Foot Ulcer and Risk of Lower Limb 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 (Lead / Corresponding author)

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19 Citations (Scopus)
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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 register (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 previous 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 survival included social deprivation, mental illness, and being underweight in addition 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
Early online date15 Nov 2021
Publication statusPublished - 1 Jan 2022

ASJC Scopus subject areas

  • Advanced and Specialised Nursing
  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism


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