial disease, and yet the conclusion from all was the same. Thus, it probably matters little that some of these definitive studies used equipment that is not in general use in the community (such as a biothesiometer) or that that there is no consensus on the choice or number of sites to be tested with, for example, a 10 g monofilament.…”

Reliability and credibility analysis of Inlow’s 60 second diabetic foot screening tool for diabetic foot risk stratification and its feasibility in India: a systematic review

“…11,12 Several diabetic foot ulcer risk stratification tools have been developed over the years wherein a systematic review by Monteiro-Soares et al, reveals the following: International Working Group on Diabetic Foot (IWGDF), University of Texas Foot Risk Stratification (UTFRS), Scottish Intercollegiate Guideline Network (SIGN), American Diabetes Association (ADA) and a tool developed by Boyko et al 12,13 Of all these tools, only Boyko et al, examined predictive validity through an external system wherein HbA1c is considered as a predictive variable. 12,13 However, predictive validity is highly examined in the tool developed by Inlow, wherein various researches examined the reliability and validity of the tool. [15][16][17][18][19] Hence, the Inlow's sixty second tool is found to be highly reliable for risk stratification of diabetic foot ulcers.…”