Effects of the COVID-19 Pandemic on the Management of Diabetic Foot Ulcers: Experiences From a Dedicated Diabetic Foot Care Center

Novel coronavirus (2019-nCoV, or COVID-19) is among the gravest health catastrophes in recent decades and has had devastating consequences for humans worldwide.¹ The COVID-19 viral pandemic, which is believed to have first occurred in humans near the end of 2019 and quickly spread across the world, was first recorded in Turkey on March 11, 2020. Since March 16, 2020, the Turkish government has implemented precautions and lockdown measures.² Health care authorities have aimed to reduce the transmission rate to alleviate the increased burden on the health care system. The pandemic has caused millions of deaths globally and resulted in transient and permanent adverse health-related conditions. The most significant negative effects of the pandemic on the health care system were the delay in health care services resulting from the increased workload at hospitals, and the spread of the virus among health care professionals. Additionally, many patients have been hesitant to seek professional medical advice because of the high risk of COVID-19 transmission at high-volume medical centers.

An important issue in treating patients with diabetic foot ulcers (DFUs) is lack of access to state-of-the-art, dedicated diabetic foot centers staffed by health care professionals who specialize in such care; few such facilities exist. Insufficient treatment inevitably leads to amputation in patients with DFU, mostly among those with concomitant chronic diseases and nonhealing wounds.³

This retrospective study evaluates the effects of the COVID-19 pandemic on the management of patients with DFU and highlights the experiences of a tertiary diabetic foot center.

After receiving approval from the Ethics Committee of the Hitit University School of Medicine (number 331/14.07.2020), the data from patients hospitalized at the authors’ diabetic foot clinic were retrospectively obtained from the hospital information system. Patients were categorized into 2 groups. The study group consisted of patients hospitalized between March 11, 2020, and June 11, 2020, which marked the first 3 months of the COVID-19 pandemic in Turkey. The control group consisted of patients hospitalized during the same period in 2019, before the pandemic.

Demographic data, length of hospital stay, Wagner grade of DFU, comorbidities, laboratory parameters, wound duration, duration of diabetes, and treatments applied were recorded. The authors’ hospital is in Çorum province, which is located in the Central Anatolia region of Turkey, and accepts patients mostly from neighboring cities within a radius of 150 km (Yozgat, 136 km; Amasya, 95 km; and Kırıkkale, 152 km). However, this institution is also a referral center in Turkey; thus, a considerable number of patients also present from more distant cities located in the north of the country, such as Trabzon (534 km) and Samsun (292 km), as well as from southern cities, including Kayseri (234 km), Adana (494 km), and Mersin (519 km), and also western cities such as Kocaeli (508 km). Patients’ place of permanent residence was also noted.

Statistical analysis was performed using the Pearson chi-square test, Mann-Whitney U test, and t test to determine the differences between the pandemic period (2020) and the prepandemic period (2019). A statistical significance value of P less than .05 was used for this study.

During the 2 study periods, 72 patients were hospitalized at the authors’ diabetic foot clinic—46 during the prepandemic period (2019) and 26 during the pandemic period (2020). Each patient hospitalized during the pandemic as well as the patient’s companion were tested for COVID-19 using the polymerase chain reaction test, and none was positive for the virus. There was no difference between the 2 groups concerning sex, age, and comorbidities at presentation (Table 1). Among the patients who presented to the hospital during the non-COVID period, 39.1% lived in neighboring cities and 34.8% lived in distant cities (> 300 km from the hospital); these rates significantly decreased to 15.4% and 7.7%, respectively, during the pandemic period (P <.001).

Analysis of time between the onset of DFU and hospital admission showed that a lower percentage of patients were admitted to the diabetic foot center in the early stage of their DFU at the pandemic compared with the prepandemic period (Table 1). Whereas in the prepandemic period, 2 of 6 patients (33.3%) and 3 of 11 patients (27.3%) with acute exacerbation of DFU were admitted within 14 days and 21 days, respectively, during the pandemic period, the 1 patient with acute exacerbation of DFU (100%) and 4 of 5 patients with acute exacerbation of DFU (80%) were admitted within 14 days and 21 days, respectively.

The mean duration of diabetes was similar between the 2 groups (Table 2). The mean C-reactive protein and blood glucose levels were also similar between the 2 groups. However, the hemoglobin (Hb) A1c level was significantly higher in the pandemic group. Furthermore, according to the Wagner classification of DFU, patients who presented to the hospital during the pandemic period had significantly worse conditions than those in the prepandemic group who presented to the hospital.

During the pandemic period, the rate of patients undergoing debridement alone significantly decreased and the rate of amputation significantly increased (P =.008) (Table 3). After removing the patients who underwent grafting, the rate of amputation was significantly higher in the pandemic group than in the nonpandemic group (71.4% vs. 34.1%, respectively; P =.005). There was no significant difference between the 2 groups in length of hospital stay, and there was no mortality in either group.

On March 16, 2020, the Turkish government began implementing strict lockdowns nationwide to minimize the spread of the COVID-19 infection. Worldwide, lockdowns have been implemented in an attempt to prevent people from convening in common and public places, with the goal of decreasing face-to-face contact and preventing the spread of airborne virus transmission.⁴ Turkey is known to have a good hospital capacity to manage routine health care load; however, in Turkey as in many other countries, the pandemic substantially increased the number of patients requiring care, resulting in insufficiencies in the provision of health care services.^5,6 Thus, preventive measures and lockdowns have also aimed to decrease the workload at health care centers.

