Burden of patients with foot disease in our hospitals

A new study, from DFAs Pete Lazzarini and colleagues, investigated the inpatient burden caused by foot-related conditions. The authors screened all patients in five carefully selected Queensland hospitals on one day, to find out how many had foot disease, foot trauma or another foot problem. An enormous undertaking, performed by a well-trained team. And an important undertaking, as such a prospective audit is more reliable than any retrospective chart review can ever be.

All this work essentially boils down to three numbers: 11.2% of the inpatients had a foot related condition, with this being the primary admission reason for 7.4%, and a secondary reason for 3.8%. This number is much higher compared to our previous thoughts, such as the 4.6% found in a recent systematic review. When extrapolated to Australia, this gives A$1.29 billion direct annual costs and a top 10 cause of hospital admission related to foot conditions, or A$350 million for diabetic foot disease alone.

Diabetes was only present in 2.0% (primary admission reason) and 2.6% (secondary admission reason), or 28% of the foot-related admissions. However, the authors do not present this as a proportion of the population with diabetes in the hospital on that specific day, which limits our interpretation in relation to other diabetic foot ulcer papers. Given that percentages are always relative numbers, it is likely that what this study finds is a great underestimation of non-diabetes related foot disease in previous studies. The well-known risk factors for diabetic foot disease (neuropathy, peripheral artery disease, foot deformity) are confirmed in this population inclusive of people without diabetes. Based on that, it could be argued that we might have to shift our attention to all people with neuropathy, rather than only those with diabetes, if we aim to prevent foot disease related hospitalizations.

The current study was a point-prevalent investigation, which has its strengths and limitations. As the true inpatient burden is largely determined by the number of bed days, rather than by presence on one specific day, it would be a helpful addition if a future study could take the bed days of people with (diabetic) foot disease included on the day of study into account. The average 13 days used in the current study to extrapolate findings is based primarily on diabetes related studies. As these patients generally present with more, and more severe, comorbidities, this could be an overestimation, especially with the 2.1% trauma-related inpatients where the trauma has likely occurred in younger and healthier patients. For patients with diabetic foot disease, however, it might be an underestimation of the true burden.

In conclusion, this is an important study, showing that the inpatient burden of foot disease and foot trauma in Australia is greater than previously thought. More attention for feet in inpatients, and greater efforts to prevent foot-related hospitalizations in people with neuropathy is needed to reduce this burden.