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Profile of the patients with diabetic foot receiving care at the José Carneiro School Hospital and at the Armando Lages Emergency Unit
(Portuguese PDF version)

Guilherme Benjamim Brandão Pitta,¹ Aldemar Araújo Castro,² Alexandre Magno Macário Nunes Soares,³ Cícero do Juazeiro Job Maciel,³ João Domingos Montoni da Silva,³ Vládia Maria Torres Muniz,³ Selem Brandão Asmar,³

1. Physician. Associate professor, Department of Surgery, Universidade de Ciências da Saúde de Alagoas (UNCISAL). Vascular surgeon, Armando Lages Emergency Unit and José Carneiro School Hospital, Maceió, AL, Brazil.
2. M.Sc. Associate professor, Department of Social Medicine, Universidade de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil.
3. Medical student, Universidade de Ciências da Saúde de Alagoas (UNCISAL), Maceió, AL, Brazil.

Financial source: Program of Scientific Initiation of UNCISAL/Coordination of Research and Extension.

Correspondence:
Alexandre Magno Macário Nunes Soares
Rua Manoel Menezes, 411-A/301, Pinheiro
CEP 57055-690 - Maceió, AL, Brazil
Phone: +55 82 338.2775
E-mail: amagnos@bol.com.br

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ABSTRACT

Objective: To carry out an epidemiological study of patients with diabetic foot, considering their origin, socio-economic and cultural level, and the type of primary care..

Method: Descriptive, observational, and prospective study of a group of patients with necrotic and/or infectious injuries on lower limbs receiving care at the José Carneiro School Hospital and at the Armando Lages Emergency Unit.

Results: 614 patients were studied. Of these, 57.17% were male and 42.83% were female; 68.73% were between 61 and 80 years old; 51.47% did not live in Maceió; 90.55% were illiterate or semi-illiterate; 84.20% earned up to one minimum wage a month; 71.82% had received primary care, although only 11.07% of the care had been specialized. The prevailing surgical treatment was the amputation of toes (31.6%), followed by fore foot (22.64%) and leg (21.99%). The prevailing type of injury was the compound injury (57.49%), followed by the infectious injury (29.80%) and the ischemic injury (12.70%).

Conclusion: Most patients receiving care were not from Maceió, were illiterate or semi-illiterate, earned up to a minimum wage a month, and had received non-specialized primary care.

Key-words: diabetes mellitus, diabetic foot, epidemiology, amputation, public health.

J Vasc Br 2005;4(1):05

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Diabetes mellitus is a multiple syndrome, consequence of the lack of insulin and/or of the insulin inability to appropriately perform its effects.¹ The impact of the disease is frightening. There is a large association between the diabetes mellitus and the development of renal insufficiency, blindness, and cardiopathies.^2,3 Cardiovascular disease is still the main responsible for the reduction of life expectancy and disability in diabetic patients.^4,5

Diabetes mellitus is considered a public health problem due to its chronic character, and also because it is a disease that affects great proportions of the population.^5-8 Diabetes mellitus is currently one of the most important health problems, whether in terms of number of affected people, disability and mortality, or in terms of costs involved in the control and treatment of its complications.^1,2,7,^9,10

The diabetic foot is the infection, ulceration and/or destruction of deep tissues associated to neurological abnormalities and several degrees of the peripheral vascular disease on the lower limb.³,¹¹ It is characterized by the pathogeny of the complications in the foot of the patient with diabetes mellitus and results in the interaction of three factors: neuropathy, ischemia, and infection.³,¹¹ The complications in the diabetic foot occur frequently, being responsible for about 20% of hospitalizations of diabetic patients.^10,12-14 The diabetic foot causes considerable suffering, changes in the patient's lifestyle and quality of life, avoiding their normal functions and, finally, in some cases, it leads to amputation, with severe consequences.^8,10,11,^15,16 Among them, for instance, is the overload of the social welfare due to early retirement, loss of working abilities in a productive age group, high hospital costs for its treatment and rehabilitation.^7,10,12,¹⁷

Diabetes mellitus affects approximately 6.25% of the North-American population - nearly 16 million people.¹⁸ Moreover, data provided by the Pan American Health Organization show that there are about 30 million diabetics in the Americas.^13,19 It is estimated that there are more than 5 million diabetics in Brazil, half of them being unaware of the diagnosis.¹,²⁰ The great majority will only find out about the disease in case of a complication, often causing irreparable damage in the organism.¹,^20,21 The aging of the population has been aggravating the growing index of diabetic complications.¹⁹ This creates a higher probability of development of reduction of sensitiveness, reduction of peripheral circulation, and infection; such cases are aggravated if the disease is precariously controlled.³,^20,22,23 Such facts make diabetic patients particularly vulnerable to the severe problems of the foot and the leg.³,^20,22-24

Considering all the range of problems such disease can cause, we highlight those of a vasculonervous type.^15,16,²⁵ To have a more concrete idea, it is enough to cite that five out of six large limb amputations are performed in diabetic patients.¹¹,^26,28

Diabetic patients have a higher risk of undergoing amputations, about 15 to 40 times more than non-diabetics, and approximately 20% of amputated patients die within 2 years.^2,5,7,^10,11,15,^29,30 Due to the multiple complications and the disabling nature of diabetes mellitus, around 14% of the population affected is hospitalized annually, with an average of 6 weeks for each hospitalization.¹²,^26,29 Costs are estimated at about 200,000,000 dollars a year.⁷

The objective of our study is to build up an epidemiological profile of the patients with diabetic foot at the José Carneiro School Hospital and at the Armando Lages Emergency Unit, considering the origin of the patients, their socio-economic, cultural level, and the type of primary care received.

