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Meta-Analysis
. 2021 Jun;58(6):735-747.
doi: 10.1007/s00592-020-01662-x. Epub 2021 Feb 6.

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis

Bernardo Meza-Torres  1   2 , Fabrizio Carinci  3   4 , Christian Heiss  3   5 , Mark Joy  6 , Simon de Lusignan  6
Affiliations
Meta-Analysis

Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis

Bernardo Meza-Torres et al. Acta Diabetol. 2021 Jun.

Abstract

Aims: Despite the evidence available on the epidemiology of diabetic foot ulcers and associated complications, it is not clear how specific organizational aspects of health care systems can positively affect their clinical trajectory. We aim to evaluate the impact of organizational aspects of care on lower extremity amputation rates among people with type 2 diabetes affected by foot ulcers.

Methods: We conducted a systematic review of the scientific literature published between 1999 and 2019, using the following key terms as search criteria: people with type 2 diabetes, diagnosed with diabetic foot ulcer, treated with specific processes and care pathways, and LEA as primary outcome. Overall results were reported as pooled odds ratios and 95% confidence intervals obtained using fixed and random effects models.

Results: A total of 57 studies were found eligible, highlighting the following arrangements: dedicated teams, care pathways and protocols, multidisciplinary teams, and combined interventions. Among them, seven studies qualified for a meta-analysis. According to the random effects model, interventions including any of the four arrangements were associated with a 29% reduced risk of any type of lower extremity amputation (OR = 0.71; 95% CI 0.52-0.96). The effect was larger when focusing on major LEAs alone, leading to a 48% risk reduction (OR = 0.52; 95% CI 0.30-0.91).

Conclusions: Specific organizational arrangements including multidisciplinary teams and care pathways can prevent half of the amputations in people with diabetes and foot ulcers. Further studies using standardized criteria are needed to investigate the cost-effectiveness to facilitate wider implementation of improved organizational arrangements. Similarly, research should identify specific roadblocks to translating evidence into action. These may be structures and processes at the health system level, e.g. availability of professionals with the right skillset, reimbursement mechanisms, and clear organizational intervention implementation guidelines.

Keywords: Diabetic foot ulcers; Health service organization; Lower extremity amputation; Type 2 diabetes.

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Conflict of interest statement

Dr. Heiss reports research grants from the University of Surrey and the Economic and Social Research Council (ES/V00980X/1) outside the submitted work.

Figures

Fig. 1
Fig. 1
Diagram of selection of eligible studies
Fig. 2
Fig. 2
Forest plot of quantitative meta-analysis of eligible studies
Fig. 3
Fig. 3
Publication bias funnel plots
See this image and copyright information in PMC

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