title: Impact of health-care accessibility and social deprivation on diabetes related foot disease.
abstract: OBJECTIVE
  To determine whether geography and/or social deprivation influences the occurrence of foot ulcers or amputations in patients with diabetes.
  
  
  METHODS
  A population-based cohort of people with diabetes (n = 15 983) were identified between 2004 and 2006. Community and hospital data on diabetes care, podiatry care and onset of ulceration and amputation was linked using a unique patient identifier, which is used for all patient contacts with health-care professionals. Postcode was used to calculate social deprivation and distances to general practice and hospital care.
  
  
  RESULTS
  Over 3 years' follow-up 670 patients with diabetes developed new foot ulcers (42 per 1000) and 99 proceeded to amputation (6 per 1000). The most deprived quintile had a 1.7-fold (95% CI 1.2-2.3) increased risk of developing a foot ulcer. Distance from general practitioner or hospital clinic and lack of attendance at community retinal screening did not predict foot ulceration or amputation. Previous ulcer (OR 15.1, 95% CI 11.6-19.6), insulin use (OR 2.7, 95% CI 2.1-3.5), absent foot pulses (5.9: 4.7-7.5) and impaired monofilament sensation (OR 6.5, 95% CI 5.0-8.4) all predicted foot ulceration. Previous foot ulcer, absent pulses and impaired monofilaments also predicted amputation.
  
  
  CONCLUSIONS
  Social deprivation is an important factor, especially for the development of foot ulcers. Geographical aspects such as accessibility to the general practitioner or hospital clinic are not associated with foot ulceration or amputation in this large UK cohort study.
authors.affiliation: Department of Diabetes, Ninewells Hospital and Medical School, Dundee, UK. grahamleese@nhs.net
authors.forename: G P
authors.initials: GP
authors.lastname: Leese
authors.forename: Z
authors.initials: Z
authors.lastname: Feng
authors.forename: R M
authors.initials: RM
authors.lastname: Leese
authors.forename: C
authors.initials: C
authors.lastname: Dibben
authors.forename: A
authors.initials: A
authors.lastname: Emslie-Smith
mesh_terms: D000671:Amputation, Surgical / Q000706:statistics & numerical data; D015331:Cohort Studies; D003922:Diabetes Mellitus, Type 1 / Q000453:epidemiology / Q000628:therapy*; D003924:Diabetes Mellitus, Type 2 / Q000453:epidemiology / Q000628:therapy*; D017719:Diabetic Foot / Q000453:epidemiology / Q000628:therapy*; D005194:Family Practice / Q000706:statistics & numerical data; D005260:Female; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054624:Health Status Disparities; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data; D011032:Podiatry / Q000706:statistics & numerical data; D012111:Residence Characteristics / Q000706:statistics & numerical data; D012606:Scotland / Q000453:epidemiology; D061665:Time-to-Treatment