title: Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes.
abstract: OBJECTIVE
  Diabetic foot ulcers are associated with an increased risk of death. We evaluated whether ulcer severity at presentation predicts mortality.
  
  
  METHODS
  Patients from a national, retrospective, cohort of veterans with type 2 diabetes who developed incident diabetic foot ulcers between January 1, 2006 and September 1, 2010, were followed until death or the end of the study period, January 1, 2012. Ulcers were characterized as early stage, osteomyelitis, or gangrene at presentation. Cox proportional hazard regression identified independent predictors of death, controlling for comorbidities, laboratory parameters, and healthcare utilization.
  
  
  RESULTS
  66,323 veterans were included in the cohort and followed for a mean of 27.7months: 1-, 2-, and 5-year survival rates were 80.80%, 69.01% and 28.64%, respectively. Compared to early stage ulcers, gangrene was associated with an increased risk of mortality (HR 1.70, 95% CI 1.57-1.83, p<0.001). The magnitude of this effect was greater than diagnosed vascular disease, i.e., coronary artery disease, peripheral arterial disease, or stroke.
  
  
  CONCLUSIONS
  Initial diabetic foot ulcer severity is a more significant predictor of subsequent mortality than coronary artery disease, peripheral arterial disease, or stroke. Unrecognized or under-estimated vascular disease and/or sepsis secondary to gangrene should be explored as possible causal explanations.
authors.affiliation: University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705; Edward Hines Jr. Veterans Hospital, 5000 S 5(th) Ave, Hines, IL 60141. Electronic address: mbbrennan@medicine.wisc.edu.
authors.forename: Meghan B
authors.initials: MB
authors.lastname: Brennan
authors.affiliation: University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Hess
authors.affiliation: Edward Hines Jr. Veterans Hospital, 5000 S 5(th) Ave, Hines, IL 60141.
authors.forename: Brian
authors.initials: B
authors.lastname: Bartle
authors.affiliation: University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL 60637.
authors.forename: Jennifer M
authors.initials: JM
authors.lastname: Cooper
authors.affiliation: William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Kang
authors.affiliation: Edward Hines Jr. Veterans Hospital, 5000 S 5(th) Ave, Hines, IL 60141; University of Chicago Medical Center, 5841 S Maryland Ave, Chicago, IL 60637.
authors.forename: Elbert S
authors.initials: ES
authors.lastname: Huang
authors.affiliation: University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705.
authors.forename: Maureen
authors.initials: M
authors.lastname: Smith
authors.affiliation: Edward Hines Jr. Veterans Hospital, 5000 S 5(th) Ave, Hines, IL 60141; University of Virginia School of Medicine, 1215 Lee St, Charlottesville, VA 22908.
authors.forename: Min-Woong
authors.initials: MW
authors.lastname: Sohn
authors.affiliation: University of Wisconsin School of Medicine and Public Health, 1685 Highland Ave, Madison, WI 53705; William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI 53705.
authors.forename: Christopher
authors.initials: C
authors.lastname: Crnich
mesh_terms: D000368:Aged; D015331:Cohort Studies; D003924:Diabetes Mellitus, Type 2 / Q000150:complications* / Q000401:mortality*; D017719:Diabetic Foot / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D057286:Electronic Health Records; D005260:Female; D005500:Follow-Up Studies; D005734:Gangrene / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010019:Osteomyelitis / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D014481:United States / Q000453:epidemiology; D014493:United States Department of Veterans Affairs; D058014:Veterans Health
keywords: Diabetes; Foot ulcer; Gangrene; Mortality; Vascular disease