Volume 24 Number 1
Foot-related conditions in hospitalised populations: a literature review
Peter A Lazzarini, Sheree E Hurn, Suzanne S Kuys, Maarten C Kamp and Lloyd Reed
Keywords Foot, conditions, wounds, infections, risk factors.
Abstract
Background: No reviews have investigated foot-related conditions prevalence in hospitalised populations. This literature review reports foot-related conditions (foot wounds, foot infections, amputations, other) and foot risk factors (peripheral arterial disease [PAD], peripheral neuropathy [PN], foot deformity) prevalence in representative or specific hospitalised populations.
Methods: Electronic databases were searched for publications between 1980 and 2011. Keywords and synonyms relating to foot-related conditions, foot risk factors, inpatients and prevalence were used. Studies reporting any foot-related conditions or foot risk factor prevalence in representative or specific hospitalised populations were included, and data were extracted.
Results: Of 3,297 records identified, 141 studies were included; 27 in representative and 114 in specific inpatients. Foot wound prevalence was: 0.9–8.3% in representative and 0.1-96.4% in specific inpatients; foot infection: 0.1–1.1% in representative inpatients; amputation: 0.1–1.5% in representative, 0.2–82.5% in specific inpatients; PAD: 2.1–25.0% in representative, 9.0–72.0 in specific inpatients; and PN: 0.2–100% in specific inpatients.
Conclusions: This review suggests foot wounds are the main foot-related condition in hospitalised populations. Indications are up to 25% of representative inpatients have a foot risk factor for a foot wound, up to 8% have a foot wound and up to 1.5% an amputation. These rates were higher in specific inpatients, particularly inpatients with chronic disease and major trauma.
Background
Foot-related conditions appear to be present in many hospitalised patients and may result in amputation1-5. Leading causes of foot-related condition hospitalisation include foot trauma and foot disease disorders such as foot wounds, foot infections and other severe foot-related conditions such as ischaemia1-6. These foot disease disorders are typically precipitated by common foot risk factors, such as peripheral arterial disease (PAD), peripheral neuropathy (PN), and foot deformity1-4.
Much literature investigating foot-related conditions in hospital has been focused on inpatient groups with specific conditions. Diabetes is frequently acknowledged as the specific condition that is associated with most foot-related hospitalisations1-4,6 and has been reported to account for up to 5% of total hospital bed days used in Australia1,2,7. Other specific chronic diseases have also been shown to cause foot-related hospitalisation, including chronic kidney disease8-10, cardiovascular disease11-13, cancer14,15 and arthritis16,17. Furthermore, other specific conditions, such as trauma4,18,19, infections20,21 and hospital-acquired complications5,22 have been reported to cause foot-related hospitalisation.
Although foot-related conditions and foot risk factors appear to be present in a substantial proportion of hospitalised patients, prevalence estimates across representative and specific inpatient groups has not been ascertained. Without this information it is difficult for clinicians, researchers and policy makers to understand the overall burden of foot-related hospitalisation. This literature review aimed to search, review and tabulate the existing literature reporting prevalence of foot-related conditions (foot wounds, foot infections, other foot-related conditions and amputations) and foot risk factors (PAD, PN and foot deformity) in representative or specific hospitalised populations.
Methods
Data sources
Electronic databases (Medline, Embase, and CINAHL) were searched for all publications between 1980 and 2011 discussing prevalence of foot-related conditions and foot risk factors in hospitalised inpatient populations. Broad keywords and synonyms were used combining: foot-related conditions or foot risk factors, inpatients and prevalence. The search strategy is displayed in Figure 1.
Figure 1: Literature review full search syntax used for electronic databases
Study selection
Figure 2 displays the PRISMA flow diagram of the search used. All titles and abstracts retrieved were scanned by the first author (PAL) using an overarching initial screening question: Does the article appear to discuss prevalence of major foot-related conditions or foot risk factors within populations staying overnight in hospital? The full text was sought if the article appeared to address the screening question and was electronically available.
