medwireNews: Individuals with type 2 diabetes on dialysis who develop a new diabetic foot ulcer (DFU) are less likely to require an amputation if they have already received specialist foot and ankle care than if they have not, says a team of US-based researchers.
In a retrospective cohort study, individuals who saw a podiatrist in the 3 months before an index DFU diagnosis versus those who did not had an 11% lower likelihood of death and/or amputation and a 9% lower likelihood of major amputation, either above or below the knee, after adjusting for age, race, kidney disease and dialysis-related characteristics, comorbidity, and other confounding factors.
“[R]eceiving foot and ankle care by podiatrists before the onset of diabetic foot ulcers may be associated with improved outcomes,” say Tze-Woei Tan (Keck School of Medicine of University of Southern California, Los Angeles) and associates in JAMA Network Open.
The combination of type 2 diabetes and kidney failure is known to heighten the risk for DFUs, say the researchers. While prompt care by podiatrists once an ulcer exists has been proven to prevent amputations and hospitalizations, it has been unclear, until now, whether such a benefit also exists for pre-emptive care.
To find out, the researchers queried the US Renal Data System (USRDS) to identify individuals who were Medicare beneficiaries, had type 2 diabetes, were receiving dialysis for kidney failure, and had received a new diagnosis of a DFU in 2017. Anyone with a prior diagnosis of a DFU, a history of major amputation above or below the knee, kidney transplantation, or incomplete baseline information was excluded.
The resulting study population consisted of 14,935 individuals aged a mean of 59.3 years, 55.4% of whom were men. Over half (58.5%) of the population identified as White, 35.0% as Black or African American, 17.7% as Hispanic, and 2.7% as Asian.
“Only 18.4% of patients received care by podiatrists within the 3 months preceding the DFU diagnosis,” report the researchers. They add that these 2736 individuals were older than the 12,199 individuals who had not received prior podiatric care (62.8 vs 58.5 years), were more likely to be men (56.5 vs 55.2%), and had more comorbidities (Charlson Comorbidity Index score, 6.4 vs 6.0).
Over a mean of 13.5 months of follow-up, the primary endpoint of death, major amputation, or both, occurred in a respective 70% and 74% of individuals who did and did not receive pre-emptive podiatric care.
Notably, mortality and amputation rates were “substantial,” say the researchers. Among those who saw a podiatrist before their DFU was diagnosed, 44.5% died and 25.8% had an amputation. Similar rates were seen among those who did not see a podiatrist, at 44.7% and 28.9%, respectively.
Unadjusted Kaplan-Meier survival analysis showed that survival probabilities at 36 months significantly differed between the podiatric care and no podiatric care groups, at 26.3% and 22.8%, respectively, as did the cumulative incidence of amputation alone at 36 months (26.4 vs 29.8%), the researchers report.
“While future fully powered studies are needed to further support these findings, these results suggest positive potential benefits for preventive foot and ankle care to mitigate complications in this high-risk population,” the researchers conclude.
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