A new study has found that patients with diabetic foot disease have the highest number of doctor visits, longest doctor visits, highest number of referrals to other doctors and highest risk of hospitalization than all other common diseases studied. This study published in the leading journal Diabetes Care – authored by global diabetic foot experts Professors Grant Skrepnek, Joe Mills, Larry Lavery and David Armstrong – is a timely reminder of the urgent need for all of us to focus on feet as the leading cause of diabetes-related morbidity this World Diabetes Day.
The study analysed an enormous sample of data from all doctor visits in the US. The authors obtained 2007-2013 data on >200,000 adult patient visits to doctors clinics from the respected US Centers for Disease Control and Prevention. This centre adjusted the data to make sure it was representative of all US ambulatory doctor visits before providing it to the authors. The authors then analysed the data for patients presenting with 16 common diseases; including ischaemic heart disease, chronic kidney disease, chronic obstructive pulmonary disease, cancer, arthritis, osteoporosis, depression, asthma, diabetes (without foot disease), diabetic foot infections and diabetic foot ulcers. The key outcomes they were investigating were: i) number of doctor visits in the past year, ii) time taken for the each doctor’s visit, iii) referral to another doctor, and iv) referral for hospital admission.
Firstly they found that for patients visiting their doctor with a diabetic foot infection, they had 5 doctor visits on average in the past year, visits took on average 23 minutes, 13% of visits needed a referral to another doctor and 5% of visits needed referral for hospital admission. For patients presenting with a diabetic foot ulcer (not infected), they had 7 visits in the past year, visits took on average 26 minutes, 19% of visits needed a referral to another doctor and 3% needed referral for hospital admission.
Secondly, they analysed visits for each of the 16 common presenting diseases to determine the odds of being independently linked with each key outcome, after controlling for multiple demographic and disease factors. For patients with a diabetic foot infection they found they had significantly higher odds of having more previous visits to the doctor (1.5 times) and referrals for hospital admission (6.7) compared to other patients; but not for referrals to another doctor or time taken for each visit. Patients with a diabetic foot ulcer had significantly higher odds of having more previous visits to the doctor (1.8 times), time taken for each visit (1.4), referral to another doctor (2.1) and hospital admission (3.4) compared to other patients.
Lastly, they compared their findings for each of the 16 common diseases and found that patients that presented with a diabetic foot ulcer had the highest odds of all diseases for more previous visits to the doctor, longer time spent with the doctor, referral to another doctor and referral for hospital admission; except diabetic foot infection had higher odds of referral for hospital admission.
Put simply this means that patients presenting with diabetic foot disease (ulcer or infection) are more likely to need to see their doctor more often, also see other doctors more often, need longer consults for each doctor visit and need to be hospitalized more frequently than patients presenting with cancer, heart disease, kidney disease, lung disease, depression and the list goes on. The authors display these comparisons beautifully in the main figure of their paper which is definitely worth a look.
While this study had many strengths – including a huge sample of nationally representative data to analyse and robust statistical analyses – it did have some limitations. The data was cross-sectional and analysed retrospectively for patient visits, rather than for each individual patient. This meant the authors could only report on visits at one point in time and could not follow individual patients over time. Also they only had access to factors already contained in the data provided and therefore did not have access to diabetic foot disease specific data such as ulcer severity.
In conclusion, this high-quality paper adds significant weight to recent UK and Australian findings that diabetic foot disease is a leading global cause of all hospitalisation, not just of diabetes-related hospitalisation. The authors recommend this common, complex and costly diabetic foot disease situation needs “continued work … directed towards optimizing access, cost and quality, as well as towards understanding treatment preferences and perceptions of both patients and providers”. This statement could not have aligned any better with the three key recommendations for improved access to care, quality of care and research into care contained in the Australian diabetes-related foot disease strategy 2018-2022: The first step towards ending avoidable amputations within a generation .
With diabetic foot disease now found to cause a greater use of health and hospital services than all other common diseases, could there be a better time to start a global push to end avoidable amputations within a generation than on the eve of World Diabetes Day?