The online version of this article (doi:10.1186/s12933-017-0524-8) contains supplementary material, which is available to authorized users.
Patients with diabetes concomitant to critical limb ischemia (CLI) represent a sub-group at particular risk. Objective of this analysis is to evaluate the actual impact of diabetes on treatment, outcome, and costs in a real-world scenario in Germany.
We obtained routine-data on 15,332 patients with CLI with tissue loss from the largest German health insurance, BARMER GEK from 2009 to 2011, including a follow-up until 2013. Patient data were analyzed regarding co-diagnosis with diabetes with respect to risk profiles, treatment strategy, in-hospital and long-term outcome including costs.
Diabetic patients received less overall revascularizations in Rutherford grades 5 and 6 (Rutherford grade 5: 45.0 vs. 55.5%; Rutherford grade 6: 46.5 vs. 51.8; p < 0.001) and less vascular surgery (Rutherford grade 5: 13.4 vs. 23.4; Rutherford grade 6: 19.7 vs. 29.6; p < 0.001), however more often endovascular revascularization in Rutherford grade 6 (31.0 vs. 28.1; p = 0.004) compared to non-diabetic patients. Diabetes was associated with a higher observed ratio of infections (35.3 vs. 23.5% Rutherford grade 5; 44.3 vs. 27.4% Rutherford grade 6; p < 0.001) and in-hospital amputations (13.0 vs. 7.3% Rutherford grade 5; 47.5 vs. 36.7% Ruth6; p < 0.001). Diabetes further increased the risk for amputation during follow-up [Rutherford grade 5: HR 1.51 (1.38–1.67); Rutherford grade 6: HR 1.33 (1.25–1.41); p < 0.001], but not for death.
Diabetes increases markedly the risk of amputation attended by higher costs in CLI patients with tissue loss (OR 1.67 at Rutherford 5, OR 1.53 at Rutherford 6; p < 0.001), but is associated with lower revascularizations. However, in Rutherford grades 5 and 6, concomitant diabetes does not further worsen the overall poor survival.
Additional file 1: Table S1. ICD- and OPS codes of diagnoses and procedures.
Additional file 2: Table S2. Impact of Choice of Variables in multivariate Cox regression models on the potential “protective”role of diabetes on long-term Mortality.
Additional file 3: Figure S1. In-hospital complications in patients with vs. without diabetes at Rutherford grade 5 and 6. Complication rates for infection, sepsis, in-hospital amputation, and in-hospital death in patients at Rutherford grade 5 (panel A) and Rutherford grade 6 (panel B) are given as percentages among patient sub-groups with diabetes (DM; orange bars) and without (grey bars). Differences between DM and non-DM sub-groups are considered significant for p-values < 0.05.
Additional file 4: Table S3. Binary Logistic Regression Analysis of In-hospital Outcomes.
Additional file 5: Figure S2. Costing analysis related to Rutherford grade and diabetes status. Costs per case are given in EURO for the in-hospital period (bottom dark bars) and subsequent in-patient costs (upper light bars) in diabetic (DM; orange) and non-DM patients (grey) related to Rutherford grades. Data show about equal in-hospital costs for patients with and without diabetes at the same Rutherford grade, but increased subsequent in-patient costs in patients with DM compared to non-DM CLI patients. Costs are increasing with increasing Rutherford grade.
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- Impact of diabetes on outcome in critical limb ischemia with tissue loss: a large-scaled routine data analysis
Nasser M. Malyar
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