The impact of the organizational arrangements of health systems on lower extremity amputation in people with type 2 diabetes and foot ulcers: retrospective analyses of routine data from England and Scotland
Creators: name: MEZA-TORRES, BERNARDO
Publisher: name: University of Surrey
Year: 2022

description: <b>Background:</b> Diabetic foot ulcers (DFU) are an important complication of people with type 2 diabetes
description: (T2D), associated to high mortality and lower extremity amputation (LEA) rates. There is a gap of
description: knowledge on how LEA, as an outcome for DFU, can be independently affected by the processes of
description: care of different health systems.<br>
description: <br>
description: <b>Aim:</b> To inform health policy through an analysis of the variation in the quality of care of people who
description: have DFUs complicating their T2D. The study includes the impact of health system organizational
description: determinants on the complications of DFU including LEA in England and Scotland.<br>
description: <br>
description: <b>Methods:</b> The general research methodology was positivist and based on published evidence and my
description: own analyses of routine health data.<br>
description: <br>
description: The Donabedian hierarchical model was used for evaluation studies, together with other international
description: frameworks, to organise the data. How context and mechanism might impact a change in outcomes
description: was explored using the critical realist approach of Pawson &amp; Tilley. This involved associations between
description: health service organisation, quality markers and outcomes, using routinely collected data from
description: registries in England and Scotland. Time-to-event analyses with a retrospective cohort design were
description: conducted for both countries.<br>
description: <br>
description: <b>Results:</b> Higher adherence to bundled care-processes was associated to better outcomes, amputationfree survival, after presenting foot complications in both England and Scotland.<br>
description: <br>
description: Specific organizational arrangements have the potential to decrease the rate of major LEA in people
description: with T2D and DFU, within the bounds of existing health systems’ structures.<br>
description: <br>
description: Retrospective observational studies using routine data can be useful to monitor and evaluate
description: organizational arrangements as exposures for low-incidence complications in T2D.<br>
description: <br>
description: <b>Conclusions:</b> The thesis contributes to public reporting and benchmarking of performance indicators
description: to promote quality improvements in people with chronic conditions.<br>
description: <br>
description: Clinicians and health systems should target and engage high-risk patients at an early stage, through
description: the optimal provision of bundled care-processes before the occurrence DFUs, and prompt specialist
description: referral following a DFU. Further research is needed to design care pathways for those not receiving
description: adequate assistance prior to foot ulceration.<br>
description: <br>
description: The results should be interpreted within the macro-level structures of healthcare systems, where
description: adherence to the bundled care-processes depends on both patients and providers.<br>