title: A diabetic foot service established by a department of vascular surgery: an observational study.
abstract: BACKGROUND
  The mechanism by which the multidisciplinary approach to diabetic foot disease reduces amputation rates is unclear. Ischemia, sepsis, and necrosis represent aspects of severe diabetic foot disease amenable to intervention. In 2006, a vascular unit introduced a rapid access service for severe foot disease, augmenting the established community provision. This study aimed to determine whether concurrent changes in amputation rates were observed, and to identify areas that may have influenced outcomes.
  
  
  METHODS
  Unit data prospectively collected during 4 years for patients with lower-limb disease were compared with data retrieved over 2 years before the foot service. Outcome measurements were major amputations, foot surgery, vascular interventions, admissions, and length of stay.
  
  
  RESULTS
  Major amputation rates associated with diabetes peaked in 2005 at 24.7/10,000 vs. 1.07/10,000 in 2009; (relative risk = 0.043, 95% confidence interval = 0.006-0.322). The proportion of diabetic to nondiabetic amputations decreased; foot surgery rates also dropped (53.7/10,000 in 2006 vs. 7.5/10,000 in 2009). The number of open revascularization procedures decreased, but the rates of endovascular procedures remained generally constant. Hospital admission rates decreased after initially peaking, and the length of stay was unchanged (16 vs. 15.5 days in 2004 and 2009, respectively).
  
  
  CONCLUSIONS
  The integration of a vascular unit with community care has been associated with improved outcomes for patients with diabetic foot disease. Improvements were not related to the increased number of vascular procedures or hospitalizations, but did coincide with a greater proportion of patients attending the foot unit. The referral of patients to the unit facilitates the rapid management of severe disease, reducing delays deleterious to outcomes.
authors.affiliation: Department of Vascular Surgery, Ysbyty Gwynedd Hospital, Bangor, Gwynedd, UK. dean.williams2@wales.nhs.uk
authors.forename: Dean T
authors.initials: DT
authors.lastname: Williams
authors.forename: Muhammad U
authors.initials: MU
authors.lastname: Majeed
authors.forename: Guy
authors.initials: G
authors.lastname: Shingler
authors.forename: Mohammed J
authors.initials: MJ
authors.lastname: Akbar
authors.forename: Diane G
authors.initials: DG
authors.lastname: Adamson
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Whitaker
mesh_terms: D000671:Amputation, Surgical; D016009:Chi-Square Distribution; D003299:Cooperative Behavior; D019033:Delivery of Health Care, Integrated / Q000458:organization & administration; D017719:Diabetic Foot / Q000175:diagnosis / Q000628:therapy*; D006297:Health Services Accessibility / Q000458:organization & administration; D006302:Health Services Research; D006767:Hospitals, District / Q000458:organization & administration*; D006769:Hospitals, General / Q000458:organization & administration*; D006801:Humans; D007902:Length of Stay; D023821:Limb Salvage; D016015:Logistic Models; D017146:Models, Organizational; D010043:Outcome and Process Assessment, Health Care / Q000458:organization & administration*; D010044:Outpatient Clinics, Hospital / Q000458:organization & administration*; D010343:Patient Admission; D010348:Patient Care Team / Q000458:organization & administration*; D011446:Prospective Studies; D012017:Referral and Consultation / Q000458:organization & administration; D018570:Risk Assessment; D012307:Risk Factors; D013222:State Medicine / Q000458:organization & administration*; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000458:organization & administration*; D014852:Wales