Timing of access to secondary healthcare services and lower extremity amputations in patients with diabetes: a case-control study.
OBJECTIVE
To investigate the association between timing of patient access to secondary healthcare services for diabetes management and lower extremity amputation (LEA) among patients with diabetes.


METHODS
A case-control study was conducted in the secondary healthcare system in Ireland. Cases were 116 patients with diabetes who underwent a first major non-traumatic LEA between 2006 and 2012. Controls were 348 patients with diabetes, over 45 years, admitted to the same hospital as an emergency or electively, frequency-matched for gender, type of diabetes, and year. Data were collected for 7 years prior to the event year. ORs for LEA in patients with diabetes comparing early versus late referral from primary to secondary healthcare were calculated.


RESULTS
Statistically significant risk factors associated with LEA in patients with diabetes included being single, chronic kidney disease, hypertension, and hyperglycemia. Documented retinopathy was a significant protective factor. In unconditional logistic regression analysis adjusted for potential confounders, there was no evidence of a reduced risk of LEA among patients referred earlier to secondary healthcare for diabetes management.


CONCLUSIONS
Specialist referral may need to occur earlier than the 7-year cut-off used to demonstrate an effect on reducing LEA risk. Documented retinopathy was associated with reduced risk of LEA, most likely as a proxy for better self-care. Variation in the management of diabetes in primary care may also be impacting on outcomes. Efforts to develop more integrated care between primary and secondary services may be beneficial, rather than focusing on timing of referral to secondary healthcare.
Department of General Practice , University College Cork , Cork , Ireland ; Department of Epidemiology and Public Health , University College Cork , Cork , Ireland.
Claire M
CM
Buckley
Department of Endocrinology , University Hospital Waterford , Waterford , Ireland.
Fauzi
F
Ali
Department of Endocrinology , University Hospital Waterford , Waterford , Ireland.
Graham A
GA
Roberts
Department of Epidemiology and Public Health , University College Cork , Cork , Ireland.
Patricia M
PM
Kearney
Department of Epidemiology and Public Health , University College Cork , Cork , Ireland.
Ivan J
IJ
Perry
Department of General Practice , University College Cork , Cork , Ireland.
Colin P
CP
Bradley
Access to Care; Epidemiology; Health Service Delivery; Health Service Research