Incidence and characteristics of diabetic foot ulcers in subjects with type 2 diabetes in Catalonian primary care centres: An observational multicentre study

  • Magdalena Bundó
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Primary Health Care Center Ronda Prim, Gerència d’Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Mataró, Spain
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  • Judit Llussà
    Affiliations
    Primary Health Care Centre Sant Roc, Gerència d’Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Mataró, Spain Catalan Health Institute, Badalona, Spain
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  • Marta Serra
    Affiliations
    Primary Health Care Centre Ca n’Oriac, Gerència d’Àmbit d'Atenció Primària Metropolitana Nord de Barcelona, Institut Català de la Salut, Sabadell, Spain
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  • Paloma Prats de la Iglesia
    Affiliations
    Primary Health Care Centre Raval Sud, Gerència d’Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain
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  • Rosa M. Gimbert
    Affiliations
    Primary Health Care Centre El Carmel, Gerència d’Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain
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  • Jordi Real
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Universitat Internacional de Catalunya, Epidemiologia i Salut Pública, Sant Cugat, Spain
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  • Bogdan Vlacho
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Pharmacology Department, Universitat Autònoma de Barcelona (UAB), Cerdanyola del Vallès, Spain

    Fundació Institut d'Investigació en Ciències de la Salut Germans Trias i Pujol (IGTP), Badalona, Spain
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  • Manel Mata-Cases
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Primary Health Care Center La Mina, Gerència d’Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Sant Adrià de Besòs, Spain

    CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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  • Xavier Cos
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Innovation office at Institut Català de la Salut, Barcelona, Spain
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  • Josep Franch-Nadal
    Correspondence
    Corresponding author at: DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Carrer Sardenya 375, Entresuelo, 08025 Barcelona, Spain.
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Primary Health Care Centre Raval Sud, Gerència d’Àmbit d'Atenció Primària Barcelona Ciutat, Institut Català de la Salut, Barcelona, Spain

    CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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  • Dídac Mauricio
    Correspondence
    Corresponding author at: DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Carrer Sardenya 375, Entresuelo, 08025 Barcelona, Spain.
    Affiliations
    DAP-Cat group, Unitat de Suport a la Recerca Barcelona Ciutat, Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain

    Department of Endocrinology & Nutrition, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

    Departament of Medicine, University of Vic - Central University of Catalonia, Vic, Spain

    CIBER of Diabetes and Associated Metabolic Diseases (CIBERDEM), Instituto de Salud Carlos III (ISCIII), Madrid, Spain
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Published:August 18, 2021DOI:https://doi.org/10.1016/j.pcd.2021.08.002

      Highlights

      • The annual incidence of a new DFU was 0.42% in the primary health care setting in our region.
      • More than half of the participants had peripheral arterial disease.
      • About 8.9% of participants had a history of amputation.
      • Almost half of the ulcers had signs of infection.
      • One in four of the ischemic ulcers were infected.

      Abstract

      Aims

      The main objective was to assess the incidence of diabetic foot ulcers in type 2 diabetes individuals from primary care centres in Catalonia, Spain.

      Methods

      Prospective observational study in 36 Primary Care centres in Catalonia during February 2018 and July 2019 was conducted. We included participants with type 2 diabetes and a new foot ulcer. We estimated the annual foot ulcer incidence and described the characteristics: presence of comorbidities, clinical parameters and the characteristics of the diabetic foot ulcers (DFU) at inclusion in the study.

      Results

      The incidence of a new DFU during the 12-month recruitment period was 0.42%. The mean age of the participants was 72.2 years (± 12.7), the majority of them were males (n = 178; 69.5%). Overall, 43.8% of DFUs were located on the dorsal aspect of toes or interdigital spaces. A percentage of 43.4% of the participants had ulcers of less than 1 cm2 surface. Further, 44.1% of the participants had a neuroischemic, 20.3% a neuropathic, 20.3% an ischemic ulcer. A 25.3% of ulcers with a concomitant peripheral artery disease were infected.

      Conclusions

      Although the incidence found was low, our study shows the great complexity of patients with foot ulcers treated in primary care.

