Foot Complications in a Representative Australian Inpatient Population

Abstract

We investigated the prevalence and factors independently associated with foot complications in a representative inpatient population (adults admitted for any reason with and without diabetes). We analysed data from the Foot disease in inpatients study , a sample of 733 representative inpatients. Previous amputation, previous foot ulceration, peripheral arterial disease (PAD), peripheral neuropathy (PN), and foot deformity were the foot complications assessed. Sociodemographic, medical, and foot treatment history were collected. Overall, 46.0% had a foot complication with 23.9% having multiple; those with diabetes had higher prevalence of foot complications than those without diabetes ( p<0.01 ). Previous amputation (4.1%) was independently associated with previous foot ulceration, foot deformity, cerebrovascular accident, and past surgeon treatment ( p<0.01 ). Previous foot ulceration (9.8%) was associated with PN, PAD, past podiatry, and past nurse treatment ( p<0.02 ). PAD (21.0%) was associated with older age, males, indigenous people, cancer, PN, and past surgeon treatment ( p<0.02 ). PN (22.0%) was associated with older age, diabetes, mobility impairment, and PAD ( p<0.05 ). Foot deformity (22.4%) was associated with older age, mobility impairment, past podiatry treatment, and PN ( p<0.01 ). Nearly half of all inpatients had a foot complication. Those with foot complications were older, male, indigenous, had diabetes, cerebrovascular accident, mobility impairment, and other foot complications or past foot treatment.

Full text

Research Article
Foot Complications in a Representative Australian
Inpatient Population
Peter A. Lazzarini,
1,2,3,4
Sheree E. Hurn,
1,2
Suzanne S. Kuys,
3,5
Maarten C. Kamp,
1
Vanessa Ng,
3
Courtney Thomas,
6
Scott Jen,
7
Jude Wills,
8
Ewan M. Kinnear,
3
Michael C. d’Emden,
1,9
and Lloyd F. Reed
1,2
1
School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
2
Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia
3
Allied Health Research Collaborative, Metro North Hospital & Health Service, Brisbane, QLD, Australia
4
Wound Management Innovation Cooperative Research Centre, Brisbane, QLD, Australia
5
Faculty of Health Sciences, School of Physiotherapy, Australian Catholic University, Brisbane, QLD, Australia
6
Department of Podiatry, North West Hospital & Health Service, Mount Isa, QLD, Australia
7
Department of Podiatry, West Moreton Hospital & Health Service, Queensland Health, Ipswich, QLD, Australia
8
Department of Podiatry, Central Queensland Hospital & Health Service, Rockhampton, QLD, Australia
9
Department of Endocrinology & Diabetes, Metro North Hospital & Health Service, Brisbane, QLD, Australia
Correspondence should be addressed to Peter A. Lazzarini; peter.lazzarini@health.qld.gov.au
Received 18 May 2017; Accepted 18 September 2017; Published 15 October 2017
Academic Editor: Patrizio Tatti
Copyright © 2017 Peter A. Lazzarini et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
We investigated the prevalence and factors independently associated with foot complications in a representative inpatient
population (adults admitted for any reason with and without diabetes). We analysed data from the Foot disease in
inpatients study, a sample of 733 representative inpatients. Previous amputation, previous foot ulceration, peripheral arterial
disease (PAD), peripheral neuropathy (PN), and foot deformity were the foot complications assessed. Sociodemographic,
medical, and foot treatment history were collected. Overall, 46.0% had a foot complication with 23.9% having multiple;
those with diabetes had higher prevalence of foot complications than those without diabetes (p<001). Previous
amputation (4.1%) was independently associated with previous foot ulceration, foot deformity, cerebrovascular accident, and
past surgeon treatment (p<001). Previous foot ulceration (9.8%) was associated with PN, PAD, past podiatry, and past nurse
treatment (p<002). PAD (21.0%) was associated with older age, males, indigenous people, cancer, PN, and past surgeon
treatment (p<002). PN (22.0%) was associated with older age, diabetes, mobility impairment, and PAD (p<0 05). Foot
deformity (22.4%) was associated with older age, mobility impairment, past podiatry treatment, and PN (p<0 01). Nearly half
of all inpatients had a foot complication. Those with foot complications were older, male, indigenous, had diabetes,
cerebrovascular accident, mobility impairment, and other foot complications or past foot treatment.
1. Introduction
Active foot disease (ulcers, infection, or ischaemia) is com-
monly precipitated by the foot complications of previous
amputations, previous foot ulcers, peripheral arterial disease
(PAD), peripheral neuropathy (PN), and foot deformity in both
diabetes and nondiabetes populations [1–4]. These foot compli-
cations not only increase the risk of developing active foot
disease in the community but also have been found to increase
the risk of developing active foot disease, falls, and pressure
injuries in the inpatient setting [3, 5–8]. Thus, it seems impor-
tant for clinicians, researchers, and policy makers to understand
how often these foot complications present and what other
factors may precipitate them in inpatient populations.
Studies investigating foot complications in inpatient pop-
ulations have predominantly focused within diabetes and
Hindawi
Journal of Diabetes Research
Volume 2017, Article ID 4138095, 12 pages
https://doi.org/10.1155/2017/4138095

geriatric inpatient populations [4–9]. These studies suggest
that up to 80% of diabetes inpatients, and up to 50% of geri-
atric inpatients, have at least one of these foot complications
[4–9]. A recent systematic review of this field found previous
studies have investigated either a single foot complication
(such as PAD) in a representative adult inpatient population
(defined as a typical hospital’s inpatient population inclusive
of patients admitted for any reason, with or without diabetes
and of any age) or multiple foot complications in a specific
inpatient population (such as all foot complications in
diabetes inpatients only) [3]. This review concluded that no
previous study had investigated the prevalence or factors
associated with multiple foot complications in a represen-
tative inpatient population [3]. Thus, the primary aim of
this study was to investigate the point prevalence and
factors independently associated with foot complications
in a representative adult inpatient population. A secondary
aim was to investigate if there were any differences in the
prevalence of foot complications between diabetes and
nondiabetes inpatients.
2. Materials and Methods
This study was a secondary analysis of data collected from
the Foot disease in inpatients study, a large multisite observa-
tional point prevalence study with the aim of investigating
active foot disease and other foot-related conditions in a rep-
resentative inpatient population [1, 2]. Previous papers from
the Foot disease in inpatients study have investigated and
reported on the outcomes of (i) primary and secondary
admissions for any foot-related conditions [1] and (ii) the
presence of active foot disease (ulcers, infection, and
ischaemia) [2]. Thus, the design and methodology of the Foot
disease in inpatients study that form the basis of this paper
have been described in detail elsewhere [1, 2]. This paper
now aims to investigate and report on the outcomes of the
presence of different foot complications (previous amputa-
tions, previous foot ulcers, PAD, PN, and foot deformity).
In brief, the Foot disease in inpatients study investigated
all adult inpatients present (in hospital at the time of the
study for any medical reason) in five representative public
hospitals in Queensland (considered representative of the
five different categories of Australian hospitals) on one desig-
nated day and they were all invited to participate on that
same day, excluding those with a cognitive deficit and those
in a maternity or psychiatric ward [1]. Of a total of 1146
inpatients present on those days, 883 were eligible for the
study and 733 consented to participate [1]. Those eligible
participants who consented reported no age or sex differ-
ences to those who did not consent [1]. This sample of 733
inpatients has been reported to be highly reflective of the
demographic, social determinant, medical history, and
reason for admission characteristics reported elsewhere for
representative inpatient populations present in Australia
and in other developed nations [1, 2, 10]. Highly trained
and tested data collectors collected all data on the 733 partic-
ipants by surveying each participant to determine their self-
reported medical history and physically assessing their feet
to clinically diagnose any foot-related conditions [1, 11]. All
data were captured on a validated data collection instrument
(the Queensland Foot Disease Form) [1, 2].