METHODS

The present study has been evaluated by the Research Ethics Committee at the University of Health Sciences of Alagoas/School of Medical Sciences (PP013), having been totally approved.

It is a descriptive, observational, transversal, and prospective study of a group of patients receiving care at the Armando Lages Emergency Unit and at the José Carneiro School Hospital from July, 2000 to June, 2003.

Patients with diabetes mellitus types I or II laboratory diagnosed, who presented necrotic and/or infectious injuries, primary or recurrent, on lower limbs were included, independent from gender, race, color, origin, or profession, in the period from July, 2000 to June, 2003.

Patients who did not agree with their participation, diabetic patients who did not present injuries on lower limbs, patients with necrotic and/or infectious injuries without diabetes mellitus types I or II, mentally disabled, and pregnant women were excluded from the research.

Primary variables included origin of patients, referring to the place of residence; socio-economic, cultural level, considering the family income and the education level; and primary care received before the approach of the institutions mentioned above. Secondary variables included gender; age group; type of primary care, considering the cases in which the patient received any type of prior care related to the issue being discussed and the nature of such care, if it resulted in a purely clinical, surgical or specialized care (podologist, angiologist/vascular surgeon, endocrinologist, orthopedist, neurologist); associated co-morbidities; type of injury; hospitalization period, and period of the diagnosed disease.

We used our own form for investigation and storage of the data. The patients or their legal representatives were informed about the importance of the study in terms of public health. The form was showed and explained, and patients were free to decide their participation. The patients' authorization was given in a document for previous acceptance.

Data obtained with clinical examination (anamnesis and physical examination) were introduced in our own study questionnaire and filed in a databank.

All data were explained in trust intervals, as well as the percentages, with a significance level of 95% and illustrated with tables.

RESULTS

After the data collection, a study universe of 614 patients was obtained. Of these, 57.17% (IC 95%, 53.3-61.1%) were male, and 42.83% (IC 95%, 38.9-46.7%) were female (Table 1). Concerning age group, 68.73% (IC 95%, 65-72.4%) of the studied sample was between 61 and 80 years old.

Table 1 - Distribution of patients with diabetic foot by gender at the José Carneiro School Hospital and at the Armando Lages Emergency Unit

Gender	n	%
Male	351	57.17
Female	263	42.83
Total	614	100

Concerning the origin of the patients, 48.53% (IC 95%, 44.6-52.5%) lived in Maceió, while 51.47% (IC 95%, 44.6-55.4%) came from other cities (Table 2). Distribution by education level showed that 90.55% (IC 95%, 88.2-92.8%) of the sample was composed of illiterate or semi-illiterate (Table 3). Regarding family income, 84.2% (IC 95%, 81.3-87.1%) earned up to a minimum wage a month (Table 4). Most patients, 71.8% (IC 95%, 68.24-75.36%), received primary care prior to the care given at these institutions (Table 5).

Table 2 - Distribution of patients with diabetic foot by origin at the José Carneiro School Hospital and at the Armando Lages Emergency Unit

Origin	n	%
Maceió	298	48.53
North Coast	112	18.24
South Coast	83	13.52
Countryside	54	8.8
Hinterland	53	8.63
Other locations	14	2.28
Total	614	100

 

Table 3 - Distribution of patients with diabetic foot by education level at the José Carneiro School Hospital and at the Armando Lages Emergency Unit

Education level	n	%
Illiterate	409	66.61
Semi-illiterate	147	23.94
Elementary School	50	8.14
High School	8	1.3
Total	614	100

 

Table 4 - Distribution of patients with diabetic foot by family income at the José Carneiro School Hospital and at the Armando Lages Emergency Unit

Income	n	%
Up to one minimum wage	517	84.20
From one to three minimum wages	74	12.05
Above three minimum wages	23	3.75
Total	614	100

 

Table 5 - Distribution of patients with diabetic foot according to primary care

	n	%
With care	441	71.82
Clinical	319	51.95
Specialized	68	11.07
Previous amputation	54	8.79
Without Care	173	28.18
Total	614	100

 

Concerning the type of primary care, 88.92% (IC 95%, 86.4-91.4%) did not receive specialized primary care, and 8.79% (IC 95%, 6.55-11.03%) of the patients had already undergone at least one surgical procedure to treat the problem being discussed (Table 5).

The surgical treatment most performed on the patients of this sample was the amputation of toe, with 31.6% of the cases (IC 95%, 27.9-35.3%), followed by amputation of fore foot, with 22.64% (IC 95%, 19.3-25.9%), and leg, with 21.99% (IC 95%, 18.6-25.2%) (Table 6).

