Study Details Impact of Deferred Care During Pandemic on Amputations in Patients with Diabetes

A population-based cohort study from investigators in Canada is shedding light on the potential impact of deferred care among patients with diabetes on risk of acute foot complications during the COVID-19 pandemic.

An analysis of more than 1.4 million adult patients with diabetes, results of the study demonstrate excess leg amputations were not observed among people with diabetes during the first 11 months of the COVID-19 pandemic despite fewer in-person assessments and restrictions to scheduled hospital-based procedures.

“This analysis found that the COVID-19 pandemic was not associated with additional limb loss for people living with diabetes. However, as we emerge from the pandemic, ongoing efforts to strengthen comprehensive diabetes care, including foot screening as well as improving access to interdisciplinary limb salvage expertise, remain critical to maintain these positive results,” wrote investigators.

Although patients with diabetes face the possibility of multiple serious complications as a result of the disease, limb amputation poses a significant threat to the quality of life of patients. As more and more studies have examined the impact of deferred treatment or visits during the pandemic, a team of investigators from Canada sought to assess whether deferred visits, stay-at-home orders, and other byproducts of the pandemic may have impacted the rate of diabetes-related foot complications and amputations.

To do so, investigators designed their study as a population-based cohort study of all adult residents in Ontario, Canada with diabetes with the intent of comparing rates of selected outcomes from January 1, 2020-February 23, 2021 versus January 1, 2019-February 23, 2020. Outcomes of interest for the study included major amputation and 7 related diabetes care and outcomes measures, including comprehensive in-person diabetes care assessment, HbA1c measurements, emergency department visit for diabetic foot ulceration, osteomyelitis, or gangrene, hospitalization for a diabetic foot ulceration, osteomyelitis, or gangrene, minor amputation, endovascular lower extremity revascularization, and open surgical lower extremity revascularization. The investigators’ planned to assess the rates and rate ratios for each outcome measure in 10-week periods, with anchoring relative to onset of the pandemic on March 11, 2020.

On March 11, 2020, the study included 1,448,605 adults with diabetes. These patients had a median age of 65 (IQR, 55-74) years and 52.2% were men. On March 11, 2019, the study included 1,441,029 adults with diabetes. These patients had a median age of 65 (IQR, 55-74) years and 52.1% were men.

Upon analysis, results suggested rates of major amputation in 2020-2021 decreased compared with 2019-2020 levels. During the prepandemic period from January 1-March 10 the RR for amputations was 1.05 (95% CI, 0.88-1.25) compared to 0.86 (95% CI, 0.72-1.03) from May 20-July 28 and 0.95 (95% CI, 0.80-1.13) from October 7-December 15. Additionally, investigators pointed out there were no consistent differences observed for demographic characteristics or comorbidities of patients who underwent amputation in the prep anemic and pandemic periods.

Further analysis indicated rates of comprehensive in-person diabetes care assessment and HbA1c measurements fell during the pandemic period and remained below the 2019-2020 levels. In contrast, rates of emergency department visits, hospitalization, open revascularization, endovascular revascularization, and minor amputation initially dropped during the pandemic period but recovered to 2019-2020 levels during the duration of the study period.

“As we emerge from a third severe wave of COVID-19 and some jurisdictions are facing additional waves, we must remain vigilant about the potential long-term consequences of the pandemic on the risk of diabetic foot complications and limb loss,” investigators wrote.

This study, “A Population-Based Analysis of Diabetes-Related Care Measures, Foot Complications, and Amputation During the COVID-19 Pandemic in Ontario, Canada,” was published in JAMA Network Open.