The explanatory variables for this study were grouped
into the domains of participant demographics (age and
sex), social determinants (socioeconomic status, geographi-
cal remoteness, education levels, country of birth, and
indigenous status), medical condition history (diabetes,
hypertension, dyslipidaemia, myocardial infarct, cerebrovas-
cular accident, chronic kidney disease, smoking, cancer,
arthritis, depression, and acute foot trauma), self-care ability
(mobility impairment, vision impairment, and main foot-
wear worn inside and outside the home), and past foot treat-
ment in the year prior to hospitalisation (by podiatrist,
general practitioner, specialist physician, surgeon, nurse,
orthotist, and other) [1, 2]. All variables have been defined
in detail elsewhere [1, 2, 11].
The foot complication outcome variables for this study
were previous amputation, previous foot ulceration, periph-
eral arterial disease (PAD), peripheral neuropathy (PN),
and foot deformity [1, 2, 11–17]. All foot complication out-
come variables were defined, assessed, and reported
according to national and international standards for
reporting research on the prevention and management of
foot ulcers [13–16] and have been defined in detail else-
where [1, 2, 11]. Previous amputation was diagnosed as
a healed amputation site on the lower extremity (foot or
leg) during the clinical examination [1, 2, 12–14]. Previous
foot ulceration was diagnosed as a self-reported foot ulcer
that had healed, and this was verified during the clinical
examination [1, 2, 12–14]. PAD was diagnosed as the
absence of at least one-foot pulse with a toe systolic
pressure of <70 mmHg [1, 2, 11, 14–16]. Peripheral neurop-
athy was diagnosed as the failure to perceive the sensation
of a 10-gram monofilament on at least two of three plantar
forefoot sites on one foot [1, 2, 11–14, 16]. Foot deformity
was diagnosed as having at least three of the following
deformity characteristics on one foot: small muscle
wastage, bony prominence, prominent metatarsal heads,
hammer or claw toes, limited joint mobility, or Charcot
deformity [1, 2, 11, 13, 17].
2.1. Statistical Analysis. All data were analysed using SPSS
22.0 for Windows (SPSS Inc., Chicago, IL, USA) or Graph-
Pad Software. Descriptive statistics were used to display all
variables. Prevalence with 95% confidence intervals (95%
CI) was evaluated for all foot complication outcome
variables. Pearson’s chi-square tests and Student’st-tests
were used to test for differences in categorical variables
(proportions) and continuous variables (mean (standard
deviation)), respectively. Mann–Whitney Utests were also
used to test for differences in continuous variables (median
(interquartile ranges)) if they were identified not to be nor-
mally distributed using Kolmogorov–Smirnov tests. Univar-
iate logistic regression was used to test for crude associations
between all explanatory variables and each foot complication
outcome (p<005). All explanatory variables achieving a sta-
tistical significance of p<02, except those deemed illogical
to be potentially on a causal pathway, were included in
backwards stepwise multivariate logistic regression analysis
2 Journal of Diabetes Research

for that foot complication outcome until only variables reach-
ing statistical significance remained (p<005) (unadjusted
model) [1, 18, 19]. All omitted variables from the unadjusted
models were reentered and retained in the models as
confounders if the beta effect estimates of any unadjusted inde-
pendent explanatory variable changed by >20% (adjusted
model) [1, 18, 19]. Missing data were treated by excluding cases
with any missing data in all models as the proportion of miss-
ing data cases was minimal (<5% in most cases) [1, 18, 19].
3. Results
Table 1 displays the prevalence proportions (95% CI) for all
foot complications in all participants (n= 733), including
diabetes participants (n= 172) and nondiabetes partici-
pants (n= 561). Overall, 336 participants (46.0% (95%
CI: 42.4–49.7%)) had at least one foot complication,
including 175 (23.9% (20.9–27.1%)) with multiple foot
complications and 81 (11.1% (9.0–13.6%)) with a history
of previous foot disease (previous amputation or foot
ulceration). Diabetes participants had fewer numbers with
a foot complication (n= 112) than nondiabetes participants
(n= 224). Yet diabetes participants had much higher
proportions of foot complications (65.5%) than nondiabetes
participants (40.1%), including those with multiple foot
complications (38.6% diabetes, 19.5% nondiabetes) and
previous foot disease (22.1% diabetes, 7.7% nondiabetes)
(all p<0001).
3.1. Previous Amputation. Thirty participants (4.1% (2.9–
5.8%)) had a previous amputation (Table 1), including 16
(2.2% (1.3–3.6%)) with diabetes and 24 (3.3% (2.2–4.9%))
over 60 years old of total participants (Table 2). After univar-
iate analysis, 19 explanatory variables were associated with
previous amputations (all, p<0 05) (Table 2). Adjusting for
the identified confounder of geographical remoteness, a
previous amputation was independently associated with pre-
vious foot ulcer (odds ratio (95% CI)) (22.0 (6.9–70.4)), past
foot treatment by a surgeon (10.7 (2.9–40.1)), cerebrovascu-
lar accident (CVA) history (6.8 (1.9–25.2)), and foot defor-
mity (5.6 (1.9–16.5)) (all, p<001) (Table 3).
3.2. Previous Foot Ulcer. Previous foot ulcers were present in
72 participants (9.8% (7.9–12.2%)) (Table 1), including 35
(4.8% (3.4–6.6%)) with diabetes and 48 (6.6% (5.0–8.6%))
over 60 years old (Table 2). After univariate analysis, 14
explanatory variables were associated with previous foot
ulcers (all, p<005) (Table 2). Adjusting for the identified
confounders of geographical remoteness and socioeconomic
status, a previous foot ulcer was independently associated
with past foot treatment by a nurse (18.8 (5.1–68.7)), PAD
(3.9 (2.1–7.1)), PN (3.7 (2.1–6.8)), and past foot treatment
by a podiatrist (2.9 (1.6–5.2)) (all, p<001) (Table 4).
3.3. Peripheral Arterial Disease. Peripheral arterial disease
(PAD) was present in 153 participants (21.0% (18.2–
24.1%)) (Table 1), including 60 (8.2% (6.4–10.5%)) with dia-
betes and 121 (16.6% (14.1–19.5%)) over 60 years old
(Table 5). After univariate analysis, 22 explanatory variables
were associated with PAD (all, p<0 05) (Table 5). Adjusting
for the identified confounders of past podiatry treatment,
PAD was independently associated with older age groups
(41–60 years (4.7 (1.5–14.2)), 61–80 years (8.9 (3.0–26.3)),
and 81+ years (12.7 (4.1–39.4))), past foot treatment by a sur-
geon (5.2 (2.3–11.5)), indigenous status (3.1 (1.4–7.2)), PN
(2.3 (1.5–3.4)), male gender (1.7 (1.1–2.6)), and cancer
history (0.5 (0.3–0.8)) (all, p<0 01) (Table 6).
3.4. Peripheral Neuropathy. Peripheral neuropathy (PN) was
present in 160 participants (22.0% (19.1–25.1%)) (Table 1),
including 74 (10.2% (8.2–12.6%)) with diabetes and 124
(17.0% (14.5–19.9%)) over 60 years old (Table 5). After uni-
variate analysis, 16 explanatory variables were associated
with PN (all, p<005) (Table 5). Adjusting for the identi-
fied confounder of geographical remoteness, PN was inde-
pendently associated with older age groups (41–60 years
(2.8 (1.0–7.6)), 61–80 years (4.5 (1.7–11.8)), and 81+ years
(4.4 (1.6–12.3))), diabetes (3.9 (2.5–6.1)), mobility impair-
ment (3.4 (2.2–5.2)), and PAD (2.1 (1.3–3.2)) (all, p<0 05)
(Table 7).
