Foot Ulcer and Risk of LowerLimb Amputation or Death in People With Diabetes: A National Population-Based Retrospective Cohort Study

Rosemary C. Chamberlain, Kelly Fleetwood, Sarah H. Wild, Helen M. Colhoun, Robert S. Lindsay, John R. Petrie, Rory J. McCrimmon, Fraser Gibb, Sam Philip, Naveed Sattar, Brian Kennon, Graham P. Leese* (Corresponding Author)

*Corresponding author for this work

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31 Citations (Scopus)


OBJECTIVE To describe incidence of foot ulceration and amputation-free survival associated with foot ulceration status in a national population-based cohort study of people with diabetes. RESEARCH DESIGN AND METHODS The study population included 233,459 people with diabetes who were alive in Scotland on 1 January 2012 identified from the national population-based regis¬ter (national prevalence 4.9%). Characteristics of patients identified from linked hospital and mortality records during follow-up to the end of November 2017 were compared by outcome. Cox regression was used to assess the association between history of foot ulcer and amputation-free survival. RESULTS The population included 23,395 people with type 1 diabetes and 210,064 people with type 2 diabetes. In total there were 13,093 (5.6%) people who had a previ¬ous foot ulceration, 9,023 people who developed a first ulcer, 48,995 who died, and 2,866 who underwent minor or major amputation during follow-up. Overall incidence of first-time foot ulcers was 7.8 per 1,000 person-years (95% CI7.6-7.9) and 11.2 (11.0-11.4) for any ulcer. Risk factors for reduced amputation-free sur¬vival included social deprivation, mental illness, and being underweight in addi¬tion to conventional cardiovascular risk factors. Adjusted hazard ratios (95% CI) were 2.09 (1.89-2.31) for type 1 diabetes and 1.65 (1.60-1.70) for type 2 diabetes. CONCLUSIONS The overall incidence of foot ulceration in a population-based study of people with diabetes was 11.2 per 1,000 person-years. Foot ulceration is associated with lower amputation-free survival rate, a potential measure of effectiveness of care among people with diabetes. Mental illness and social deprivation are also highlighted as risk factors.

Original languageEnglish
Pages (from-to)83-91
Number of pages9
JournalDiabetes Care
Issue number1
Publication statusPublished - 1 Jan 2022

Bibliographical note

Funding Information:
Acknowledgments. These data were available for analysis by members of the Scottish Diabetes Research Network Epidemiology Group thanks to the hard work of numerous people and organizations (staff on each Health Board, the SCI-Diabetes Steering Group, the Scottish Diabetes Group, the Scottish Diabetes Survey Group, and the managed clinical networks managers and the staff at the Information Services Division of National Health Service [NHS] National Services Scotland) involved in providing data and setting up, maintaining, and overseeing SCI-Diabetes and other linked databases. The authors acknowledge the support of the Diabetes Epidemiology Group at the University of Edinburgh for managing research data. Funding. This study was funded by NHS Tayside research endowments. The authors acknowledge the financial support of NHS Research Scotland, through Diabetes Network, for data linkage. Duality of Interest. No potential conflicts of interest relevant to this article were reported. Author Contributions. R.C.C. and K.F. undertook the data curation and the formal analysis and helped write the manuscript. S.H.W. and G.P.L. designed the study, wrote the protocol, had overview of the analysis, were supervisors, and wrote the original manuscript. H.M.C., R.S.L., J.R.P., R.J.M., F.G., S.P., N.S., and B.K. were involved in the methodology, reviewed the study design, and contributed to the revision of the manuscript. G.P.L. is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.


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