Figure 2: Literature review search results
As this was a narrative literature review, the inclusion eligibility criteria were quite broad. Studies were eligible for inclusion if published in a peer-reviewed journal and referred to the prevalence or number of any foot-related conditions or foot risk factors (the numerator) in a defined inpatient population (the denominator). The numerator of foot-related conditions (foot wound, foot infection, amputation or other foot-related conditions such as ischaemia, Charcot, malignancy or fracture) or foot risk factors (PAD, PN or foot deformity) were defined as listing the foot-related condition or foot risk factor concerned (or a synonym) in the study. The inpatient population denominator could have been either a representative or specific inpatient population. Representative inpatient populations were defined as those that incorporated the diverse range of people hospitalised in the majority of wards of a typical hospital. Specific inpatient populations were a subgroup of inpatients with the same specific medical condition, such as those with diabetes or affected by trauma. Exclusion criteria included case studies, literature reviews, validity or reliability studies; studies investigating populations of primarily children, outpatients or day elective surgery patients; and studies reporting prevalence or incidence in populations other than inpatient populations (for example, amputation procedures per 100,000 general population). The eligibility assessment was undertaken by the first author (PAL) to determine final study inclusion.
Papers that met the inclusion criteria were reviewed and grouped into representative or specific inpatient populations. No formal quality assessment was performed as part of this literature review. Data extracted and tabulated included sample size, age (mean or median), gender, study design and foot-related conditions or foot risk factors prevalence.
Statistical analysis
Descriptive statistics were reported on included studies. If only numbers were reported, these were converted to a prevalence proportion using the ratio of the number of individuals with the foot-related condition or foot risk factor variables (numerator) and the number of the total sample size of the study (denominator).
Results
Search results
Figure 2 displays the results of the literature review search strategy. Database searches yielded a total of 3,297 unique records, of which 540 relevant records were identified for detailed evaluation. Of these, 290 full texts were sourced electronically for evaluation and the remaining 250 could only be evaluated by title and abstract (conference papers, non-English papers or full text unavailable electronically). After evaluation of the 540 records, 141 satisfied the inclusion criteria and were included in this review.
Study characteristics
Table 1 summarises the 141 included studies grouped according to study inpatient population (representative or specific), while individual study characteristics are outlined in Tables 2–7. Study characteristics varied considerably in terms of inpatient population, sample size, demographics, study design and the foot-related condition or foot risk factor outcome investigated. Sample sizes varied from 15 to 57 million. There were a large range of average ages (22–79 years) and proportion of males investigated (23–100%). Ninety-three studies (66%) were retrospective, employing medical record audits or hospital discharge database analysis, whilst 48 (34%) were prospective audits using clinical examinations or self-reported questionnaires. One hundred and seven studies were published after the year 2000, 23 in the 1990s and 11 in the 1980s. Lastly, studies were conducted across the world, including 39 in Europe, 31 in Africa, 28 in Asia, 25 in North America, eight in the Middle East, eight in Australasia and two in South America.
Table 1: Summary characteristics of 141 included studies grouped by representative or specific inpatient population
k = Study numbers; n: numbers in study; % prevalence; +Age range from the median or mean age of different studies; ^Prospective study design includes prospective longitudinal and cross-sectional studies; ++Other is either malignancy, combination of injuries or hand-foot-syndrome, unless otherwise specified (refer to Tables 2–7 for further details); *Foot deformity; - Not reported; Amp: Amputations; Inf: Infection; PAD: Peripheral arterial disease; PN: Peripheral neuropathy.
Included studies reported different foot-related conditions and foot risk factors in a wide variety of representative and specific inpatient populations. Twenty-seven studies investigated a representative inpatient population; including five studies investigating foot-related conditions in representative inpatients, 16 investigating only diabetes-related foot conditions in representative inpatients and six investigating foot-related conditions in representative geriatric inpatient populations (Table 2). The other 114 studies investigated a specific inpatient population; including 38 in diabetes (Table 3), 21 other chronic disease (Table 4), 28 trauma-related (Table 5), 29 infection-related (Table 6) and seven in other specific populations (Table 7).