3.5. Foot Deformity. Foot deformity was present in 158
participants (22.4% (19.5–25.6%)) (Table 1), including
Table 1: Proportion of the diabetes and nondiabetes participants with foot complications.
Foot complication All
n(% (95% CI))
Diabetes
n(% (95% CI))
Nondiabetes
n(% (95% CI)) pvalue
Participants 733 172 561
Foot complication(s)
a
336 (46.0% (42.4–49.7)) 112 (65.5% (58.1–72.2) 224 (40.1% (36.2–44.3)) <0.001∗
Multiple foot complications
b
175 (23.9% (20.9–27.1)) 66 (38.6% (31.6–46.1)) 109 (19.5% (16.4–23.0)) <0.001∗
Previous foot disease
c
81 (11.1% (9.0–13.6)) 38 (22.1% (16.5–28.9)) 43 (7.7% (5.7–10.2)) <0.001∗
Previous amputation 30 (4.1% (2.9–5.8)) 16 (9.3% (5.7–14.7)) 14 (2.5% (1.4–4.2))) <0.001∗
Previous foot ulcer 72 (9.8% (7.9–12.2) 35 (20.3% (15.0–27.0)) 37 (6.6% (4.8–9.0))) <0.001∗
Peripheral arterial disease 153 (21.0% (18.2–24.1)) 60 (35.1% (28.3–42.5)) 93 (16.7% (13.8–20.0)) <0.001∗
Peripheral neuropathy 160 (22.0% (19.1–25.1)) 74 (43.3% (36.1–50.8)) 86 (15.4% (12.6–18.6)) <0.001∗
Foot deformity 158 (22.4% (19.5–25.6)) 51 (30.5% (24.0–37.9)) 107 (19.9% (16.7–23.5)) 0.004∗
∗p<005.
a
Participants with at least one foot complication.
b
Participants with two or more foot complications.
c
Participants with previous foot disease (either
previous foot ulcer or previous amputation); CI: confidence interval.
3Journal of Diabetes Research

Table 2: Participant characteristics and univariate analysis for previous amputation and previous foot ulcer.
Variables All Previous amputation Previous foot ulcer
n(%) Odds ratio (95% CI) pvalue n(%) Odds ratio (95% CI) pvalue
Participants 733 30 / 731 (4.1%) 72/731 (9.8%)
Demographics
Age: mean (SD) years 62.0 (18.6) 71.4 (11.1) 1.04 (1.01–1.06) 0.006∗∗ 65.8 (15.6) 1.01 (1.00–1.03) 0.074∗
Age: median (IQR) years 65 (50–76) 72 (66–79) 0.006∗∗ 69 (57–76) 0.128∗
Age groups NA 0.110
18–40 years 110 (15.0%) 0 1.00 5 (6.9%) 1.00
41–60 years 188 (25.7%) 6 (20.0%) 19 (26.4%) 2.38 (0.86–6.55) 0.095
61–80 years 316 (43.2%) 17 (56.7%) 39 (54.2%) 2.97 (1.14–7.73) 0.026
81+ years 117 (16.0%) 7 (23.3%) 9 (12.5%) 1.75 (0.57–5.39) 0.330
Male sex 408 (55.8) 19 (63.3%) 1.38 (0.65–2.95) 0.400 46 (63.9%) 1.46 (0.88–2.42) 0.142∗
Social determinants
Socioeconomic status 711 0.638 0.064∗
Most disadvantaged 102 (14.4%) 6 (20.7%) 1.00 16 (22.9%) 1.00
Second most
disadvantaged 159 (22.4%) 7 (24.1%) 0.74 (0.24–2.26) 0.593 17 (24.3%) 0.64 (0.31–1.34) 0.239
Middle 98 (13.8%) 2 (6.9%) 0.33 (0.07–1.69) 0.185 4 (5.7%) 0.23 (0.07–0.72) 0.011
Second least
disadvantaged 240 (33.8%) 11 (37.9%) 0.78 (0.28–2.16) 0.626 26 (37.1%) 0.66 (0.34–1.28) 0.218
Least disadvantaged 112 (15.8%) 3 (10.3%) 0.44 (0.11–1.81) 0.255 7 (10.0%) 0.36 (0.14–0.91) 0.031
Geographic remoteness 711 0.589 0.304
Major city 435 (61.2%) 18 (62.1%) 1.00 41 (58.6%) 1.00
Inner regional area 153 (21.5%) 4 (13.8%) 0.62 (0.21–1.86) 0.392 15 (21.4%) 1.04 (0.56–1.94) 0.904
Outer regional area 66 (9.3%) 5 (17.2%) 1.89 (0.68–5.28) 0.224 12 (17.1%) 2.13 (1.05–4.29) 0.036
Remote area 30 (4.2%) 1 (3.4%) 0.80 (0.10–6.17) 0.826 0 0 NA
Very remote area 27 (3.8%) 1 (3.4%) 0.89 (0.11–6.90) 0.909 2 (2.9%) 0.77 (0.18–3.35) 0.722
<10-year education level 395 (54.0%) 19 (63.3%) 1.48 (0.70–3.16) 0.307 41 (56.9%) 1.13 (0.69–1.85) 0.621
Indigenous 34 (4.6%) 1 (3.3%) 0.70 (0.09–5.27) 0.727 4 (5.6%) 1.23 (0.42–3.60) 0.704
Born overseas 161 (22.0%) 5 (16.7%) 0.70 (0.26–1.85) 0.467 11 (15.3%) 0.61 (0.31–1.19) 0.146∗
Medical condition history
Diabetes 172 (23.5%) 16 (53.3%) 3.99 (1.91–8.36) <0.001∗∗ 35 (48.6%) 3.60 (2.19–5.94) <0.001∗∗
Hypertension 359 (49.0%) 21 (70.0%) 2.54 (1.15–5.61) 0.022∗∗ 38 (52.8%) 1.18 (0.73–1.93) 0.497
Dyslipidaemia 234 (31.9%) 12 (40.0%) 1.44 (0.68–3.04) 0.341 27 (37.5%) 1.31 (0.79–2.17) 0.294
Myocardial infarct 146 (19.9%) 12 (40.0%) 2.82 (1.33–6.00) 0.007∗∗ 17 (23.6%) 1.27 (0.71–2.26) 0.417
Cerebrovascular accident 85 (11.6%) 9 (30.0%) 3.52 (1.59–7.97) 0.002∗∗ 8 (11.1%) 0.95 (0.44–2.05) 0.885
Chronic kidney disease 89 (12.1%) 11 (36.7%) 4.62 (2.12–10.08) <0.001∗∗ 19 (26.4%) 3.02 (1.69–5.39) <0.001∗∗
Smoker 104 (14.2%) 3 (10.0%) 0.66 (0.20–2.22) 0.501 12 (16.7%) 1.23 (0.64–2.38) 0.533
Ex-smoker 304 (41.5%) 14 (46.7%) 1.25 (0.60–2.60) 0.554 28 (38.9%) 0.89 (0.54–1.46) 0.642
Cancer 174 (23.7%) 8 (26.7%) 1.17 (0.51–2.68) 0.707 17 (23.6%) 0.99 (0.56–1.75) 0.968
Arthritis 274 (37.4%) 18 (60.0%) 2.64 (1.25–5.57) 0.011∗∗ 41 (56.9%) 2.43 (1.49–3.99) <0.001∗∗
Depression 191 (26.1%) 6 (20.0%) 0.70 (0.28–1.75) 0.447 21 (29.2%) 1.18 (0.69–2.03) 0.537
Acute foot trauma 26 (3.5%) 1 (3.3%) 0.93 (0.12–7.12) 0.946 7 (9.7%) 3.63 (1.47–8.95) 0.005∗∗
Self-care ability
Mobility impairment 242 (33.2%) 21 (70.0%) 5.07 (2.29–11.25) <0.001∗∗ 38 (52.8%) 2.48 (1.52–4.05) <0.001
∗∗
Vision impairment 110 (15.1%) 12 (40.0%) 4.09 (1.91–8.75) <0.001∗∗ 20 (27.8%) 2.42 (1.38–4.25) 0.002∗∗
Footwear worn: inside 0.158∗0.580
Low-risk footwear 81 (11.1%) 6 (20.7%) 1.00 11 (15.5%) 1.00
4 Journal of Diabetes Research

51 (7.2% (5.5–9.4%)) with diabetes and 133 (18.8%
(16.2–21.9%)) over 60 years old (Table 5). After univariate
analysis, 18 explanatory variables were associated with foot
deformity (all, p<005) (Table 5). No confounders were
identified. Foot deformity was independently associated with
older age groups (61–80 years (4.7 (1.8–12.2)) and 81+ years
(5.7 (2.0–15.7))), PN (2.2 (1.4–2.4)), past foot treatment by a
podiatrist (2.1 (1.4–3.1)), and mobility impairment (2.0 (1.3–
3.1)) (all, p<001) (Table 8).
