2 research outputs found
A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration
Objectives Patients presenting with chronic limb threatening ischaemia (CLTI) and diabetic foot
ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern
exists regarding late presentation and delayed management contributing to increased
amputation rates. Despite multiple guidelines existing on the management of both conditions,
there is currently no accepted timeframe in which to enact specialist care and treatment. This
systematic review aims to investigate potential time delays in the identification, referral and
management of both CLTI and DFU. Methods A systematic review, conforming to the Preferred Reporting Items for Systematic Review of
Meta-Analysis (PRISMA) statement standards, was performed searching MEDLINE, Embase,
The Cochrane Library and CINAHL from inception to 14 13 th November 2018. All English
language qualitative and quantitative articles investigating or reporting the identification,
causes and outcomes of time delays within ‘high income’ countries (annual gross domestic
product per person >$15,000) were included. Data were extracted independently by the
investigators. Given the clinical cross-over, both conditions were investigated together. A study
protocol was designed and registered at the International Prospective Register of Systematic
Reviews (PROSPERO) (registration number: CRD42018115286). Results A total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and
1,388 healthcare professionals were included. Twenty-three articles focussed predominantly
on DFU. Considerable heterogeneity was noted and only 12 articles were deemed of high
quality. Only 4 articles defined a ‘delay’ however this was not consistent between studies.
Median times from symptom onset to specialist healthcare assessment ranged from 15 to 126
days with subsequent median times from assessment to treatment ranging from 1 to 91 days.
A number of patient and healthcare factors were consistently reported as potentially causative
including, poor patient symptom recognition, inaccurate healthcare assessment and difficulties
in accessing specialist services. Twenty articles reported outcomes of delays, namely rates of
major amputation, ulcer healing and all-cause mortality. Although results were heterogeneous,
they elude to delays being associated with detrimental outcomes for patients.
Conclusions Time delays exist in all aspects of the management pathway, which are in some cases
considerable in length. The causes of these are complex but reflect poor patient health-seeking
behaviours, inaccurate healthcare assessment and barriers to referral and treatment within the
care pathway. The adoption of standardised limits for referral and treatment times, exploration
of missed opportunities for diagnosis and investigation of novel strategies for providing
specialist care are required to help reduce delays.</div
Leg Ischaemia Management collaboration (LIMb): study protocol for a prospective cohort study at a single UK centre
Introduction
Severe limb ischaemia (SLI) is the end-stage of peripheral arterial occlusive disease where
the viability of the limb is threatened. Around 25% of patients with SLI will ultimately
require a major lower limb amputation which has a substantial adverse impact on quality of
life. A newly established rapid-access vascular limb salvage clinic and modern
revascularisation techniques may reduce amputation rate. The aim of this study is to
investigate the 12-month amputation rate in a contemporary cohort of patients and
compare this to a historical cohort. Secondary aims are to investigate the use of frailty and
cognitive assessments, and cardiac MRI in risk-stratifying patients with SLI undergoing
intervention and establish a biobank for future biomarker analyses.
Methods & analysis
This single-centre prospective cohort study will recruit patients aged 18-110 years
presenting with SLI. Those undergoing intervention will be eligible to undergo additional
venepuncture (for biomarker analysis) and/or cardiac MRI. Those aged ≥65 years and
undergoing intervention will also be eligible to undergo additional frailty and cognitive
assessments. Follow-up will be at 12 and 24 months and subsequently via data-linkage with
NHS digital to 10 years post-recruitment. Those undergoing cardiac MRI and/or frailty
assessments will receive additional follow-up during the first 12 months to investigate for
peri-operative myocardial infarction and frailty related outcomes, respectively. A sample
size of 420 patients will be required to detect a 10% reduction in amputation rate in
comparison to a similar sized historical cohort, with 90% power and 5% type-I error rate.
Statistical analysis of this comparison will be by adjusted and unadjusted logistic regression
analyses.
Ethics & dissemination
Ethical approval for this study has been granted by the UK National Research Ethics Service
(19/LO/0132). Results will be disseminated to participants, via scientific meetings, peerreviewed medical journals and social media.
Study registration
ClinicalTrials.gov [NCT04027244