Improving foot ulcer risk assessment and identifying associated factors: Results of an initiative enhancing diabetes care in primary settings

Abstract

Background: Diabetes-related lower extremity complications contribute significantly to the overall disability burden of type 2 diabetes (T2D). The screening of Diabetic Foot Ulcer (DFU) risk is essential for the early identification of its components, thereby preventing the progression to advanced complications. Unfortunately, identifying elements associated with foot ulcer development is often poorly executed, especially in primary care settings, particularly in low-middle-income countries. We assess the prevalence of DFU risk and its components while exploring sociodemographic, clinical, and behavioral characteristics linked to DFU risk in patients with T2D. Methods: This cross-sectional study examined the characteristics of the feet of subjects involved in an initiative to enhance the quality of diabetes care in primary healthcare settings. The assessment included the presence of foot deformities, peripheral neuropathy through Loss of Protective Sensation (LOPS) evaluation, peripheral arterial disease (PAD), and a history of foot ulcer or lower extremity amputations. Participants were classified according to the IWGDF Risk Classification and subsequently divided into two groups for analysis: those at high risk for DFU (Groups 1, 2, or 3) and those at low risk for DFU (Group 0). Logistic regression was employed to identify the factors associated with DFU risk and its components. Results: Among the 1361 patients evaluated, 63.8 % were found to be at an increased risk for DFU. The reported prevalence of foot deformities, LOPS, PAD, and a history of foot ulcer was 91.9 %, 44.3 %, 36.5 %, and 4.5 %, respectively. In the adjusted analysis, factors significantly associated with DFU risk included male gender (OR =2.01; 95 % IC 1.54–2.61), secondary education or less (OR =1.65, 95 % IC 1.27–2.14), diabetes duration exceeding 10 years (OR = 1.75, 95 % IC 1.34–2.30), chronic kidney disease (OR =1.44, 95 % IC 1.11 – 1.88), diabetic retinopathy (OR =1.93, 95 % IC 1.42–2.62), onychomycosis (OR =1.46, 95 % IC 1.14–1.88) properly cut toenails (OR =0.60, 95 % IC 0.45–0.79), and sedentary behavior (OR =1.56, 95 % IC 1.14–2.14). Conclusions: Risk assessment of DFU within a comprehensive care program for adults with T2D receiving conventional primary care showed that a substantial proportion of these patients are at an increased risk and, thus, qualify as candidates for interventions aimed at mitigating foot-related risks. We recommend that diabetes healthcare schemes incorporate preventive organizational interventions to facilitate the timely identification of DFU risk, particularly in primary care scenarios, thereby alleviating the burden of diabetes-related lower limb complications.

Keywords

• Amputation
• Diabetic complications
• Diabetic foot ulcer, diabetic neuropathy
• Health care services
• Peripheral arterial disease