Breakdown of Diabetic Foot Ulcer Care during the First Year of the Pandemic in Poland: A Retrospective National Cohort Study

The impact of COVID-19 on the care of diabetic foot ulcers: A scoping review

AIM

The aims and objectives of this scoping review were to conduct a systematic search of the literature to identify the nature and extent of the research evidence to which the COVID-19 pandemic impacted and disrupted the care of Diabetic Foot Ulcers (DFU) and the subsequent impact on patient outcomes. Secondly, to identify transformation in models of care and service delivery, adoption of innovative technologies and new models of service innovations, including modalities such as telehealth that were adopted during the pandemic.

METHODS

This systematic scoping review was conducted in accordance with the Joanna Briggs Institute methodology for scoping reviews and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping reviews (PRISMA-ScR).

RESULTS

Nineteen papers were included. These studies explored aspects of care for DFUs during the COVID-19 pandemic. The focus of these studies ranged from exploring new modalities of care such as telehealth, reporting of clinical outcomes, development of triage systems and patient behaviors during COVID-19.

CONCLUSION

Ten of twelve studies reported on DFU outcomes and reported a worsening of outcomes compared to pre-pandemic times. Reduced DFU presentations, alongside an increase in urgent hospitalisations and amputation, were key themes that emerged from this review. More high-quality evidence is needed to establish any longer-lasting effects of the Covid-19 pandemic on people living with DFU. Further, there is a lack of evidence relating to the feasibility and success of telemedicine and limited data on changes to service delivery, including triage systems in this patient cohort.

The effect of the different waves of COVID-19 pandemic on the outcome of diabetic foot ulcers

AIMS

COVID-19 pandemic has massively impacted human health. We studied the effect of COVID-19 on outcome of Diabetic foot ulcers (DFUs).

OBJECTIVES AND METHODS

We recruited 483 people with DFUs from June 2020 to April 2022 (pandemic) together with a matched group of 226 people with DFU from March 2019 to March 2020 (pre-pandemic). Primary endpoint was outcome of ulcers-healed or amputation (major/minor). It was sub-analysed into 3 waves of COVID-19. Secondary endpoint was healing of individual types of DFUs. Basic anthropometric data included site and type of ulcer (ischemic or neuropathic), duration, presence or absence of infection and Wagner's grading of DFUs was collected for all patients. Diagnosis of peripheral neuropathy was done by monofilament testing and peripheral arterial disease by handheld Doppler and ankle brachial index (ABI). Standardized treatment protocol was provided. All patients were monitored for 6 months.

RESULTS

In the pandemic group 323 (66.9%) patients in whom ulcers healed, 70 (14.5%) underwent minor amputation, 11 (2.2%) major amputation, 29 (6%) were lost to follow up, 22 (4.6%) were not healed. Rate of healing of DFU was higher (66.9% vs 53.5%) and rate of amputation was lower (16.7% vs 23.4%) in the pandemic group than in the pre-pandemic group (P = 0.001 and 0.037 respectively). Rate of healing in first, second and third wave was 65.4%, 75.2%, 58.3% respectively (P = 0.001). Neuropathic ulcers though less prevalent (49.8% vs 57.8%) in the first two waves than in the third wave, healing was better (79.3% vs 75.6%) in the first two waves than in the third wave (P = 0.085 and 0.488 respectively). Similarly, amputation rates in ischemic and neuro-ischemic ulcers were greater in the third wave than first two waves (46.7% vs 15.7%, P = 0.049).

CONCLUSION

During the COVID-19 pandemic, healing of neuropathic ulcers was better, especially in the first and second waves and travel restriction may have accounted for this. However, worsening of ischemic and neuro-ischemic ulcers was observed with more amputation in these two groups. Conversely, in the third wave withdrawal of lockdown led to worsening of DFUs resulting in less healing and more amputation.

Two-year incidence and risk factors of diabetic foot ulcer: second phase report of Ahvaz diabetic foot cohort (ADFC) study

AIM/INTRODUCTION

This study was designed as the second phase of a prospective cohort study to evaluate the incidence and risk factors of diabetic foot ulcers (DFU).

MATERIALS AND METHODS

The study was conducted in a university hospital in Iran. Each participant was checked and followed up for two years in terms of developing newfound DFU as ultimate outcome. We investigated the variables using univariate analysis and then by backward elimination multiple logistic regression.