4. Discussion
This appears to be the first study to investigate a representa-
tive inpatient population for foot complications. Our find-
ings indicate nearly half (46%) of all inpatients had at least
one foot complication that places them at risk of developing
active foot disease, including nearly a quarter (24%) at higher
risk with multiple foot complications and a tenth (11%) at
very high risk of developing active foot disease with a history
of previous foot disease. Inpatients with diabetes had signifi-
cantly higher proportions of all foot complications than those
without diabetes; however, interestingly, there were more
patients with foot complications that did not have diabetes
than did have diabetes due to the greater overall proportion
of inpatients without diabetes. Foot complications in
inpatients were associated with older age, males, indigenous
peoples, diabetes, cerebrovascular accident (CVA) history,
mobility impairment, other foot complications, and past foot
treatment. Overall, these findings suggest that foot complica-
tions are relatively common in inpatient populations and also
have common factors independently associated with them in
both diabetes and nondiabetes inpatients.
To the best of our knowledge, the only foot complication
to have been previously investigated in a representative inpa-
tient population was PAD [3, 4]. Our 21% prevalence for
PAD seemed low compared to the 29% and 36% reported
in the two previous similar studies [3, 20, 21]; however, an
interrogation of these studies suggests closer alignment. The
previous studies used an ankle-brachial index to diagnose
PAD in inpatients over 40 years, whereas our study used
toe systolic pressures to diagnose PAD in inpatients over 18
years [20, 21]. Our equivalent PAD prevalence for our sub-
group of inpatients over 40 years of age was 24% (149/623),
and toe pressures have been found to decrease false posi-
tive PAD identification compared with the ankle brachial
indices [13, 15, 16]. These methodological differences
Table 2: Continued.
Variables All Previous amputation Previous foot ulcer
n(%) Odds ratio (95% CI) pvalue n(%) Odds ratio (95% CI) pvalue
Moderate-risk
footwear 263 (36.1%) 13 (44.8%) 0.65 (0.24–1.77) 0.399 27 (38.0%) 0.73 (0.34–1.54) 0.407
High-risk footwear 139 (19.1%) 2 (6.9%) 0.18 (0.04–0.93) 0.041 12 (16.9%) 0.61 (0.25–1.45) 0.259
No footwear worn 245 (33.7%) 8 (27.6%) 0.42 (0.14–1.26) 0.121 21 (29.6%) 0.60 (0.27–1.30) 0.193
Footwear worn: outside 0.116∗0.235
Low-risk footwear 386 (53.2%) 21 (75.0%) 1.00 36 (50.7%) 1.00
Moderate-risk
footwear 75 (10.3%) 1 (3.6%) 0.23 (0.03–1.77) 0.159 11 (15.5%) 1.67 (0.81–3.44) 0.168
High-risk footwear 250 (34.4%) 5 (17.9%) 0.35 (0.13–0.95) 0.039 21 (29.6%) 0.89 (0.51–1.56) 0.682
No footwear worn 15 (2.1%) 1 (3.6%) 1.24 (0.16–9.87) 0.840 3 (4.2%) 2.42 (0.65–8.99) 0.186
Past foot treatment
Yes 256 (34.9%) 22 (73.3%) 5.52 (2.42–12.60) <0.001∗∗ 56 (77.8%) 8.03 (4.50–14.35) <0.001∗∗
Podiatry 180 (24.6%) 18 (60.0%) 50.3 (2.37–10.67) <0.001∗∗ 41 (56.9%) 4.95 (2.99–8.18) <0.001∗∗
GP 93 (12.7%) 14 (46.7%) 6.89 (3.24–14.65) <0.001∗∗ 27 (37.5%) 5.39 (3.14–9.26) <0.001∗∗
Surgeon 36 (4.9%) 14 (46.7%) 27.01 (11.73–62.15) <0.001∗∗ 17 (23.6%) 10.41 (5.12–21.18) <0.001∗∗
Physician 21 (2.9%) 5 (16.7%) 8.56 (2.91–25.23) <0.001∗∗ 7 (9.7%) 4.96 (1.93–12.73) 0.001∗∗
Nurse 20 (2.7%) 7 (23.3%) 16.11 (5.88–44.15) <0.001∗∗ 12 (16.7%) 16.28 (6.40–41.37) <0.001∗∗
Orthotist 4 (0.5%) 3 (10.0%) 77.78 (7.83–772.35) <0.001∗∗ 2 (2.8%) 9.39 (1.30–67.67) 0.026∗∗
Other 9 (1.2%) 0 0 NA 1 (1.4%) 1.15 (0.14–9.30) 0.898
Foot disease history
Previous foot ulcer 72 (9.8%) 21 (70.0%) 30.33 (13.20–69.72) <0.001∗∗ ———
Foot risk factors
Peripheral neuropathy 160 (22.0%) 21 (72.4%) 10.65 (4.62–24.56) <0.001∗∗ 39 (54.9%) 5.39 (3.24–8.95) <0.001∗∗
PAD 153 (21.0%) 20 (69.0%) 9.44 (4.20–21.20) <0.001∗∗ 40 (56.3%) 6.20 (3.72–10.34) <0.001∗∗
Foot deformity 158 (22.4%) 17 (65.4%) 7.27 (3.17–16.66) <0.001∗∗ 29 (42.0%) 2.85 (1.70–4.77) <0.001∗∗
∗p<02;∗∗ p<0 05; CI: confidence interval; GP: general practitioner; IQR: interquartile range; PAD: peripheral arterial disease; SD: standard deviation.
5Journal of Diabetes Research

appear to explain the differences in our PAD prevalence
findings compared to previous findings and suggest our
findings are generalisable. We also found that diabetes
patients (35%) had much higher proportions of PAD than
nondiabetes patients (17%) which is also consistent with
previous literature [20, 21].
