Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study

Abstract

Aims

The aim of our study was to estimate the overall rate of first hospitalizations for diabetic foot (DF) regardless of the outcome in amputations, as well as the mortality rate with their determinants in the period 2012–2016 in Piedmont Region in Italy.

Methods

The study included all the subjects registered in the Regional Diabetes Registry and alive as at January 1, 2012. DF cases were identified by record linkage with the regional hospital discharge database. Incident cases of diabetic foot were followed up for mortality.

Results

The 5-year rates were 1762, 324, and 343 × 100,000 patients for first hospitalization without amputations, with major amputations, and with minor amputations, respectively. Patients not undergoing amputations were more than 70% of the cohort. Patients with the more severe stages of diabetes and those with low education were at higher risk of each type of hospitalization. The risk of death during a mean follow-up of 2.5 years was about 16, 18, and 30% among patients without amputations, with major amputations, and with minor amputations, respectively. Males, insulin-treated patients, those affected with severe diabetes complications, particularly on dialysis, and those with lower levels of education were at higher risk.

Conclusions

The heavier burden of DF on hospitalizations is due to cases without amputation, a condition that is seldom considered in the diabetes literature. The severity of diabetes, preexisting complications, and low educational levels are associated with both first hospitalization and subsequent survival at any level of severity of DF.

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References

  1. 1.

    Armstrong DG, Boulton AJ, Bus SA (2017) Diabetic foot ulcers and their recurrence. N Engl J Med 376:2367–2375

    Article  Google Scholar 

  2. 2.

    Abbott CA, Carrington AL, Ashe H et al (2002) The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 19:377–384

    CAS  Article  Google Scholar 

  3. 3.

    Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y (2017) Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med 49:106–116

    Article  Google Scholar 

  4. 4.

    Boyko EJ, Ahroni JH, Cohen V, Nelson KM, Heagerty PJ (2006) Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the Seattle Diabetic Foot Study. Diabetes Care 29:1202–1207

    Article  Google Scholar 

  5. 5.

    Stoekenbroek RM, Lokin JLC, Nielen MM, Stroes ESG, Koelemay MJW (2017) How common are foot problems among individuals with diabetes? Diabetic foot ulcers in the Dutch population. Diabetologia 60:1271–1275

    Article  Google Scholar 

  6. 6.

    Margolis DJ, Jeffcoate W (2013) Epidemiology of foot ulceration and amputation: can global variation be explained? Med Clin North Am 97:791–805

    Article  Google Scholar 

  7. 7.

    Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J (2005) The global burden of diabetic foot disease. Lancet 366:1719–1724

    Article  Google Scholar 

  8. 8.

    Morbach S, Furchert H, Gröblinghoff U et al (2012) Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care 35:2021–2027

    Article  Google Scholar 

  9. 9.

    Iversen MM, Tell GS, Riise T et al (2009) History of foot ulcer increases mortality among individuals with diabetes: ten-year follow-up of the Nord-Trøndelag Health Study, Norway. Diabetes Care 32:2193–2199

    Article  Google Scholar 

  10. 10.

    Moxey PW, Gogalniceanu P, Hinchliffe RJ et al (2011) Lower extremity amputations—a review of global variability in incidence. Diabet Med 28:1144–1153

    CAS  Article  Google Scholar 

  11. 11.

    Gnavi R, Karaghiosoff L, Dalmasso M, Bruno G (2006) Validazione dell’archivio di esenzione per diabete della Regione Piemonte: vantaggi e limiti per un uso epidemiologico. Epidemiol Prev 30:59–64

    PubMed  Google Scholar 

  12. 12.

    Giorda C, Carnà P, Salomone M et al (2018) Ten-year comparative analysis of incidence, prognosis and associated factors for dialysis and renal transplantation in type 1 and type 2 diabetes versus non-diabetes. Acta Diabetol 55:733–740

    Article  Google Scholar 

  13. 13.

    Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ, Schaper NC (2016) The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes Metab Res Rev 32:2–6

    Article  Google Scholar 

  14. 14.

    Giorda C, Petrelli A, Gnavi R, the Regional Board for Diabetes Care of Piemonte (2006) The impact of second-level specialised care on hospitalisation among persons with diabetes: a multilevel population based study. Diabet Med 23:377–383

    CAS  Article  Google Scholar 

  15. 15.

    Jeffcoate WJ, Harding KG (2003) Diabetic foot ulcers. Lancet 361:1545–1551

    Article  Google Scholar 

  16. 16.