During the initial peak of the pandemic, almost all elective surgical procedures were postponed, and priority was given to emergencies and oncologic cases. Hospitalized patients had no difficulty accessing medical consultation, but the limited number of medical staff available created problems for outpatients. Most wards were converted to COVID-19 clinics, which limited bed availability, and medical staff were reassigned to the newly formed COVID-19 clinics and began to work shifts to cover all days of the week. Consequent to the decreased number of outpatients, diagnostic imaging became much easier and mostly did not require an appointment; however, patients were hesitant to undergo examination in closed spaces.

Although there was no restriction to receiving medical care in hospitals and outpatient clinics during the pandemic period, this study showed that fewer patients were admitted to the diabetic foot clinic during the pandemic. In the prepandemic period, most patients treated at the authors’ clinic were referrals from distant and neighboring cities, but at the beginning of the pandemic. there was a significant decrease in the number of admissions from distant and neighboring cities (75% prepandemic to ~20% pandemic). The authors think that the fear of contracting the virus and the restrictions on intercity travel resulted in fewer patients presenting from distant cities. This finding suggests that patients refrain from referring to advanced health care facilities to receive medical support even at the risk of worsening their disease. This fear has led to detrimental consequences for patients with DFU. It has been reported that fewer patients without comorbidities have sought medical support during the COVID-19 pandemic.^3,6 In the current study, it was also determined that this hesitancy about seeking professional medical advice was more common among patients with 2 or more comorbidities than among patients with 1 comorbidity.

In this study, the results showed patients with DFUs presented to the hospital at a later stage in the wound healing process during the pandemic period compared with such patients before the pandemic period. This resulted in more acute exacerbations and more surgical interventions in the pandemic period. To prevent the delayed presentation of patients with DFU, alternative consultation methods should be offered, such as video consultations and the sharing of photographs with doctors or nurses. Such practices can help identify patients who require hospitalization. For cases suitable for outpatient treatment, home nursing should be considered. In addition, rather than prescribing modalities that require daily visits, wound care products should be provided to ensure proper wound care and decrease the frequency of dressing changes.

Lockdowns have also restricted the travel of elderly patients and decreased their daily activities.⁴ Although public authorities have used televised programs to inform the public about the importance of engaging in physical exercises at home, they were not as effective as initially thought and then physical activity decreased. In the current study, patients’ HbA1c level was found to be significantly higher during the pandemic period compared with the prepandemic period. Limited physical exercise and hesitancy about visiting high-volume hospitals for routine medical tests have led to higher uncontrolled blood glucose levels, resulting in worsened overall health status, including diabetes-related complications.

Another important outcome of COVID-19 is the stage of DFU among patients presenting to the hospital during the pandemic. Before the pandemic, the authors frequently treated patients with Wagner grade 2 and 3 DFU and rarely encountered patients with Wagner grade 4 DFU. Though the patients who presented to the hospital during the pandemic period had more advanced stages of the disease. As explained previously, this finding is also related to patients’ attempts to manage their early-stage foot ulcers at home. This delay in seeking professional medical advice for proper treatment resulted in necrotic, gangrenous wounds with a foul odor, which eventually led patients to visit a hospital, albeit reluctantly.

Delayed presentations with advanced stages of DFU have also caused a significant increase in the rate of amputation during the pandemic.⁷ In the current study, 63% of patients in the prepandemic group underwent debridement alone, compared with 23.1% of patients in the pandemic group. The rate of amputations performed in the authors’ diabetic foot center significantly increased from 34.1% during the prepandemic period to 71.4% during the pandemic period (P =.005). The detrimental effects of amputation on patients and their relatives and the physical, psychological, social, medical, and economic consequences of amputation are well known.⁷ When all the consequences of amputations are considered, the effects of the COVID-19 pandemic on patients with diabetes can be better understood. The findings reported in this study suggest that home restrictions resulting from lockdowns, fear of contracting the virus at high-volume hospitals with referral diabetic foot clinics in Turkey, and restrictions on intercity travel contributed to advanced stages of DFU and a higher amputation rate among patients in the pandemic period.

This study is limited because it is retrospective in nature and includes a limited number of patients.

The fear of contracting COVID-19 has resulted in patients with DFU delaying hospital visits, unaware of the risk of worsening their wounds with resultant detrimental consequences, including amputation. Despite the restrictions and lockdowns implemented to decrease the spread of COVID-19, patients should be encouraged to seek advanced medical advice and treatment for real emergencies. Technological tools, such as video consultations and/or sharing of photographs, should be used in health care centers to identify patients who require close follow-up. In addition, in-home care should be offered and/or supported. Every effort should be made to make wound care products available for patients to use at home. Although restrictions and lockdowns have been implemented to prevent the spread of COVID-19, because patients with DFU are at risk of amputation and associated consequences, they should be encouraged to seek specialized medical advice while following precautions such as wearing a mask, maintaining physical distance, and following hygiene practices.