Although previous amputation, previous foot ulceration,
PN, and foot deformity have not been previously investigated
in representative inpatient populations, our findings are gen-
erally consistent to those reported for diabetes and geriatric
inpatient populations [3, 4]. Previous amputation prevalence
reported by other studies were 1–8% within diabetes
inpatients [4, 22, 23] and 0–7% within over 60 years old
[4, 7, 24], which were similar to our findings of 9% and
6% (24/433), respectively. Previous foot ulcer prevalence
reported by other studies was 12–20% within diabetes
inpatients [4, 25–27] and 1–15% within over 60 years
old [4, 6, 24] which again were similar to our findings
of 20% and 11% (48/433), respectively. PN prevalence
reported by other studies was 12–81% within diabetes
inpatients [4, 9, 28] and 26% within over 60 years old [5, 6],
which were again similar to our findings of 43% and
29% (124/433), respectively. Although the 43–50% foot
deformity prevalence has only been previously reported
in geriatric inpatients [4, 7, 29], and was much higher
than our geriatric finding of 31% (133/433), this was likely
explained by the different foot deformity definitions used
between our study and the previous studies. Our study
required at least three clinical characteristics of a foot defor-
mity to be present to be defined as a foot deformity [13, 17],
whereas previous studies required a much lower threshold of
diagnosis with just one-foot deformity characteristic being
required [7, 29]. The overall interpretation of our diabetes
and geriatric specific inpatient findings reassures us that our
foot complication prevalence findings in representative
inpatient populations are plausible and generalisable.
There has also been a general lack of literature investigat-
ing independent factors associated with foot complications in
representative populations (inpatient or outpatients with and
without diabetes). Yet interestingly, our representative inpa-
tient findings for factors associated with foot complications
were very similar to previously reported diabetes outpatient
findings, even after we adjusted for diabetes. We found previ-
ous amputation was most strongly associated with previous
foot ulcers which have been consistently identified in the
diabetes literature to be the major precipitating risk factor
for amputation [12–14, 16, 17, 30]. Other factors identified
in our study were foot deformity, CVA history, and past foot
treatment by a surgeon. The association with foot deformity
is most likely explained by a minor amputation procedure
often producing a foot deformity in the remaining partial
foot and a major amputation often precipitating a compen-
satory foot deformity in the remaining contralateral foot
[13, 17]. A CVA history has also been identified in other
recent studies [30, 31] and may be explained by the similar
macrovascular pathophysiology that occurs in both CVA
and PAD which can subsequently result in amputation
[30, 31]. Lastly, past foot treatment by a surgeon in the pre-
vious year is perhaps not surprising considering amputa-
tion procedures can only be performed by surgeons;
Table 3: Independent factors associated with previous amputations (odds ratios [95% CI]).
Risk factor Unadjusted pvalue Adjusted
a
pvalue
CVA history 4.83 (1.48–15.74) 0.009∗6.85 [1.86–25.21] 0.004∗
Previous foot ulcer 17.92 (6.51–49.29) <0.001∗22.01 [6.89–70.38] <0.001∗
Foot deformity 4.50 (1.70–11.90) 0.002∗5.59 [1.89–16.55] 0.002∗
Surgeon past foot treatment 8.09 (2.50–26.20) <0.001∗10.73 [2.87–40.15] <0.001∗
Model 1 results Pseudo R
2
: 0.447
Omnibus: df =4,p<0001
Missing: 29 (4.0%);
H&L: p=0955
Pseudo R
2
: 0.516
Omnibus: df = 8,p<0001
Missing: 50 (6.8%);
H&L: p=0628
∗p<005.
a
Adjusted for identified confounder of geographical remoteness; pseudo R
2
: Nagelkerke R
2
; omnibus: omnibus tests of model coefficients; df: degrees
of freedom; missing: excluded cases with any missing data; H&L: Hosmer and Lemeshow test; CVA: cardiovascular accident.
Table 4: Independent factors associated with previous foot ulcers (odds ratios [95% CI]).
Risk factor Unadjusted pvalue Adjusted
a
pvalue
Vision impairment 2.10 (1.09–4.03) 0.026∗1.89 (0.95–3.77) 0.069
PN 3.17 (1.81–5.56) <0.001∗3.75 (2.06–6.85) <0.001∗
PAD 3.77 (2.15–6.62) <0.001∗3.88 [2.14–7.06] <0.001∗
Podiatry past foot treatment 3.16 (1.80–5.55) <0.001∗2.88 (1.59–5.22) <0.001∗
Nurse past foot treatment 8.45 (2.88–24.84) <0.001∗18.80 (5.15–68.66) <0.001∗
Model 1 results Pseudo R
2
: 0.305
Omnibus: df =5,p<0 001
Missing: 9 (1.2%);
H&L: p=0154
Pseudo R
2
: 0.364
Omnibus: df =13,p<0001
Missing: 31 (4.2%);
H&L: p=0601
∗p<005.
a
Adjusted for identified confounders of geographical remoteness and socioeconomic status; pseudo R
2
: Nagelkerke R
2
; omnibus: omnibus tests of
model coefficients; df: degrees of freedom; missing: excluded cases with any missing data; H&L: Hosmer and Lemeshow test; PAD: peripheral arterial
disease; PN: peripheral neuropathy.
6 Journal of Diabetes Research

Table 5: Participant characteristics and univariate analysis for peripheral arterial disease, peripheral neuropathy, and foot deformity.
Variables All
Peripheral arterial disease Peripheral neuropathy Foot deformity
n(%) Odds ratio
(95% CI) pvalue n(%) Odds ratio
(95% CI) pvalue n(%) Odds ratio
(95% CI) pvalue
Participants 733 153/728 (21.0%) 160/728 (22.0%) 158/706 (22.4%)
Demographics
Age: mean (SD) years 62.0 (18.6) 70.5 (13.3) 1.04 (1.03–1.05) <0.001∗∗ 70.1 (14.1) 1.04 (1.02–1.05) <0.001∗∗ 72.3 (14.4) 1.05 (1.04–1.06) <0.001∗∗