Table 2: Characteristics of studies reporting foot disease and foot risk factors in representative inpatients
Amp: Amputations; Deform: Foot deformity; Inf: Infection; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy; % prevalence; +Median or mean age of sample; - Not reported; *Osteomyelitis only; ** Pressure ulcers only; *** New foot ulcers only; ^ Necrotising fasciitis only; ^^ Case-control study; # non-diabetes inpatients; ## diabetes inpatients; ^^^ Includes history of past ulcers.
Table 3: Characteristics of studies reporting foot disease and foot risk factors in diabetes-specific inpatients
Amp: Amputations; Deform: Foot deformity; Inf: Infection; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy;% prevalence; +Median or mean age of sample; - Not reported; * Includes history of past ulcers; ** New foot ulcers only; ^^ High risk foot (past ulcer or amputation); ^^^ At risk foot risk (PAD or PN); # Foot wounds only.
Table 4: Characteristics of studies reporting foot disease and foot risk factors in other chronic disease-specific inpatients
Amp: Amputations; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy; % prevalence; +Median or mean age of sample; ++ Other is a malignancy or cancer located on the foot unless otherwise specified; - Not reported; *Median of 44 German vascular depts; ** Evaluated from mean yearly figures over 12 years); ^ Foot deformity only; ^^ Palmer erythema only; #Acral sarcoma; ##Hand-foot syndrome located on foot
Table 5: Characteristics of studies reporting foot disease and foot risk factors in trauma-related specific inpatients
Amp: Amputations; Inf: Infection; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy; % prevalence; +Median or mean age of sample; ++ Other is a combination of injuries located on the foot; - Not reported; ^Age range rather than mean age given.
Table 6: Characteristics of studies reporting foot disease and foot risk factors in infection-related specific inpatients
Amp: Amputations; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy; % prevalence; +Median or mean age of sample; - Not reported; * Methicillin-resistant Staphylococcus aureus
Table 7: Characteristics of studies reporting foot disease and foot risk factors in other specific inpatients
Amp: Amputations; Deform: Foot deformity; n: Numbers; PAD: Peripheral arterial disease; PN: Peripheral neuropathy; % prevalence; +Median or mean age of sample; - Not reported;
*PN symptoms
Prevalence of foot-related conditions and foot risk factors
Table 1 summarises the prevalence ranges from all 141 included studies for foot wounds, foot infections, other foot-related conditions, amputations, PAD, PN and foot deformity in representative and different specific inpatient populations. Data extracted from individual studies is presented in Tables 2–7. Foot wound prevalence ranged from: 0.9–8.3% in representative inpatients, 0.6–15.0% in geriatric, 5.0–53.0% in diabetes, 7.2–59.8% in other chronic diseases, 0.1–96.4 in different trauma-related and 2.9–93.8% in different infection-related specific inpatients. Foot infection prevalence ranged from: 0.1–1.1% in representative inpatients and 0.3–93.8% in different infection-related specific inpatients. Other foot-related condition prevalence ranged from: 0.01–52.0% in other chronic disease and 2.8–97.9% in trauma-related specific inpatients. Amputations occurred in 0.1–1.5% of representative inpatients, 0.4–7.0% geriatric, 0.6–8.6% diabetes, 0.4–28.9% other chronic disease, 0.2–82.5% trauma-related inpatients, 7.8–27.8% in infection-related specific inpatients. PAD prevalence ranged from: 2.1–25.0% in representative inpatients, 1.9–19.2% in geriatric, 19.0–45.7% in diabetes and 12.0–72.0% in trauma-related specific inpatients. PN prevalence ranged from: 25.8–26.0% in geriatric inpatients, 12.4–81.2% in diabetes, 0.3–17.0% in trauma-related, 25.0–46.0 in infection-related and 45.9–100% in other, mainly neurological specific inpatients. Lastly, foot deformity prevalence ranged from: 43.0–50.0% in geriatric inpatients, 20.0–70.0% arthritis and 6.9–56.6% in the other mainly neurological-specific inpatients.