      Keywords

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      References

        • Centre for Clinical Practice at NICE (UK)
        Diabetic Foot Problems: Inpatient Management of Diabetic Foot Problems.
        2011
        • Boulton A.J.
        • Vileikyte L.
        • Ragnarson-Tennvall G.
        • Apelqvist J.
        The global burden of diabetic foot disease.
        Lancet. 2005; 366: 1719-1724https://doi.org/10.1016/S0140-6736(05)67698-2
        • Hingorani A.
        • LaMuraglia G.M.
        • Henke P.
        • et al.
        The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine.
        J. Vasc. Surg. 2016; 63: 3S-21Shttps://doi.org/10.1016/j.jvs.2015.10.003
        • Prompers L.
        • Huijberts M.
        • Apelqvist J.
        • et al.
        Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study.
        Diabet. Med. 2008; 6: 700-707https://doi.org/10.1111/j.1464-5491.2008.02445
        • Diabetic Foot Ulcers
        The UCSF Center for Limb Preservation & Wound Care.
        2021 (. (Accessed 16 July 2021))
        • Yotsu R.R.
        • Pham N.M.
        • Oe M.
        • et al.
        Comparison of characteristics and healing course of diabetic foot ulcers by etiological classification: neuropathic, ischemic, and neuro-ischemic type.
        J. Diabetes Complications. 2014; 28: 528-535https://doi.org/10.1016/j.jdiacomp.2014.03.013
        • Aziz K.M.
        The diabetic foot syndrome an ignored and potential problem in medical practice.
        Int. J. Diabetol. Vasc. Dis. Res. 2013; 1: 1-3https://doi.org/10.19070/2328-353X-130003e
        • Game F.
        Classification of diabetic foot ulcers, diabetes.
        Metab. Res. Rev. 2016; 32: 186-194https://doi.org/10.1002/dmrr.2746
        • Chuan F.
        • Tang K.
        • Jiang P.
        • et al.
        Reliability and validity of the perfusion, extent, depth, infection and sensation (PEDIS) classification system and score in patients with diabetic foot ulcer.
        PLoS One. 2015; 10e0124739https://doi.org/10.1371/journal.pone.0124739
        • Prompers L.
        • Huijberts M.
        • Apelqvist J.
        • et al.
        High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study.
        Diabetologia. 2007; 50: 18-25https://doi.org/10.1007/s00125-006-0491-1
        • Winkley K.
        • Stahl D.
        • Chalder T.
        • Edmonds M.E.
        • Ismail K.
        Risk factors associated with adverse outcomes in a population-based prospective cohort study of people with their first diabetic foot ulcer.
        J. Diabetes Complications. 2007; 21: 341-349https://doi.org/10.1016/j.jdiacomp.2007.09.004
        • Gershater M.A.
        • Löndahl M.
        • Nyberg P.
        • et al.
        Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study.
        Diabetologia. 2009; 52: 398-407https://doi.org/10.1007/s00125-008-1226-2
        • Jiang Y.
        • Wang X.
        • Xia L.
        • et al.
        A cohort study of diabetic patients and diabetic foot ulceration patients in China.
        Wound Repair Regen. 2015; 23: 222-230https://doi.org/10.1111/wrr.12263
        • Iwase M.
        • Fujii H.
        • Nakamura U.
        • et al.
        Incidence of diabetic foot ulcer in Japanese patients with type 2 diabetes mellitus: the Fukuoka diabetes registry.
        Diabetes Res. Clin. Pract. 2018; 137: 183-189https://doi.org/10.1016/j.diabres.2018.01.020
        • Ramsey S.D.
        • Newton K.
        • Blough D.
        • et al.
        Incidence, outcomes, and cost of foot ulcers in patients with diabetes.
        Diabetes Care. 1999; 22: 382-387https://doi.org/10.2337/diacare.22.3.382
        • Muller I.S.
        • de Grauw W.J.C.
        • van Gerwen W.H.E.N.
        • et al.
        Foot ulceration and lower limb amputation in type 2 diabetic patients in dutch primary health care.
        Diabetes Care. 2002; 25: 570-574https://doi.org/10.2337/diacare.25.3.570
        • Abbott C.A.
        • Carrington A.L.
        • Ashe H.
        • et al.
        The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort.
        Diabet. Med. 2002; 19: 377-384https://doi.org/10.1046/j.1464-5491.2002.00698
        • Boyko E.J.
        • Ahroni J.H.
        • Cohen V.
        • Nelson K.M.
        • Heagerty P.J.
        Prediction of diabetic foot ulcer occurrence using commonly available clinical information: the seattle diabetic foot study.
        Diabetes Care. 2006; 29: 1202-1207https://doi.org/10.2337/dc05-2031
        • Stoekenbroek R.M.
        • Lokin J.L.C.
        • Nielen M.M.
        • Stroes E.S.G.
        • Koelemay M.J.W.