Age: median (IQR) years 65 (50–76) 73 (63–81) <0.001∗∗ 73 (62–80) <0.001∗∗ 75 (66–82) <0.001∗∗
Age groups <0.001∗<0.001∗∗ <0.001∗∗
18–40 years 110 (15.0%) 4 (2.6%) 1.00 6 (3.8%) 1.00 5 (3.2%) 1.00
41–60 years 188 (25.7%) 28 (18.3%) 4.70 (1.60–13.78) 0.005 29 (18.2%) 3.22 (1.29–8.03) 0.012 19 (12.1%) 2.33 (0.84–6.43) 0.103
61–80 years 316 (43.2%) 82 (53.6%) 9.41 (3.36–26.34) <0.001 87 (54.7%) 6.64 (2.81–15.69) <0.001 88 (56.1%) 7.84 (3.09–19.91) <0.001∗∗
81+ years 117 (16.0%) 39 (25.5%) 13.25 (4.55–38.62) <0.001 37 (23.3%) 8.02 (3.23–19.93) <0.001 45 (28.7%) 12.60 (4.76–33.36) <0.001∗∗
Male sex 408 (55.8) 97 (63.4%) 1.48 (1.03–2.14) 0.037∗∗ 93 (58.1%) 1.12 (0.79–1.60) 0.525 74 (46.8%) 0.62 (0.44–0.89) 0.009∗∗
Social determinants
Socioeconomic status 711 0.020∗∗ 0.798 0.274
Most disadvantaged 102 (14.4%) 32 (21.8%) 1.00 24 (15.5%) 1.00 22 (14.5%) 1.00
Second most disadvantaged 159 (22.4%) 34 (23.1%) 0.59 (0.33–1.04) 0.066 34 (21.9%) 0.88 (0.48–1.59) 0.661 35 (23.0%) 1.03 (0.56–1.89) 0.927
Middle 98 (13.8%) 13 (8.8%) 0.33 (0.16–0.67) 0.002 21 (13.5%) 0.86 (0.44–1.68) 0.666 16 (10.5%) 0.67 (0.33–1.36) 0.264
Second least disadvantaged 240 (33.8%) 49 (33.3%) 0.55 (0.32–0.93) 0.025 56 (36.1%) 0.97 (9.56–1.68) 0.910 49 (32.2%) 0.89 (0.51–1.58) 0.698
Least disadvantaged 112 (15.8%) 19 (12.9%) 0.43 (0.23–0.83) 0.012 20 (12.9%) 0.69 (0.35–1.34) 0.272 30 (19.7%) 1.40 (0.74–2.65) 0.300
Geographic remoteness 711 0.604 0.556 0.180∗
Major city 435 (61.2%) 87 (59.2%) 1.00 98 (63.2%) 1.00 103 (67.8%) 1.00
Inner regional area 153 (21.5%) 30 (20.4%) 0.98 (0.62–1.56) 0.943 32 (20.6%) 0.93 (0.59–1.46) 0.742 28 (18.4%) 0.73 (0.46–1.17) 0.196
Outer regional area 66 (9.3%) 17 (11.6%) 1.38 (0.76–2.51) 0.297 10 (15.2%) 0.61 (0.30–1.24) 0.173 15 (9.9%) 0.92 (0.50–1.71) 0.793
Remote area 30 (4.2%) 5 (3.4%) 0.79 (0.30–2.13) 0.646 9 (5.8%) 1.47 (0.65–3.30) 0.357 2 (1.3%) 0.23 (0.05–0.97) 0.046
Very remote area 27 (3.8%) 8 (5.4%) 1.67 (0.71–3.94) 0.242 6 (3.9%) 0.98 (0.38–2.49) 0.961 4 (2.6%) 0.53 (0.18–1.58) 0.256
<10-year education level 395 (54.0%) 97 (63.4%) 1.64 (1.14–2.37) 0.008∗∗ 92 (57.9%) 1.23 (0.86–1.76) 0.252 98 (62.0%) 1.54 (1.07–2.21) 0.020∗∗
Indigenous 34 (4.6%) 12 (7.9%) 2.16 (1.04–4.46) 0.039∗∗ 9 (5.6%) 1.29 (0.59–2.83) 0.521 7 (4.5%) 0.94 (0.40–2.20) 0.881
Born overseas 161 (22.0%) 33 (21.6%) 0.96 (0.62–1.47) 0.839 29 (18.1%) 0.73 (0.47–1.14) 0.164∗35 (22.3%) 1.02 (0.67–1.56) 0.925
Medical condition history
Diabetes 172 (23.5%) 60 (39.2%) 2.70 (1.84–3.96) <0.001∗∗ 74 (46.3%) 4.18 (2.86–6.11) <0.001∗∗ 51 (32.3%) 1.76 (1.20–2.63) 0.004∗∗
Hypertension 359 (49.0%) 97 (63.4%) 2.10 (1.45–3.03) <0.001∗∗ 92 (57.5%) 1.55 (1.09–2.20) 0.016∗∗ 95 (60.1%) 1.75 (1.22–2.50) 0.002∗∗
Dyslipidaemia 234 (31.9%) 66 (43.1%) 1.87 (1.30–2.70) 0.001∗∗ 65 (40.6%) 1.63 (1.13–2.34) 0.008∗∗ 53 (33.5%) 1.09 (0.75–1.58) 0.671
Myocardial infarct 146 (19.9%) 42 (27.5%) 1.73 (1.15–2.62) 0.009∗∗ 38 (23.8%) 1.33 (0.87–2.02) 0.187∗43 (27.2%) 1.66 (1.10–2.50) 0.016∗∗
Cerebrovascular accident 85 (11.6%) 29 (19.0%) 2.17 (1.33–3.54) 0.002∗∗ 24 (15.0%) 1.47 (0.88–2.44) 0.140∗21 (13.3%) 1.22 (0.72–2.08) 0.456
Chronic kidney disease 89 (12.1%) 38 (24.8%) 3.47 (2.17–5.54) <0.001∗∗ 32 (20.0%) 2.24 (1.40–3.61) 0.001∗∗ 28 (17.7%) 1.79 (1.09–2.91) 0.020∗∗
Smoker 104 (14.2%) 21 (13.7%) 0.96 (0.57–1.60) 0.866 18 (11.3%) 0.72 (0.42–1.24) 0.235 10 (6.3%) 0.35 (0.18–0.69) 0.002∗∗
7Journal of Diabetes Research

Table 5: Continued.
Variables All
Peripheral arterial disease Peripheral neuropathy Foot deformity
n(%) Odds ratio
(95% CI) pvalue n(%) Odds ratio
(95% CI) pvalue n(%) Odds ratio
(95% CI) pvalue
Ex-smoker 304 (41.5%) 69 (45.1%) 1.21 (0.84–1.73) 0.308 66 (41.3%) 0.98 (0.69–1.40) 0.914 68 (43.0%) 1.07 (0.75–1.53) 0.717
Cancer 174 (23.7%) 29 (19.0%) 0.71 (0.45–1.10) 0.127∗45 (28.1%) 1.35 (0.90–2.00) 0.143∗39 (24.7%) 1.09 (0.72–1.64) 0.694
Arthritis 274 (37.4%) 77 (50.3%) 1.99 (1.39–2.86) <0.001∗∗ 73 (45.6%) 1.57 (1.10–2.24) 0.013∗∗ 82 (51.9%) 2.24 (1.55–3.19) <0.001∗∗
Depression 191 (26.1%) 36 (23.5%) 0.85 (0.56–1.29) 0.440 41 (25.6%) 0.97 (0.65–1.45) 0.877 44 (27.8%) 1.09 (0.74–1.63) 0.660
Acute foot trauma 26 (3.5%) 5 (3.3%) 0.89 (0.33–2.40) 0.820 9 (5.6%) 1.93 (0.84–4.42) 0.119∗6 (3.8%) 1.04 (0.41–2.64) 0.931
Self-care ability
Mobility impairment 242 (33.2%) 78 (51.0%) 2.66 (1.84–3.83) <0.001∗∗ 95 (59.4%) 4.23 (2.93–6.12) <0.001∗∗ 89 (56.3%) 3.59 (2.49–5.19) <0.001∗∗
Vision impairment 110 (15.1%) 37 (24.2%) 2.22 (1.42–3.46) <0.001∗∗ 33 (20.6%) 1.68 (1.07–2.64) 0.026∗∗ 37 (23.6%) 2.14 (1.37–3.34) 0.001∗∗
Footwear worn: inside 0.002∗∗ 0.006∗∗ 0.007∗∗
Low-risk footwear 81 (11.1%) 19 (12.4%) 1.00 27 (17.0%) 1.00 22 (13.9%) 1.00
Moderate-risk footwear 263 (36.1%) 74 (48.4%) 1.28 (0.72–2.28) 0.408 66 (41.5%) 0.67 (0.39–1.16) 0.151 73 (46.2%) 1.07 (0.61–1.87) 0.813
High-risk footwear 139 (19.1%) 19 (12.4%) 0.53 (0.26–1.06) 0.074 25 (15.7%) 0.44 (0.24–0.83) 0.012 23 (14.6%) 0.56 (0.29–1.08) 0.083
No footwear worn 245 (33.7%) 41 (26.8%) 0.66 (0.36–1.21) 0.178 41 (25.8%) 0.40 (0.23–0.71) 0.002 40 (25.3%) 0.56 (0.31–1.01) 0.054
Footwear worn: outside 0.065∗0.015∗∗ 0.316
Low-risk footwear 386 (53.2%) 89 (58.6%) 1.00 91 (57.2%) 1.00 85 (54.1%) 1.00
Moderate-risk footwear 75 (10.3%) 19 (12.5%) 1.13 (0.64–2.01) 0.670 16 (10.1%) 0.88 (0.48–1.60) 0.674 22 (14.0%) 1.43 (0.82–2.49) 0.207
High-risk footwear 250 (34.4%) 39 (25.7%) 0.62 (0.41–0.94) 0.026 44 (27.7%) 0.70 (0.47–1.05) 0.081 47 (29.9%) 0.81 (0.55–1.21) 0.313
No footwear worn 15 (2.1%) 5 (3.3%) 1.67 (0.56–5.01) 0.361 8 (5.0%) 3.71 (1.31–10.50) 0.014 3 (1.9%) 0.92 (0.25–3.38) 0.901