Discussion
This literature review suggests that no study has yet investigated the overall prevalence of foot-related conditions and foot risk factors within a representative inpatient population. Overall, a very broad range of different specific conditions appeared to be associated with foot-related conditions in inpatient populations. Diabetes had by far the largest volume of specific inpatient literature in this foot-related hospitalisation area; yet, multiple studies also investigated other chronic disease, trauma-related, infection-related and other neurological-related specific inpatients for foot–related condition prevalence. All these specific inpatient populations appeared to be associated with a higher prevalence of foot-related conditions or foot risk factors than the average representative inpatient population, indicating these specific conditions may be the leading causes of major foot-related conditions in representative inpatient populations. Foot wounds were the most investigated foot-related condition and were present in approximately 1–8% of representative inpatients, rising to 5–53% in diabetes, 7–60% in other chronic diseases and 0–96% of those inpatients affected by trauma. Foot risk factors were present in up to 25% of representative inpatients and up to 100% of specific inpatient populations. The vast majority of studies identified from this review investigated specific inpatient populations, were retrospective in design and most studies did not appear to investigate the foot-related condition or foot risk factor as the primary outcome of the study. However, as this was a narrative review, it is recommended that a more robust systematic review be performed to systematically identify all literature in the area, the quality of this literature and determine pooled prevalence estimates to more precisely determine the prevalence of foot-related conditions present in inpatient populations.
No study identified in this review investigated a range of foot-related conditions and foot risk factors within a representative inpatient population. Four studies investigated an individual foot-related condition in a representative inpatient population18,20-22. Two studies reported a foot wound prevalence of 2.7%22 and 5.4%5, whilst the other two studies retrospectively investigated large national hospital discharge datasets reporting foot infection represented by an osteomyelitis prevalence of 0.1%20 and a 0.4% necrotising fasciitis prevalence21. Arguably, the closest study to report the prevalence of a range of foot-related conditions and foot risk factors across the broadest cross-section of adult inpatient populations identified by this review was a US study by Reed and colleagues6. This 2004 study retrospectively interrogated a large national discharge dataset in two evenly matched random samples of patients aged 80 years or older to determine foot disease disorder and foot risk factor prevalence for representative geriatric patients discharged with diabetes and without diabetes6. The authors specifically analysed the dataset for codes representing foot ulcers, abscesses, infections, osteomyelitis, PAD and amputation6. A 3.1% prevalence of any foot disease was reported in geriatric inpatients with diabetes and 1.3% for geriatric inpatients without diabetes6. The foot risk factor of PAD was additionally reported in 3.2% of inpatients with diabetes and 1.9% of non-diabetes inpatients6. Individual foot disease disorder prevalence was different for diabetes and non-diabetes inpatients, including foot ulcers (1.7% vs 0.6%), foot infection (0.04% vs 0.02%), osteomyelitis (0.6% vs 0.2%) and amputation (1.7% v 0.4%)6. Overall, the authors concluded that diabetes “in the octogenarian patient imposes an additive risk for [foot] complications”6. However, this study relied entirely on retrospective hospital discharge data. The accuracy of such data capture for specific foot disease disorders and foot risk factors has previously been queried150. This was evident when comparing the very low reporting of PAD in this retrospective study (1.9–3.2%)6 compared to prospective studies reporting PAD in representative inpatients included in this review (11–34%)23,42. Nevertheless, this study is arguably the most complete of the identified studies in this review.
