Background and aims: A national lockdown for COVID-19 (March 14th – May 3rd 2020) placed restrictions on the free movement of persons and allowed only urgent medical consultations and interventions in hospitals. On the other hand, diabetic foot clinics (DFCs) were advised by the professional associations to consider all active diabetic foot problem as urgent. The aim of the study was to assess the impact of these restrictions on the presentation rate and severity of diabetic foot ulcers (DFU) at presentation in Belgian DFCs.
Materials and methods: A multicentre, prospective cohort study was done among 22 recognized DFCs in Belgium in the context of an ongoing biennial national initiative for care quality improvement (IQED-Foot). A survey asked which measures DFCs took during and after the lockdown to maintain their activities. Between January 1st and September 30th, patient and ulcer characteristics were recorded for 887 consecutive patients with DFUs of Wagner 2 or higher. Based on the date of presentation in the DFC, patients were assigned to the pre-lockdown group (A, first contact between January 1st and March 13th, n = 322) or the (post-)lockdown group (B, first contact between March 14th and September 30th, n = 565). Groups were compared with each other. Inclusion rate was compared to data from the IQED-Foot survey of 2018.
Results: During the lockdown, one DFC was closed, all others remained open for active foot problems, applying specific COVID-19 measures. Reported measures included selection of patients based on urgency and ulceration risk (71%), reduced frequency of consultations (54%) while switching to telemedicine by phone or mail (79%) and spreading patients in time and space to guarantee physical distancing (50%). In the lockdown period, the rate of patients presenting in the DFCs was strongly reduced (0.6 vs. 1.4 patients/week/DFC in 2018; p < 0.001). No differences in demographic data such as age, gender, diabetes type and duration were observed between both groups. Patients seen during and after lockdown had less frequently a history of prior DFU (B: 50% vs. A: 60%; p = 0.0047). No increase in median patient-reported presentation delay [P25 - P75] was observed (A: 3 [1-8] vs. B: 3 [1-7] weeks; p = 0.8076). Patients with a first contact during or after lockdown presented with slightly larger DFU (< 1cm2 B: 32% vs. A: 38%; p = 0.0003, 1-3 cm2 B: 45% vs. A: 40%; p = 0.0152). They also had less frequently critical ischemia (B: 11% vs. A: 18%; p = 0.0103). No significant differences in depth, infection or loss of protective sensation were detected between both groups.
Conclusion: Presentation rate was strongly reduced in Belgian DFCs during the lockdown period. Thanks to great efforts of the DFCs to remain accessible to patients with active foot problems, the presentation delay did not increase and the impact of the lockdown on the severity of the DFU at presentation was limited to slightly larger wounds. Currently, treatment and outcome data of these patients are being collected and will be available by time of the EASD meeting.
