Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: A retrospective cohort study

PLoS One. 2017 May 12;12(5):e0177176. doi: 10.1371/journal.pone.0177176. eCollection 2017.


Objectives: To investigate whether A) duration of ulcer before start of treatment in specialist health care, and B) severity of ulcer according to University of Texas classification system (UT) at start of treatment (baseline), are independent predictors of healing time.

Methods: This retrospective cohort study, based on electronic medical record data, included 105 patients from two outpatient clinics in Western Norway with a new diabetic foot ulcer during 2009-2011. The associations of duration of ulcer and ulcer severity with healing time were assessed using cumulative incidence curves and subdistribution hazard ratio estimated using competing risk regression with adjustment for potential confounders.

Results: Of the 105 participants, 45.7% achieved ulcer healing, 36.2% underwent amputations, 9.5% died before ulcer healing and 8.5% were lost to follow-up. Patients who were referred to specialist health care by a general practitioner ≥ 52 days after ulcer onset had a 58% (SHR 0.42, CI 0.18-0.98) decreased healing rate compared to patients who were referred earlier, in the adjusted model. High severity (grade 2/3, stage C/D) according to the UT classification system was associated with a decreased healing rate compared to low severity (grade1, stage A/B or grade 2, stage A) with SHR (95% CI) equal to 0.14 (0.05-0.43) after adjustment for referral time and other potential confounders.

Conclusion: Early detection and referral by both the patient and general practitioner are crucial for optimal foot ulcer healing. Ulcer grade and severity are also important predictors for healing time, and early screening to assess the severity and initiation of prompt treatment is important.

MeSH terms

  • Aged
  • Aged, 80 and over
  • Amputation, Surgical
  • Diabetic Foot / pathology*
  • Diabetic Foot / surgery
  • Female
  • Foot Ulcer / pathology*
  • Foot Ulcer / surgery
  • Humans
  • Incidence
  • Male
  • Middle Aged
  • Proportional Hazards Models
  • Retrospective Studies
  • Risk Factors
  • Time Factors
  • Wound Healing / physiology*

Grant support

This work was supported from the Norwegian Research Council, project number 221065. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.