        How common are foot problems among individuals with diabetes? Diabetic foot ulcers in the Dutch population.
        Diabetologia. 2017; 60: 1271-1275https://doi.org/10.1007/s00125-017-4274-7
        • American Diabetes Association
        Standards of medical care in diabetes—2018 abridged for primary care providers.
        Clin. Diabetes. 2018; 36: 14-37https://doi.org/10.2337/cd17-0119
        • Boulton A.J.
        • Armstrong D.G.
        • Albert S.F.
        • et al.
        American Diabetes Association; American Association of Clinical Endocrinologists. Comprehensive foot examination and risk assessment: a report of the task force of the foot care interest group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists.
        Diabetes Care. 2008; 31: 1679-1685https://doi.org/10.2337/dc08-9021
        • Aboyans V.
        • Criqui M.H.
        • Abraham P.
        • et al.
        American Heart Association Council on Peripheral Vascular Disease; Council on Epidemiology and Prevention; Council on Clinical Cardiology; Council on Cardiovascular Nursing; Council on Cardiovascular Radiology and Intervention, and Council on Cardiovascular Surgery and Anesthesia. Measurement and interpretation of the ankle-brachial index: a scientific statement from the American Heart Association.
        Circulation. 2012; 126: 1262890-1262909https://doi.org/10.1161/CIR.0b013e318276fbcb
        • Schaper N.C.
        Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies, diabetes.
        Metab. Res. Rev. 2004; 20: S90-S95https://doi.org/10.1002/dmrr.464
        • Lipsky B.A.
        • Aragón-Sánchez J.
        • Diggle M.
        • et al.
        IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes, diabetes.
        Metab. Res. Rev. 2016; 32: 45-74https://doi.org/10.1002/dmrr.2699
        • Jeffcoate W.J.
        • Bus S.A.
        • Game F.L.
        • et al.
        Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: required details and markers of good quality.
        Lancet Diabetes Endocrinol. 2016; 4: 781-788https://doi.org/10.1016/S2213-8587(16)30012-2
        • Alonso-Morán E.
        • Orueta J.F.
        • Fraile Esteban J.L.
        • et al.
        The prevalence of diabetes-related complications and multimorbidity in the population with type 2 diabetes mellitus in the Basque Country.
        BMC Public Health. 2014; 1491059https://doi.org/10.1186/1471-2458-14-1059
        • Hurley L.
        • Kelly L.
        • Garrow A.P.
        • et al.
        A prospective study of risk factors for foot ulceration: the West of Ireland Diabetes Foot Study.
        QJM. 2013; 106: 1103-1110https://doi.org/10.1093/qjmed/hct182
        • Mundet X.
        • Cano F.
        • Mata-Cases M.
        • et al.
        Trends in chronic complications of type 2 diabetic patients from Spanish primary health care centres (GEDAPS study): ten year-implementation of St. Vincent recommendations.
        Prim. Care Diabetes. 2012; 6: 11-18https://doi.org/10.1016/j.pcd.2011.06.005
        • Rasmussen A.
        • Almdal T.
        • Anker Nielsen A.
        • et al.
        Decreasing incidence of foot ulcer among patients with type 1 and type 2 diabetes in the period 2001–2014.
        Diabetes Res. Clin. Pract. 2017; 130: 221-228https://doi.org/10.1016/j.diabres.2017.05.025
        • Moxey P.W.
        • Gogalniceanu P.
        • Hinchliffe R.J.
        • et al.
        Lower extremity amputations-a review of global variability in incidence.
        Diabet. Med. 2011; 28 (PMID: 21388445): 1144-1153https://doi.org/10.1111/j.1464-5491.2011.03279.x
        • Margolis D.J.
        • Hoffstad O.
        • Nafash J.
        • et al.
        Location, location, location: geographic clustering of lower-extremity amputation among Medicare beneficiaries with diabetes.
        Diabetes Care. 2011; 34 (Epub 2011 September 20th. PMID: 21933906; PMCID: PMC3198303): 2363-2367https://doi.org/10.2337/dc11-0807
        • Barshes N.R.
        • Sigireddi M.
        • Wrobel J.S.
        • et al.
        The system of care for the diabetic foot: objectives, outcomes, and opportunities.
        Diabet. Foot Ankle. 2013; 4 (PMID: 24130936; PMCID: PMC3796020)https://doi.org/10.3402/dfa.v4i0.21847
        • Mahmood K.
        • Aziz A.
        Association between high risk foot, retinopathy and HbA1c in saudi diabetic population.
        Pak. J. Physiol. 2010; 6: 22-28
        • Schaper N.C.
        • van Netten J.J.
        • Apelqvist J.
        • et al.
        IWGDF Editorial Board. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update).
        Diabetes Metab. Res. Rev. 2020; 36 (PMID: 32176447): e3266https://doi.org/10.1002/dmrr.3266