    Martins-Mendes D, Monteiro-Soares M, Boyko EJ et al (2014) The independent contribution of diabetic foot ulcer on lower extremity amputation and mortality risk. J Diabetes Complicat 28:632–638

    Article  Google Scholar 

  17. 17.

    Brennan MB, Hessa TM, Bartle B et al (2017) Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes. J Diabetes Complicat 31:556–561

    Article  Google Scholar 

  18. 18.

    Holman N, Young RJ, Jeffcoate WJ (2012) Variation in the recorded incidence of amputation of the lower limb in England. Diabetologia 55:1919–1925

    CAS  Article  Google Scholar 

  19. 19.

    van Battum P, Schaper N, Prompers L et al (2011) Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med 28:199–205

    Article  Google Scholar 

  20. 20.

    Lombardo FL, Maggini M, De Bellis A, Seghieri G, Anichini R (2014) Lower extremity amputations in persons with and without diabetes in Italy: 2001–2010. PLoS ONE 9:e86405

    Article  Google Scholar 

  21. 21.

    Carinci F, Massi Benedetti M, Klazinga NS, Uccioli L (2016) Lower extremity amputation rates in people with diabetes as an indicator of health systems performance. A critical appraisal of the data collection 2000-2011 by the Organization for Economic Cooperation and Development (OECD). Acta Diabetol 53:825–832

    CAS  Article  Google Scholar 

  22. 22.

    Geiss LS, Li Y, Hora I, Albright A, Rolka D, Gregg EW (2019) Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care 42:50–54

    Article  Google Scholar 

  23. 23.

    Giurato L, Vainieri E, Meloni M et al (2015) Limb salvage in patients with diabetes is not a temporary solution but a life changing procedure. Diabetes Care 38:e156–e157

    Article  Google Scholar 

  24. 24.

    Pscherer S, Dippel F-W, Lauterbach S, Kostev K (2012) Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Primary Care Diabetes 6:241–246

    Article  Google Scholar 

  25. 25.

    Ndip A, Lavery LA, Boulton AJ (2010) Diabetic foot disease in people with advanced nephropathy and those on renal dialysis. Curr Diab Rep 10:283–290

    Article  Google Scholar 

  26. 26.

    Meloni M, Giurato L, Izzo V et al (2016) Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract 116:117–122

    Article  Google Scholar 

  27. 27.

    Piccinelli C, Carnà P, Stringhini S et al (2018) The contribution of behavioural and metabolic risk factors to socioeconomic inequalities in mortality: the Italian Longitudinal Study. Int J Public Health 63:325–335

    Article  Google Scholar 

  28. 28.

    Petrelli A, De Luca G, Landriscina T, Costa G, Gnavi R (2018) Effect of socioeconomic status on surgery waiting times and mortality after hip fractures in Italy. J Health Qual 40:209–216

    Article  Google Scholar 

  29. 29.

    Faglia E, Clerici G, Clerissi J et al (2006) Early and five-year amputation and survival rate of diabetic patients with critical limb ischemia: data of a cohort study of 564 patients. Eur J Vasc Endovasc Surg 32:484–490

    CAS  Article  Google Scholar 

  30. 30.

    Meloni M, Izzo V, Giurato L, Cervelli V, Gandini R, Uccioli L (2018) Impact of heart failure and dialysis in the prognosis of diabetic patients with ischemic foot ulcers. J Clin Transl Endocrinol 11:31–35

    PubMed  PubMed Central  Google Scholar 

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Authors

Contributions

ML and GR conceived of and guided the analysis and wrote the manuscript. CP and GR conducted the analysis. BF, GC, CP and BG contributed to the data collection and reviewed and edited the manuscript. ML and GR are the guarantors of this work and, as such, had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Corresponding authors

Correspondence to Luca Monge or Roberto Gnavi.

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Conflict of interest

No potential conflicts of interest relevant to this article were reported.

Ethical standard

This is an observational study and data were collected retrospectively. All data were anonymously linked and no personal identifiers were available to researchers. No ethical approval was required according to Italian law 211/2003, which explains that no ethics committee permission is required for this kind of study.

Informed consent

Data were drawn from anonymous regional database and informed consent was impossible to obtain. According to Italian privacy law, no patient’s or relative’s consent is required for large retrospective population-based studies and if data are published only in aggregated form.

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Monge, L., Gnavi, R., Carnà, P. et al. Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study. Acta Diabetol 57, 221–228 (2020). https://doi.org/10.1007/s00592-019-01412-8

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Keywords

  • Diabetic foot
  • Diabetes mellitus
  • Amputation
  • Hospitalization
  • Epidemiology
  • Health services research