medwireNews: People with diabetic foot ulcers (DFUs) who live in areas with a high level of deprivation may be more likely to require major amputation than those living in less deprived areas, suggest findings from a French cohort study.
Jean-Baptiste Bonnet (Hôpital Lapeyronie, Montpellier) used the French National Health Data System to evaluate amputation data from 15,507 individuals in the Languedoc-Roussillon administrative area with any type of diabetes who experienced a first DFU between 2015 and 2017. These people were aged an average of 70 years, 55% were men, and 20% required hospitalization.
In all, 253 major amputations (at the mid-foot or above) occurred within 1 year of ulcer onset, giving an overall rate of 17.5 per 1000 person–years.
When people were categorized according to neighborhood deprivation as measured by the fDep index, amputation rates were highest for those in the two most deprived quartiles, at 17.0–18.0 per 1000 person–years, and decreased to 8.0 per 1000 person–years for those in the least deprived quartile. People in the lowest quartile for deprivation had a significant 54% lower risk for amputation than those in the highest quartile. Rates of DFU – calculated using the total population of the region – were not substantially different across quartiles, ranging from 1.8 per 1000 person–years for the least deprived group to 2.4 per 1000 person–years for the most deprived group.
In addition, the team found that neighborhoods around major cities and coastal areas “seemed to have better prognoses regarding amputation.” Analysis of healthcare provider density maps showed that amputation rates according to healthcare access were likely to be higher in rural areas on the periphery of the area studied, and that low accessibility to private-practice nurses, but not general practitioners, was significantly associated with increased amputation rates.
These findings suggest that “nurse accessibility might be a key strategic point for DFU medical care,” write Bonnet et al in Diabetes Care.
In contrast to their amputation results, the researchers found no significant associations between socioeconomic deprivation and mortality rates. The death rate in the overall study population was 117.0 per 1000 person–years, and rates were not significantly different across quartiles of deprivation.
They say that “several hypotheses may explain” these discordant findings, including different risk factors for amputation and mortality, and “delayed or suboptimal care” for DFUs “due to the lack of a multidisciplinary approach or material resources.”
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Diabet Med 2022; doi:10.1111/dme.14820