Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes

J Diabetes Complications. 2017 Mar;31(3):556-561. doi: 10.1016/j.jdiacomp.2016.11.020. Epub 2016 Dec 10.


Aim: 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.

Conclusion: 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.

Keywords: Diabetes; Foot ulcer; Gangrene; Mortality; Vascular disease.

MeSH terms

  • Aged
  • Cohort Studies
  • Diabetes Mellitus, Type 2 / complications*
  • Diabetes Mellitus, Type 2 / mortality*
  • Diabetic Foot / complications
  • Diabetic Foot / diagnosis*
  • Diabetic Foot / mortality
  • Diabetic Foot / physiopathology
  • Electronic Health Records
  • Female
  • Follow-Up Studies
  • Gangrene / complications
  • Gangrene / diagnosis*
  • Gangrene / mortality
  • Gangrene / physiopathology
  • Humans
  • Male
  • Middle Aged
  • Osteomyelitis / complications
  • Osteomyelitis / diagnosis*
  • Osteomyelitis / mortality
  • Osteomyelitis / physiopathology
  • Prognosis
  • Proportional Hazards Models
  • Retrospective Studies
  • Severity of Illness Index
  • Survival Analysis
  • United States / epidemiology
  • United States Department of Veterans Affairs
  • Veterans Health*