Table 6 - Distribution of patients with diabetic foot according to surgical treatment

	n	%
Amputation of toe	194	31.60
Amputation of fore foot	139	22.64
Amputation of leg	135	21.99
Amputation of thigh	114	18.57
Debridement	30	4.89
Graft	2	0.33
Total	614	100

 

The type of injury most found was the combined injury (ischemic associated to infections), with 57.49% (IC 95%, 53.5-61.3%) of the analyzed cases.

Among co-morbidities found, the most frequent was the arterial hypertension, with 50.81% (IC 95%, 46.8-54.75%).

The period of hospitalization had a higher incidence between 7 to 15 days, with 49.19% (IC 95%, 45.1-53.05%).

Concerning the time of disease evolution, 63.03% (IC 95%, 59.2-66.82%) of the patients showed en evolution higher than 10 years.

DISCUSSION

Injuries on lower limbs of diabetic patients constitute a major problem of public health, since they are frequent in the diabetic population of low socio-economic level, with inappropriate hygiene conditions and little access to health services.^10,12,16,^20,23 When patients seek medical service, the injuries are usually in advanced stages, requiring surgical treatment, which many times makes them incapable of performing routine activities.²² Moreover, the treatment of these injuries requires long periods of hospitalization in specialized services, and the use of expensive antibiotics.^6,12

The origin of the patients reflects the inability of certain locations to handle this problem. This sample is composed by people from poor regions, without access to a qualified health system. The absence of qualified personnel for the early diagnosis and the follow-up is also part of this reality. Besides, there is a limited ability to assimilate information by these patients, since most of them have a low socio-economic, cultural level.⁵,²³,³¹ Precarious hygiene conditions also contribute to the lack of control of the disease. Data obtained with our study show that these patients have been receiving primary care that is not enough or efficient for the proposed objective, despite the adequate primary care being the most efficient form of combating the problem.^2,3,5,8,^20,22

In the present study, a significant variation between genders was not observed. Several studies have shown that there is no correlation between gender and diabetes mellitus.^6,7,¹⁴,²³,³¹ A study involving different departments has been performed in Brazil and it has also shown the weak relation between gender and diabetes mellitus.³² However, other studies showed some significant differences between genders. It was observed in some studies that male is the most frequent gender.^5,11,¹²,¹,²⁹ On the other hand, in other studies female was the most frequent gender.¹⁰,²⁷ Therefore, the predominance of one of the genders has not been showed yet.

The most frequent age group was between 61 and 80 years old, with time of disease evolution above 10 years. Prior studies showed the insidious evolution of diabetes mellitus^5,11,^12,14,^23,27,^31,33 and confirmed its chronic character.

Specialized care had a restrict access, justified by the non-existence and/or the few number of health professionals specialized in this disease.

Due to the severity of the cases found, the treatment for most patients was the amputation. Such procedure is practically seen as routine in complications and bad evolution of diabetic foot.^11,12,14,²³,³¹ A few studies showed that cares and prevention are still the best treatment for the diabetic foot^3,5,8,^15,21-23,^34-36 and if this is done, the disease's impairments, if present, have a lower intensity.^7,8,^34-36 According to the International Consensus on the Diabetic Foot, made by the International Working Group on the Diabetic Foot, the amputation rates can be reduced in 50%, with a reduction of 20% to 40% in the direct cost of approach to feet ulcers, if strategies are implemented, such as regular inspection of feet and shoes during the patient's clinic visits, preventive treatment to the feet of patients with a high risk foot, that is, chiropody, cares with shoes, education, multifactorial and multidisciplinary approach of established injuries, early diagnosis of the peripheral vascular disease, continuous follow-up of patients with previous feet ulcers and record of amputations and ulcers. Therefore, awareness of the problem of diabetic foot will have the benefit of public expenditure reduction, which can represent an improvement on the care of the diabetic patient and the improvement on their quality of life.¹⁵

The type of injury most found was that in which there was an association between ischemia and infection. Such datum is commented in the literature and in our environment, and justified by the low hygiene conditions to which most patients are submitted.^37,38

Co-morbidities like hypertension, cerebral vascular accident, obesity, diabetic nephropathy and diabetic retinopathy were also found, reflecting the chronic and multisystemic character of diabetes mellitus.^7,11,12,14,^23,29,³¹

The hospitalization period met our expectations, once the literature affirms that this pathology occupies hospital beds for a period above the predicted average, also contributing to the increase of financial overload of health services.^6,9,11,12,^27-29

CONCLUSION

The profile of diabetic foot patients receiving care in the two institutions in Maceió (State of Alagoas, Brazil) where the research took place was of patients with a low socio-economic, cultural level who had access to a non-specialized primary care in other locations of our State and also in other States. Although most patients had combined ischemic and infectious alterations, very few had any type of vascular restoration. The prevailing treatment in the origin locations was constituted by smaller and larger amputations. Such facts show the need for actions and educational campaigns along with the physicians of basic health units, aiming at preserving the extremities of this population.

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