RESULTS

We followed up 901 eligible patients with diabetes for two years. The mean age of the participants was 53.24 ± 11.46 years, and 58.53% of them were female. The two-year cumulative incidence of diabetic foot ulcer was 8% (95% CI 0.071, 0.089) [Incidence rate: 49.9 /1000 person-years]. However, the second-year incidence which was coincident with the COVID-19 pandemic was higher than the first-year incidence (4.18% and 1.8%, respectively). Based on our analysis, the following variables were the main risk factors for DFU incidence: former history of DFU or amputation [OR = 76.5, 95% CI(33.45,174.97), P value < 0.001], ill-fitting foot-wear [OR = 10.38, 95% CI(4.47,24.12), P value < 0.001], smoking [OR = 3.87,95%CI(1.28, 11.71),P value = 0.016], lack of preventive foot care [OR = 2.91%CI(1.02,8.29),P value = 0.045], and insufficient physical activity[OR = 2.25,95% CI(0.95,5.35),P value = 0.066].

CONCLUSION

Overall, the two-year cumulative incidence of diabetic foot ulcer was 8% [Incidence rate: 49.9 /1000 person-years]; however, the second-year incidence was higher than the first-year incidence which was coincident with the COVID-19 pandemic (4.18% and 1.8%, respectively). Independent risk factors of DFU occurrence were prior history of DFU or amputation, ill-fitting footwear, smoking, lack of preventive foot care, and insufficient physical activity.

The impact of the COVID-19 pandemic and associated disruptions in health-care provision on clinical outcomes in people with diabetes: a systematic review

The COVID-19 pandemic triggered disruptions to health care and lifestyles that could conceivably impact diabetes management. We set out to identify the impact of disruptions caused by COVID-19 on clinical outcomes in people with diabetes. We performed a systematic review of the available literature in the MEDLINE and OVID databases from Jan 1, 2020, to June 7, 2023, and included 138 studies (n>1 000 000 people). All but five studies were judged to be at some risk of bias. All studies compared prepandemic with pandemic periods. All-cause mortality (six studies) and diabetes-related mortality (13 studies) showed consistent increases, and most studies indicated increases in sight loss (six studies). In adult and mixed samples, data generally suggested no difference in diabetic ketoacidosis frequency or severity, whereas in children and adolescents most studies showed increases with some due to new-onset diabetes (69 studies). Data suggested decreases in hospital admissions in adults but increases in diabetes-related admissions to paediatric intensive care units (35 studies). Data were equivocal on diabetic foot ulcer presentations (nine studies), emergency department admissions (nine studies), and overall amputation rates (20 studies). No studies investigated renal failure. Where reported, the impact was most pronounced for females, younger people, and racial and ethnic minority groups. Further studies are needed to investigate the longer-term impact of the pandemic and the on potential differential impacts, which risk further exacerbating existing inequalities within people with diabetes.

The Indirect Impact of COVID-19 Pandemic on Lower Extremity Amputations - An Australian Study

Background

The COVID-19 pandemic has had indirect and deleterious effects on patient health due to interruptions to routine provision of healthcare. This is particularly true for patients with chronic conditions like peripheral vascular disease (PVD). This study aims to evaluate the impact of the pandemic on patients with PVD in Australia by analysing rates of amputation, indications for amputation and urgency of surgery in the pre-pandemic and pandemic periods.

Methods

The Australian Vascular Audit was used to capture lower extremity amputation data in Victoria, Australia, in the 22 months before and after the start of the pandemic.

Results

The number of total amputations increased from 1770 pre-pandemic to 1850 during the pandemic, a 4.3% increase. This was largely driven by a statistically significant, 19% increase in major amputations. The number of minor amputations remained relatively similar in the two time periods. Amputations due to tissue loss secondary to arterial insufficiency increased from 474 to 526, an 11% increase, potentially indicating disruptions to revascularisation procedures contributing to the rise in amputations. Elective and emergency surgeries fell by 14% and 18%, respectively, while semi-urgent amputations increased by 32%.

Conclusion

This study found an increase in the number of amputations overall and a significant increase in major amputations during the pandemic compared to pre-pandemic times. Tissue loss secondary to arterial insufficiency was an increasingly common indication for amputation that was observed in the pandemic group, indicating that disruption to revascularisation likely contributed to this increase in amputations. These findings can inform and direct future vascular surgery service delivery to prepare for the post-pandemic recovery. Additionally, this study further confirms that patients with chronic diseases are often disproportionately disadvantaged when global crises affect routine provision of healthcare and calls for better systems to be developed that can be used in such crises in the future.