The main foot-related condition reported in inpatient populations was foot wounds. Foot wound prevalence from this review ranged from 0.9–8.3% in representative inpatients37,38 and 0.6–15% in geriatric inpatients6,42. Diabetes-related foot wounds appeared to make up the majority of these reported foot wounds37,38. The higher diabetes-related foot wound prevalence rates (2.7–8.3%) were reported in developing countries34-37, whilst lower rates (1–1.7%) were reported in developed countries29,30,38, with some studies reporting up to 4.9% of representative inpatients had either a current or past diabetes-related foot wound7,31. Interestingly, an interrogation of the studies in developed countries reporting both diabetes and foot wound prevalence in representative inpatients indicates approximately 14–23% of representative inpatients have diabetes7,26,31 and of those foot wounds are present in 11–16%49,50,53,72. These ranges suggest a perhaps more plausible diabetes-related foot wound prevalence of 1.5–3.7% in representative inpatients. In general, diabetes contributed to the largest proportion of foot wound admissions identified from studies in this review6,50. Interestingly, a retrospective US study suggested that diabetes-related foot wounds made up approximately 81% of all foot wound admissions50. Meanwhile, a large pressure ulcer study indicated that pressure ulcers on the foot contributed up to 5% of representative inpatient admissions5. Furthermore, foot wounds were consistently reported to have long lengths of hospitalisation (7–60 days)24,25,27,31,33,35-38, thus potentially inflating this prevalence rate for an analysis of inpatient occupied hospital bed days; although a recent retrospective Irish study reported around 1% of beds were used for diabetes-related foot wound management38.
Most amputations were reported to result in people with a preceding foot wound from the studies included in this review6,27,28,30,35-37,49,50,53. With the exception of a few outliers, amputations appeared to occur in 12–38% of diabetes-related foot wound admissions, or contribute to approximately 0.1–1.5% of representative inpatient admissions in developed countries27,28,30,35-37. Interestingly, amputations in patients admitted with vascular disease also appeared to occur in 10–30% of cases11,12. Most diabetes-related amputations seemed to be the result of severe infection or osteomyelitis of a foot wound6; thus it seems plausible that study results reported in this review had similar amputation6,27,28,30 and osteomyelitis6,20,21,25 prevalence rates as a proportion of total representative inpatient admissions.
The major foot risk factors for foot disease are PAD, peripheral neuropathy and foot deformity2,3,8,9. PAD in this review was present in approximately 11–46% of prospectively examined inpatient populations depending on the underlying specific condition11,23,39,71; the highest prevalence occurred in inpatients with diabetes and kidney disease78,79. Peripheral neuropathy was also highly prevalent in diabetes inpatients (12–81%)39,42,56,60,63,69,73,75,77 and inpatients with other neurological conditions (46–100%), including Guillain-Barre syndrome and Friedreich’s ataxia143,144,148. Interestingly, in one study, PN was reported to be highly prevalent in dementia inpatients; however, this study did state that eliciting a clinical response to neurological testing may have had limitations in this population147. Foot deformity was highly prevalent in geriatric inpatients and those with other neurological conditions. Although foot deformity criteria did differ in most studies, prevalence rates were around 43–50% in geriatric inpatients41,43, 20–70% in arthritic conditions16,17,94 and around 50% of other neurological conditions143,144,148.
Apart from diabetes, other specific conditions that appeared to cause higher prevalence of foot-related conditions and foot risk factors in inpatients identified from this review included cancer14,15,82,85,88, cardiovascular disease11,12,91, arthritis16,17,94, trauma19,101,105,116,117,122, infection126,132,134,142 and different neurological conditions143,144,148. However, studies investigating these specific conditions were extremely heterogeneous, in terms of the populations and foot-related conditions studied, sample sizes, and quality of methodology. Foot-related conditions and foot risk factors seem to be involved in similar proportions of each specific condition’s inpatient population. For example, cancers located on the foot contributed to around 0.4–3.0% of all bone cancers, sarcoma and melanoma admissions15,82,85, excluding studies with small samples and one historical African study conducted over 25 years ago suggesting an 8.4% prevalence14. Furthermore, hand-foot-syndrome, a hospital-acquired complication of chemotherapy in cancer inpatients, was present in 2–13.9% of those particular inpatients88,90. Lastly, the prevalence of foot trauma admissions seemed to contribute to 2.8–6.3% of admissions caused by the overall trauma investigated, such as replantation of severed body parts, motorbike accidents and high fall injuries106,109,110.
