â€” Shift to virtual care and prioritization of certain procedures key, researchers say
Despite delays in screening and care during the COVID-19 pandemic, there wasn't a spike in diabetes-related foot amputations, a Canadian study found.
In an analysis of nearly 1.5 million adults with diabetes living in Ontario, rates for nearly all diabetes-related services took quite a nosedive in 2020, noted Charles de Mestral, MDCM, PhD, of St. Michael's Hospital in Toronto, and colleagues.
HbA1c measures were also taken far less frequently during the pandemic, initially dropping to only 41% of the 2019 level, which later increased to 84% between the first and second COVID waves.
Following a similar pattern, rates of lower-extremity revascularization (open revascularization: RR 0.66, 95% CI 0.56-0.79; endovascular revascularization: RR 0.70, 95% CI 0.61-0.81) and minor amputation (RR 0.70, 95% CI 0.60-0.83) also seemed to rebound after taking an initial downturn during the first wave of the pandemic.
Despite the sweeping and significant declines in diabetes care during the first wave, amputation and death rates in 2020 were analogous to 2019. Specifically, the 50-week cumulative incidences of major amputation and death without major amputation for adults with diabetes were only 0.08% and 3.07%, respectively, in 2020 compared with 0.09% and 2.77%, respectively, in 2019.
So what explains this positive outcome in Ontario? The researchers noted that one factor that worked in their favor was how "hospital resources were not overburdened by patients with COVID-19 in the first wave of the pandemic." Therefore, hospital restrictions to care only lasted about 10 weeks early in the pandemic and weren't reinstated during the second wave.
"Second, invasive procedures necessary to treat limb-threatening complications of diabetes, such as toe or partial-foot amputations and revascularization, remained prioritized during care restrictions," de Mestral's group explained. They also pointed out that Ontario placed a large emphasis on maintaining capacity to evaluate urgent ambulatory presentations in person, including by wound care and surgical specialists.
The researchers also said early adoption of virtual care visits likely offset some of the gaps in diabetes care.
"The result of our analysis ... can be viewed as a positive outcome as governments sought to maintain essential health services during a time of unprecedented uncertainty," de Mestral and team wrote.
But as the pandemic continues to rage on, they suggested that providers and centers adopt a "multipronged prevention of diabetic foot complications," prioritizing periodic foot screening and footwear evaluation, glycemic management, cardiovascular and kidney disease risk factor management, and patient education. Some diabetic foot care prevention can also shift to virtual care, with remote wound monitoring and wearable technologies for self-assessment of pressure offloading, for example.