In important work from Paisey and coworkers, incidence of first foot ulceration was nearly cut in half over a sustained 18-year period in Devonshire, UK with the implementation of podiatric diabetic foot services.
Recurrent ulcers for people in diabetic foot remission increased by 60%, echoing other studies showing that ulcer-free days may be an important quality metric. These data also support the fact that, when in high-quality team diabetic foot care, more incident ulcers are likely being identified earlier.
- Prevention of diabetic foot ulceration has been difficult to achieve
- Survival after diabetic foot ulceration has historically been poor
- This study has shown reduction in first diabetes related foot ulceration with improved foot care services
- Participant survival after development of first diabetic foot ulceration was longer than in recent reports especially for those under 65 years of age, where ulcers healed, and in those without peripheral vascular disease
- Adequate commissioning of diabetic foot care services is necessary to prevent first foot ulceration
- Counselling for younger patients with diabetic foot ulceration can be more positive
To ascertain the effects of improvements in diabetic foot services over 18 years on incidence of diabetic foot ulceration. We also compared survival time from first ulcer development with presence of neuropathy, peripheral vascular disease, age and healing.
Persons with new ulceration and those at high risk of ulcer development were referred to community podiatry from 1998. Their details were recorded, with verbal consent, on a central database. The effects of neuropathy, peripheral vascular disease, healing and age on survival were analysed by Cox proportional hazards ratios.
The incidence of first ulcer presentation decreased from 11.1 to 6.1 per 1000 persons between 2003 to 2017 (P <0.0001). Recurrent ulceration incidence remained stable. Prevalence of chronic and new foot ulceration combined increased from 20.7 to 33.1 per 1000 persons (P <0.0001). Ten-year survival was 85% for persons presenting with first ulcer and aged < 65 years, 50% for those aged 65-74 years and 25% for those aged 75-81 years (P < 0.0001). In those with peripheral vascular disease 5-year survival was 35% (P <0.001).
Integrated care for the diabetic foot in one National Health Service (NHS) health service area over 18 years was associated with a reduction in first presentations of diabetic foot ulceration, but failed to reduce recurrent ulceration. Cumulative prevalence of all ulcers continues to increase. Monitoring ulceration incidence can inform audit and planning of diabetic foot care services. Survival is better than reported previously in persons < 65 years and in the absence of peripheral vascular disease.
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