Other specific conditions with seemingly high prevalence of foot-related hospitalisations were conditions associated with the ground in developing nations with warm climates or those in war zones; such as animal attacks19,101, land mine injuries113,114, burns117,120, injuries from natural disasters121,122 and fungal infections123,126. Animal attacks resulting in hospitalisation were mainly reported in developing nations, with injuries mostly occurring from snakes, scorpions and dogs19,97-99,101-103, and affecting the feet in 36–82% of cases. Land mine injury admissions affected the feet in up to 96% of admissions and were predominantly reported in nations that had been affected by war111,113,114. Burns to the feet typically from walking on hot surfaces made up 7–17% of burns admissions in studies undertaken in both developing and developed nations117,118. Foot fungal infections occurred in 20–38% of admissions for different conditions and again were reported in developing nations with a warmer climate123-125, with a higher prevalence in medical conditions causing immunosuppression such as cancer and diabetes123,124. Lastly, two studies reported foot-related conditions made up 12–43% of all hospitalisations caused by injuries following natural disasters121,122. The main foot-related injuries following an earthquake were reported to be fractures, lacerations and contusions (Indonesia121), whilst diabetic foot wounds were the main foot-related condition requiring hospitalisation following a hurricane (Grenada122).
Interestingly, no papers meeting criteria in this review specifically focussed on chronic kidney disease-specific inpatient populations. Outpatient populations with chronic kidney disease or end-stage kidney disease have consistently been found to have foot disease disorders and foot risk factors that are similar to those found in diabetes populations8-10. However, kidney disease in this review was often found to be included as a subgroup of diabetes populations78,79. A number of included studies investigated patients with diabetes together with chronic kidney disease and reported foot wound prevalence of 25%, and a PAD prevalence of 45% for this specific inpatient population78,79. These studies also demonstrated diabetes patients on dialysis again had much higher rates of foot wounds (67–75%)78,79, PAD (72–77%)78,79 and amputations (approximately 7%)45,78.
Age and gender also appeared to influence foot-related conditions and foot risk factor rates in inpatient populations. Of the studies investigating representative inpatient populations for foot-related conditions, average age ranged from 49–75 years and there were more males (46–85%) than females in these populations5,20,21,23. Patients admitted with diabetes-related foot disease also tended to demonstrate similar mean age ranges (49–83 years) and higher male proportions (52–70%)24,35-37,48,50,51,53,54,57-59,62,65,81. Other chronic disease-specific foot-related hospitalisations occurred between the ages of 45 and 65 years, and more evenly affected males and females (males 29–72%)14,16,17,84,90,94. Whereas, foot-related hospitalisation due to trauma affected predominantly younger (mean age 22–53 years) male populations (37–100%)19,43,98,110,114,117. Yet, foot infection admissions appeared to occur across a broad range of mean ages (27–71 years) depending on the type of infection and affect similar proportions of males and females126,132,134,138,140.
Only a limited number of studies reported on current or past foot treatment of inpatients with foot-related conditions. This may have been due to the focus of this review being primarily on prevalence and not on treatment. However, those studies reporting past foot treatment were mainly UK-based studies investigating diabetes complications in inpatients26,30,31,46,75. The only study that discussed past foot treatment prior to hospitalisation was a 1996 UK paper indicating 50% of diabetes-specific inpatients had visited a podiatrist in the preceding 12 months, irrespective of their foot-related condition or foot risk factor present75. However, several large point-prevalence cross-sectional studies conducted in UK diabetes inpatient populations indicate that less than one-third of diabetes-specific inpatients have their feet examined whilst in hospital30,31,46. Furthermore, around one-quarter of hospitals did not have inpatient podiatry services or multidisciplinary foot teams26,46.
Limitations
There were several consistent limitations in the papers identified in this review. First, the vast majority of identified studies were retrospective and investigated specific inpatient populations. Second, the majority of papers were primarily investigating other non-foot outcomes and reported foot-related conditions or foot risk factors as minor additional outcome variables. Third, very few prospective papers reported the instruments used for data collection. The only papers specifically reporting testing data collection instruments referred to piloting the instrument prior to the study but did not report any validity or reliability results. Thus, the reliance on either retrospective datasets or prospective data collection instruments of unknown quality and reliability, poses the significant risk of under-reporting foot-related conditions150.
