The coronavirus disease of 2019 (COVID-19) pandemic has resulted in millions of infections and over 1 million deaths worldwide, but the toll of indirect effects of the pandemic are now being discovered. There have been an estimated 100,000 excess deaths in the United States since February 1, 2020.1 Excess deaths are those that are not related to COVID-19 but above the predicted number of deaths from all other causes. The World Health Organization surveyed 155 countries during May of 2020 and found that half of the countries had partially or completely disrupted services for diabetes and diabetes-related complications and warned of the pandemic’s global impact on noncommunicable diseases.2
In June of 2020, an editorial in The New England Journal of Medicine spoke of the “Untold toll [of the] pandemic’s effects on patients without [emphasis added] COVID-19.”3 Now, 4 months later, that toll is no longer untold, especially for patients with lower extremity complications of diabetes.
Early in the pandemic, the Alliance of Wound Care Stakeholders advised hospitals, policymakers, and governments not to close wound centers or delay necessary care to wound patients because it would result in an increase in infections, hospital admissions, emergency room visits, and amputations.4
In “A Tale of Two Cities,” Shin et al5 described the approaches to the diabetic foot at centers of excellence in Los Angeles and Manchester, United Kingdom. Both centers used telemedicine to reduce in-person contact with the health system, but the authors cautioned not to avoid necessary care. Appropriate triage was noted as a central necessity in the strategies to reduce severe diabetic foot infections and complications during epidemics to reduce amputation during epidemics.6 Rogers et al7 proposed the Pandemic Diabetic Foot Triage System, which helps determine the urgency and site needed for treatment. In the “Wound Center Without Walls,”8 Rogers et al later described strategies to reduce the COVID-19 exposure risk to the patient and still provide the best practices in wound care in lower risk settings.
Accompanying this editorial, Casciato et al9 report on the effect of the COVID-19 pandemic on those with diabetic foot problems in a Level I trauma center in Ohio. A comparison of patients admitted to the podiatric service before the pandemic versus during the pandemic found that those with diabetes were more likely to present with Infectious Diseases Society of America severe infections and more likely to present emergently. Patients with diabetes were 10.8 times more likely to undergo any level of amputation and 12.5 times more likely to receive a major amputation (transfemoral or transtibial) during the pandemic.
Three recent additional published reports found similar results in the United States and Europe. From Italy, Caruso et al10 found that patients admitted to the hospital in 2020 versus 2019 were more likely to be emergencies and have gangrene; the number of amputations doubled. From The Netherlands, Schuivens et al11 compared pandemic period data with those of 2018 and 2019. They found that, in 2020, patients presented with more severe peripheral arterial disease (scored by the Rutherford classification) and that there were three times the number of amputations versus 2019.11 In fact, there were more amputations performed in 2020 so far than in 2018 and 2019 combined. This is especially notable because The Netherlands has a strategy for team-based care that previously reduced diabetes-related amputations by 34% nationwide.12
From the United States, Lancaster et al13 compared prepandemic limb salvage service data in a university vascular practice from several affiliated hospitals with those of the “shelter-in-place” period. Using the wound, ischemia, and foot infection classification,14 they found a more severe presentation of patients during the pandemic, mostly because of increased severity of infections. The number of major amputations more than tripled during the pandemic and the high-to-low amputation ratio, a quality marker in limb salvage, more than doubled. All four reports note the pandemic’s negative effect on best practices in diabetic foot ulcer care resulting in delayed diagnosis and treatment. It is likely that patients’ reluctance and fear to seek medical care during this period created complications that resulted in these catastrophic results.