Past foot treatment
Yes 256 (34.9%) 83 (54.2%) 2.80 (1.95–4.04) <0.001∗∗ 86 (53.8%) 2.77 (1.93–3.96) <0.001∗∗ 86 (54.4%) 2.80 (1.95–4.02) <0.001∗∗
Podiatry 180 (24.6%) 62 (40.5%) 2.67 (1.82–3.91) <0.001∗∗ 67 (41.9%) 2.93 (2.01–4.27) <0.001∗∗ 73 (46.2%) 3.71 (2.54–5.42) <0.001∗∗
GP 93 (12.7%) 36 (23.5%) 2.85 (1.79–4.54) <0.001∗∗ 37 (23.1%) 2.81 (1.77–4.45) <0.001∗∗ 25 (15.8%) 1.42 (0.86–2.25) 0.168∗
Surgeon 36 (4.9%) 20 (13.1%) 5.61 (2.80–11.26) <0.001∗∗ 18 (11.3%) 4.11 (2.07–8.18) <0.001∗∗ 14 (8.9%) 2.71 (1.33–5.53) 0.006∗∗
Physician 21 (2.9%) 9 (5.9%) 2.93 (1.21–7.09) 0.017∗∗ 8 (5.0%) 2.25 (0.92–5.52) 0.078∗9 (5.7%) 2.95 (1.20–7.25) 0.018∗∗
Nurse 20 (2.7%) 10 (6.5%) 3.95 (1.61–9.68) 0.003∗∗ 11 (6.9%) 4.59 (1.87–11.27) 0.001∗∗ 9 (5.7%) 3.25 (1.30–8.14) 0.012∗∗
Orthotist 4 (0.5%) 1 (0.7%) 1.25 (0.13–12.14) 0.845 3 (1.9%) 10.83 (1.12–104.88) 0.040 1 (0.6%) 1.74 (0.16–19.30) 0.652
Other 9 (1.2%) 2 (1.3%) 1.08 (0.22–5.23) 0.929 1 (0.6%) 0.44 (0.06–3.55) 0.441 3 (1.9%) 1.75 (0.43–7.07) 0.433
Foot risk factors
Peripheral neuropathy 160 (22.0%) 62 (40.5%) 3.35 (2.27–4.95) <0.001∗∗ ———66 (42.0%) 3.69 (2.50–5.45) <0.001∗∗
PAD 153 (21.0%) ———62 (39.0%) 3.35 (2.27–4.95) <0.001∗∗ 53 (33.8%) 2.43 (1.63–3.62) <0.001∗∗
Foot deformity 158 (22.4%) 52 (35.8%) 2.43 (1.63–3.62) <0.001∗∗
a
66 (42.3%) 3.69 (2.50–5.45) <0.001∗∗
a
———
∗p<02;∗∗ p<0 05.
a
Explanatory variable excluded from multivariate model as considered not on causal pathway for outcome; CI: confidence interval; GP: general practitioner; IQR: interquartile range; PAD:
peripheral arterial disease; SD: standard deviation.
8 Journal of Diabetes Research

however, we only captured past foot treatment for the year
prior to hospitalisation and did not record the duration
since the previous amputation was performed. Thus, fur-
ther research would be required to determine how long
people with a previous amputation maintain ongoing foot
treatment with their surgeon after their procedure.
The independent factors we identified to be associated
with previous foot ulceration were also consistent with those
reported in the diabetes outpatient literature [12–14, 17, 32].
Our findings indicate that PAD, PN, and past foot treatment
factors are important factors associated with foot ulceration,
regardless of diabetes status [13, 17, 32]. Furthermore, a
recent study also identified that PAD and PN were
independently associated with active foot ulcers, regardless
of diabetes; however, that study identified an association with
past foot treatment by a surgeon rather than a podiatrist or
nurse [2]. This adds weight to previous recommendations
that best practice guidelines must emphasise the need for a
podiatrist and nurse, in conjunction with a surgeon, to be
part of the recommended outpatient multidisciplinary foot
team to prevent foot ulcer inpatient admissions in diabetes
and nondiabetes patients, rather than wait until the foot ulcer
has healed to seek podiatry and nursing foot treatment as our
findings suggest happens [13, 33, 34]. Nevertheless, these
findings suggest, in both diabetes and nondiabetes popula-
tions, that these foot complications significantly increase
Table 6: Independent factors associated with peripheral arterial disease (odds ratios [95% CI]).
Risk factor Unadjusted pvalue Adjusted
a
pvalue
Age groups <0.001∗<0.001∗
18–40 years Referent Referent
41–60 years 4.98 (1.64–15.14) 0.005∗4.69 (1.55–14.23) 0.006∗
61–80 years 10.42 (3.56–30.51) <0.001∗8.94 (3.04–26.33) <0.001∗
81+ years 15.61 (5.10–47.80) <0.001∗12.72 (4.10–39.40) <0.001∗
Male sex 1.55 (1.04–2.32) 0.031∗1.70 (1.13–2.56) 0.012∗
Indigenous 3.23 (1.40–7.43) 0.006∗3.12 (1.36–7.18) 0.007∗
Cancer history 0.52 (0.32–0.85) 0.009∗0.52 (0.32–0.84) 0.008∗
PN 2.38 (1.56–3.61) <0.001∗2.26 (1.48–3.45) <0.001∗
Surgeon past foot treatment 6.01 (2.74–13.18) <0.001∗5.16 (2.32–11.47) <0.001∗
Model 1 results Pseudo R
2
: 0.213
Omnibus: df = 8,p<0001
Missing: 11 (1.5%);
H&L: p=0498
Pseudo R
2
: 0.222
Omnibus: df = 9,p<0001
Missing: 11 (1.5%);
H&L: p=0038
∗p<005.
a
Adjusted for identified confounder of past podiatry treatment; pseudo R
2
: Nagelkerke R
2
; omnibus: omnibus tests of model coefficients; df: degrees of
freedom; missing: excluded cases with any missing data; H&L: Hosmer and Lemeshow test; PN: peripheral neuropathy.
Table 7: Independent factors associated with peripheral neuropathy (odds ratios [95% CI]).
Risk factor Unadjusted pvalue Adjusted
a
pvalue
Age groups 0.007∗0.008∗
18–40 years Referent Referent
41–60 years 2.93 (1.07–8.01) 0.037∗2.77 (1.01–7.62) 0.048∗
61–80 years 4.66 (1.80–12.08) 0.002∗4.55 (1.75–11.80) 0.002∗
81+ years 4.73 (1.70–13.15) 0.003∗4.42 (1.59–12.32) 0.004∗
Diabetes 3.91 (2.57–5.97) <0.001∗3.94 (2.55–6.07) <0.001∗
Mobility impairment 3.37 (2.22–5.11) <0.001∗3.41 (2.24–5.20) <0.001∗
PAD 1.93 (1.25–2.99) 0.003∗2.08 (1.33–3.25) 0.001∗
Outside footwear worn 0.017∗0.055
Low risk Referent Referent
Moderate risk 0.58 (0.29–1.15) 0.117 0.57 (0.28–1.13) 0.108
High risk 0.71 (0.45–1.11) 0.132 0.72 (0.45–1.14) 0.158
No footwear 3.99 (1.19–13.35) 0.025∗3.01 (0.85–10.65) 0.088
Model 1 results Pseudo R
2
: 0.284
Omnibus: df = 9,p<0001
Missing: 15 (2.0%);
H&L: p=0100
Pseudo R
2
: 0.289
Omnibus: df = 13,p<0001
Missing: 33 (4.5%);
H&L: p=0189
∗p<005.
a
Adjusted for identified confounder of geographical remoteness; pseudo R
2
: Nagelkerke R
2
; omnibus: omnibus tests of model coefficients; df: degrees
of freedom; missing: excluded cases with any missing data; H&L: Hosmer and Lemeshow test; PAD: peripheral arterial disease.