Efficacy of telemedicine applications in patients with diabetic foot ulcers: A focus on mortality and major amputation rates

Amputations related to diabetic foot ulcers (DFU) are associated with high morbidity and mortality rates. Glycaemic control and close follow-up protocols are essential to prevent such ulcers. Coronavirus disease (COVID) related restrictions and regulations might have a negative impact on patients who are with DFU or candidates for DFU. We retrospectively analysed 126 cases that had DFU underwent amputation surgery. Comparative analyses were done between cases that were admitted before COVID restrictions (Group A) and cases admitted after COVID restrictions (Group B). Two groups were homogenic demographically. There was no significant difference between groups in terms of mortality (p = 0.239) and amputation rates (p = 0.461). The number of emergent cases in the pandemic period doubled the number in pre-pandemic period even though this finding was not statistically significant (p = 0.112). Fastly adapted consulting practice and follow-up protocols to compensate for the problems created by COVID-related regulations seem to be effective in terms of mortality and amputation rates.

The indirect impact of COVID-19 pandemic on limb preservation care- a retrospective analysis of trends in lower limb revascularisation

BACKGROUND

Disruptions caused by COVID-19 pandemic have profoundly influenced the management of many conditions, especially vascular pathologies including limb preservation care. The aim of this study is to evaluate the impact of the pandemic on patients with peripheral arterial disease (PAD) focusing on lower limb revascularisation procedure volume, their indication and urgency of surgery.

METHODS

The Australian Vascular Audit (AVA) was used to capture data on revascularisation procedures before and after the onset of the pandemic in Victoria, Australia. Information on patient demographics, procedures performed, their indication and urgency of surgery were collected.

RESULTS

There was a significant 22.7% increase in revascularisations for PAD during the COVID-19 pandemic, driven solely by a 31.9% increase in endovascular revascularisation procedures. Revascularisation procedures for all indications of PAD, namely claudication, rest pain and tissue loss, increased by 14.8%, 39.2% and 27.4% respectively, during the pandemic compared to pre-pandemic times. Open procedures declined by 10.2% during the pandemic. There were significant 13.9% and 62.2% increases in elective and semi-urgent revascularisations respectively during the pandemic while emergency revascularisations for PAD fell by 4.2%. There were no significant increases in toe, forefoot or below knee amputations during the pandemic compared to pre-pandemic times.

CONCLUSIONS

This study found that the volume of revascularisation for PAD increased significantly during the pandemic indicating that patients with PAD had significant deterioration of their condition during the pandemic. This is likely multifactorial; due to disruptions to standard provision of podiatry, vascular surgery and endocrinology services to these patients, a decline in overall health and changes in health-related behaviours due to restrictions and infection control methods imposed during the pandemic. The number of elective and semi-urgent procedures also increased during the pandemic which reflects the significant deterioration of PAD patients during the pandemic. This study highlights a concerning trend of worsening PAD when routine care of these patients is disrupted. Such data should be instrumental in contingency planning and resource allocation for managing the ongoing pandemic.

A review of disparities in peripheral artery disease and diabetes-related amputations during the COVID-19 pandemic

The COVID-19 pandemic has profoundly affected health care delivery. In addition to the significant morbidity and mortality associated with acute illness from COVID-19, the indirect impact has been far-reaching, including substantial disruptions in chronic disease care. As a result of pandemic disruptions in health care, vulnerable and minority populations have faced health inequalities. The aim of this review was to investigate how the COVID-19 pandemic has impacted vulnerable populations with limb-threatening peripheral artery disease and diabetic foot infections.

The role of artificial intelligence technology in the care of diabetic foot ulcers: the past, the present, and the future

Foot ulcers are common complications of diabetes mellitus and substantially increase the morbidity and mortality due to this disease. Wound care by regular monitoring of the progress of healing with clinical review of the ulcers, dressing changes, appropriate antibiotic therapy for infection and proper offloading of the ulcer are the cornerstones of the management of foot ulcers. Assessing the progress of foot ulcers can be a challenge for the clinician and patient due to logistic issues such as regular attendance in the clinic. Foot clinics are often busy and because of manpower issues, ulcer reviews can be delayed with detrimental effects on the healing as a result of a lack of appropriate and timely changes in management. Wound photographs have been historically useful to assess the progress of diabetic foot ulcers over the past few decades. Mobile phones with digital cameras have recently revolutionized the capture of foot ulcer images. Patients can send ulcer photographs to diabetes care professionals electronically for remote monitoring, largely avoiding the logistics of patient transport to clinics with a reduction on clinic pressures. Artificial intelligence-based technologies have been developed in recent years to improve this remote monitoring of diabetic foot ulcers with the use of mobile apps. This is expected to make a huge impact on diabetic foot ulcer care with further research and development of more accurate and scientific technologies in future. This clinical update review aims to compile evidence on this hot topic to empower clinicians with the latest developments in the field.