There are a number of limitations to the methodology used for this review. First, the literature search was very broad, performed by one author only, was unable to obtain all full texts, did not hand-search reference lists of included papers, or contact prominent authors for any papers overlooked in the search; thus, there is a likelihood that papers may have been missed. Second, no formal quality assessment of included papers was performed and only descriptive data was extracted. Lastly, only papers published between 1980 and 2011 were included in this review and further applicable literature may have become available. However, a delay between the final search date and the publication date of large literature reviews in the field of foot disease is not unusual151,152 as they still typically provide the first synthesis of the literature in a particular sub-field of the foot disease literature. This review is also the first to synthesise the literature in this sub-field of foot disease and provides a comprehensive understanding of foot-related hospitalisation; demonstrating that foot wounds are the main foot-related conditions in hospitalised populations.
This literature review indicates a gap in the literature investigating the prevalence of foot-related conditions and foot risk factors in representative inpatient populations. It also recommends further more robust systematic reviews are required to verify this gap and provide pooled prevalence estimates of the foot-related inpatients burden. Additionally, it seems that no comprehensive data collection instrument designed to capture foot-related condition data in representative inpatient populations has been tested for validity and reliability. Thus, there is need to develop and test such instruments in future and ensure the instrument includes the specific conditions identified from this review to be associated with higher prevalence of foot-related conditions. Whilst large point-prevalence studies investigating foot-related conditions and foot risk factors within diabetes-specific inpatient populations are beginning to occur26,30,31,46, studies investigating foot-related conditions and foot risk factors in more representative inpatient populations are still required to fully appreciate the overall foot-related hospitalisation.
Conclusions
This review appears to be the first to synthesise the literature surrounding the prevalence of foot-related conditions and risk factors in hospitalised populations. No individual study has investigated the overall foot-related inpatient burden. Specific conditions reported to increase the likelihood of foot-related hospitalisation were diabetes, other chronic diseases, trauma, infection and some neurological conditions. It appears foot wounds have the largest impact on foot-related hospitalisation; contributing to an estimated 1–8% of representative inpatients. Foot infection and amputation appears to complicate 10–40% of these foot wound admissions, whilst the foot risk factors of PAD and PN were present in up to 25% of all inpatients. Interestingly, foot disease-related hospitalisation appears to disproportionately affect 50- to 80-year-old males, whilst foot trauma-related hospitalisation affects 20- to 50-year-old males. The majority of included papers analysed in this review were retrospective, investigated specific conditions and did not report foot-related conditions or foot risk factors as primary outcomes. To more accurately understand the overall foot-related inpatient burden systematic reviews are required to provide more precise prevalence estimates.
Authorship statement
PAL conceived and designed the study, carried out the literature searches, data extraction, and drafted the manuscript. SHE, SSK, MCK and LFR conceived and designed the study, contributed to discussion and reviewed/edited the manuscript.
Competing interests
The authors declare they have no competing interests.
Acknowledgements
This work was supported by grant funding from Queensland Health (Queensland Government, Australia) and the Wound Management Innovation Cooperative Research Centre (Australia).
Author(s)
Peter A Lazzarini*
BAppSci, PhD Candidate
School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD, Australia
Department of Podiatry, Metro North Hospital & Health Service, Queensland Health, Brisbane,
QLD, Australia
Wound Management Innovation Cooperative Research Centre, Brisbane, QLD, Australia
Tel: (07) 3139 6172
Email: Peter.Lazzarini@health.qld.gov.au
Sheree E Hurn
PhD
School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
Suzanne S Kuys
PhD
Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD, Australia
School of Physiotherapy, Australian Catholic University, Banyo, QLD, Australia
Maarten C Kamp
MBBS, FRACP, MHA
School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
Lloyd Reed
PhD
School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
*Corresponding author
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