9Journal of Diabetes Research

the risk of developing future active foot disease (ulcers, infec-
tion, or ischaemia) which in turn increases the risk of poten-
tial hospitalisation and amputation.
PAD in our study was independently associated with
older age, male gender, and PN, which is consistent with
previous outpatient literature [20, 21, 35]. Furthermore, our
study identified Australian indigenous peoples as an inde-
pendent factor associated with PAD which has also been
identified by two previous diabetes-related Australian studies
[36, 37]. The independent associated factor of past surgical
treatment for PAD is a welcome finding and suggests patients
with PAD are being regularly assessed by vascular surgeons
as recommended by best practice guidelines [13, 15, 16],
whereas our finding that a cancer history decreased the
likelihood of having PAD is potentially a novel finding. It is
perhaps most likely explained by cancer sufferers being
hospitalised at younger ages [10], but more likely because
our definition of cancer history was broad and included any
cancers in the participant’s history. Thus, it is recommended
that any further research into this association captures data
on different cancer types, severity, durations, and treatments
to determine if the association is with particular types of can-
cers or treatments.
PN was found to be independently associated with older
age, diabetes, and mobility impairment in our study, again all
of which have been reported in the diabetes outpatient
literature [32, 38]. In contrast to best practice guideline rec-
ommendations that people with PN should receive regular
foot monitoring by a podiatrist to prevent active foot disease,
falls, or pressure injuries [13, 33], our study found no past
foot treatment variables were independently associated with
PN. PN has been reported to be the most important foot
complication that precipitates the development of active foot
disease, falls, and pressure injuries [3, 5–8]. Thus, our find-
ings that one in every five inpatients, including nearly one
in every two diabetes inpatients, has PN and is unlikely to
have received any past foot treatment are concerning and
highlight that further strategies are necessary to identify
and monitor these patients in both the inpatient and outpa-
tient settings [13, 33, 34]. The independent factors for foot
deformity of older age, PN, mobility impairment, and past
podiatry treatment identified in our inpatient study are also
consistent with similar outpatient literature [17, 38–40].
The association between foot deformity and PN has been
consistently identified in the diabetes literature, and our
findings suggest this link may be of similar importance in
nondiabetes patients and should be investigated further in
the future [17, 38–40].
Our overall findings suggest that foot complications that
have been commonly reported to precipitate the develop-
ment of active foot disease in the community are also present
frequently in the inpatient population and have common
factors independently associated with them, regardless of
diabetes. Further research is recommended to more precisely
determine the causal relationships for foot complications in
nondiabetes populations in particular. It is recommended
that policy makers and clinicians adopt simple hospital tri-
age procedures that identify inpatients with these foot
complications early to ensure that they do not develop
into future active foot disease, falls, or pressure injuries
whilst in hospital [1, 2, 33, 34]. These procedures could
be as simple as questioning all inpatients on admission,
particularly those with diabetes or over 60 years of age,
as to their previous foot disease history or using simple
screening tools to identify PAD, PN, and foot deformity
[1, 2, 13, 34]. Nevertheless, clinicians and policy makers
should continue to recommend inpatients identified with
foot complications be assessed and managed whilst in an
hospital and discharged to an outpatient multidisciplinary
foot team for ongoing management in order to prevent
potential hospitalisation from active foot disease, falls,
and pressure injuries in the future [1, 2, 33, 34].
Additionally, although the independent associations
between past foot treatment and most foot complications
appear encouraging in our findings, this was not the case
for PN. It could be argued that PN is the most critical foot
complication that leads to active foot disease, falls, and
pressure injuries, and thus, best practice guidelines need
to better highlight that patients with PN require ongoing
monitoring to ensure they can identify problems early to
prevent possible future hospitalisation [13, 17, 32–34].
Lastly, it is recommended that policy makers incorporate
Table 8: Independent factors associated with foot deformity (odds ratios [95% CI]).
Risk factor Unadjusted pvalue Adjusted
a
pvalue
Age groups <0.001∗No confounders identified
18–40 years Referent
41–60 years 1.76 (0.62–4.99) 0.289
61–80 years 4.67 (1.79–12.17) 0.002∗
81+ years 5.68 (2.05–15.71) 0.001∗
Mobility impairment 2.04 (1.35–3.08) 0.001∗
PN 2.20 (1.44–2.36) <0.001∗
Podiatry past foot treatment 2.06 (1.36–3.12) 0.001∗
Model 1 results Pseudo R
2
: 0.233
Omnibus: df = 6,p<0001
Missing: 32 (4.4%);
H&L: p=0938
∗p<005.
a
No confounders were identified; pseudo R
2
: Nagelkerke R
2
; omnibus: omnibus tests of model coefficients; df: degrees of freedom; missing: excluded
cases with any missing data; H&L: Hosmer and Lemeshow test; PN: peripheral neuropathy.
10 Journal of Diabetes Research

these foot complications into their existing inpatient bedside
audit programs alongside general diabetes, falls, and pressure
injury bedside audit programs [2, 10, 26]. This should enable
efficient monitoring of the influence of these foot complica-
tions on inpatient populations in the future and particularly
their impact on inpatient adverse events [1, 2].
4.1. Strengths and Limitations. This study has a number of
strengths and limitations which have been discussed
elsewhere [1, 2]. In brief, the strengths were this study
investigated a highly representative Australian inpatient pop-
ulation [1, 2, 10]; data collectors were highly experienced,
trained, and reliable in collecting validated and internation-
ally agreed definitions of clinically diagnosed foot complica-
tions [11, 14]; and multivariate logistic regression models
were used to adjust for confounding variables [1, 18, 19].
The limitations were this study was a cross-sectional study
and was unable to test for causal relationships; excluded a
large number of older cognitively impaired patients which
may have led to a more conservative prevalence estimate of
foot complications; had to aggregate minor and major
previous amputations which are arguably the result of differ-
ent causal pathways due to small numbers of both; did not
exclude patients with active foot disease; and was a secondary
analysis of a large dataset [1, 2] which increases the likelihood
of type 1 statistical error [18, 19].
5. Conclusions
This study was the first to investigate multiple foot complica-
tions in a representative inpatient population. It identified
that half of all inpatients had at least one-foot complication,
with a quarter having multiple foot complications, which
have been reported to be risk factors for the development
active foot disease, pressure injuries, or falls whilst in
hospital. The findings of this study suggest that regardless of
having diabetes or not, common factors precipitate these foot
complications. It is recommended that all inpatients are
screened for these common foot complications on admission,
particularly those with diabetes, and are managed accordingly
to potentially prevent the large burden that foot disease already
imposes on inpatient and outpatient populations.
Conflicts of Interest
The authors declare that there is no conflict of interest
regarding the publication of this article.
Acknowledgments
This work was kindly supported by grant funding from
Queensland Health (Queensland Government, Australia)
and the Wound Management Innovation Cooperative
Research Centre (Australia). The authors also wish to
warmly acknowledge the tireless work of the Queensland’s
health-employed podiatrists and Queensland University of
Technology podiatry students that undertook training,
testing, and data collection for this project. Without their
enthusiasm, this study would not have been possible.
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