Amputations are not without their consequences either. Major limb loss affects quality of life and results in excessive costs to the health system. Major amputations are also associated with a 70% 5-year relative mortality rate.15 Best practices in diabetic foot care are both limb and life saving. We surmise that this increase in the rate of diabetes-related amputations will also contribute to the excess mortality resulting from the COVID-19 pandemic. The New England Journal of Medicine editorial cautioned us not to make “trade-offs [in care] we don’t have to make.” From these reports, it is clear that delays in care for diabetic foot ulcers have catastrophic effects. Increased awareness, proper prioritization, and efficiencies of care in lower risk settings are the first steps in mitigating this parallel pandemic of diabetes-related amputations.
Financial Disclosure: None reported.
Conflict of Interest: None reported.
References
- 1↑
Centers for Disease Control and Prevention: Excess deaths associated with COVID-19. Available at: https://www.cdc.gov/nchs/nvss/vsrr/covid19/excess_deaths.htm. Accessed October 10, 2020.
- 2↑
World Health Organization: COVID-19 significantly impacts health services for noncommunicable diseases. Available at: https://www.who.int/news-room/detail/01-06-2020-covid-19-significantly-impacts-health-services-for-noncommunicable-diseases. Accessed October 10, 2020.
- 3↑
Rosenbaum L: The untold toll—the pandemic’s effects on patients without Covid-19. N Engl J Med 382: 2368, 2020.
- 4↑
Alliance of Wound Care Stakeholders: Wound care is an essential—not elective—service that prevents hospital admissions and ED visits among a fragile cohort of patients at high-risk of COVID-19. 2020. Available at: https://www.woundcarestakeholders.org/images/Final2_Statement_-_Wound_Care_as_Essential.pdf. Accessed October 10, 2020.
- 5↑
Shin L, Bowling FL, Armstrong DG, et al.: Saving the diabetic foot during the COVID-19 pandemic: a tale of two cities. Diabetes Care 43: 1704, 2020.
- 6↑
Schmidt BM, Munson ME, Rothenberg GM, et al.: Strategies to reduce severe diabetic foot infections and complications during epidemics (STRIDE). J Diabetes Complications 34: 107691, 2020.
- 7↑
Rogers LC, Lavery LA, Joseph WS, et al.: All feet on deck—the role of podiatry during the COVID-19 pandemic. JAPMA [E-published online ahead of print March 25, 2020].
- 8↑
Rogers LC, Armstrong DG, Capotorto J, et al.: Wound center without walls: the new model of providing care during the COVID-19 pandemic. Wounds 32: 178, 2020.
- 9↑
Casciato DJ, Yancovitz S, Thompson J, et al.: Diabetes-related major and minor amputation risk increased during the COVID-19 pandemic. JAPMA 113: 2, 2023; doi:10.7547/20-224.
- 10↑
Caruso P, Longo M, Signoriello S, et al.: Diabetic foot problems during the COVID-19 pandemic in a tertiary care center: the emergency among the emergencies. Diabetes Care 43: e123, 2020.
- 11↑
Schuivens PME, Buijs M, Boonman-de Winter L, et al.: Impact of the COVID-19 lockdown strategy on vascular surgery practice: more major amputations than usual. Ann Vasc Surg 69: 74, 2020.
- 12↑
van Houtum WH, Rauwerda JA, Ruwaard D, et al.: Reduction in diabetes-related lower-extremity amputations in The Netherlands: 1991-2000. Diabetes Care 27: 1042, 2004.
- 13↑
Lancaster EM, Wu B, Iannuzzi J, et al.: Impact of the COVID-19 pandemic on an academic vascular practice and a multi-disciplinary limb preservation program. J Vasc Surg 72: 1850, 2020.
- 14↑
Conte MS, Mills JL, Bradbury AW, et al.: Implementing global chronic limb-threatening ischemia guidelines in clinical practice: utility of the Society for Vascular Surgery Threatened Limb Classification System (WIfI). J Vasc Surg 72: 1451, 2020.
- 15↑
Gök Ü, Selek Ö, Selek A, et al.: Survival evaluation of the patients with diabetic major lower-extremity amputations. Musculoskelet Surg 100: 145, 2016.
