Abstract
ObjectivesTo investigate whether A) duration of ulcer before start of treatment in specialist health care, and B) severity of ulcer according to University of Texas classification system (UT) at start of treatment (baseline), are independent predictors of healing time.MethodsThis retrospective cohort study, based on electronic medical record data, included 105 patients from two outpatient clinics in Western Norway with a new diabetic foot ulcer during 2009–2011. The associations of duration of ulcer and ulcer severity with healing time were assessed using cumulative incidence curves and subdistribution hazard ratio estimated using competing risk regression with adjustment for potential confounders.ResultsOf the 105 participants, 45.7% achieved ulcer healing, 36.2% underwent amputations, 9.5% died before ulcer healing and 8.5% were lost to follow-up. Patients who were referred to specialist health care by a general practitioner ≥ 52 days after ulcer onset had a 58% (SHR 0.42, CI 0.18–0.98) decreased healing rate compared to patients who were referred earlier, in the adjusted model. High severity (grade 2/3, stage C/D) according to the UT classification system was associated with a decreased healing rate compared to low severity (grade1, stage A/B or grade 2, stage A) with SHR (95% CI) equal to 0.14 (0.05–0.43) after adjustment for referral time and other potential confounders.ConclusionEarly detection and referral by both the patient and general practitioner are crucial for optimal foot ulcer healing. Ulcer grade and severity are also important predictors for healing time, and early screening to assess the severity and initiation of prompt treatment is important.
Highlights
Diabetic foot ulcer is a feared complication of diabetes with a yearly incidence around 2–4% [1]
Patients who were referred to specialist health care by a general practitioner ! 52 days after ulcer onset had a 58% (SHR 0.42, CI 0.18–0.98) decreased healing rate compared to patients who were referred earlier, in the adjusted model
High severity according to the University of Texas (UT) classification system was associated with a decreased healing rate compared to low severity with sub distribution hazard ratio (SHR) equal to 0.14 (0.05–0.43) after adjustment for referral time and other potential confounders
Summary
Diabetic foot ulcer is a feared complication of diabetes with a yearly incidence around 2–4% [1]. Factors affecting healing time include duration of ulcer, but limited research on the influence of duration of ulcer before treatment starts in specialist health care is available. Some have investigated the associations between duration of ulcer before specialist health care treatment and healing time among persons with a diabetic foot ulcer [3,4,5,6,7], referral pathways are still not optimal. Many patients have delayed specialist health care referral due to lack of awareness of the potential consequences of a diabetic foot ulcer among patients and health care professionals and poor management strategies or ischemia detection [8]. To our knowledge, no studies have assessed the different periods of the referral pathway among individuals with diabetic foot ulcers. More evidence is needed to assess the delay in referral pathways and the impact of these delays
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