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Female disadvantage in risk of adverse outcomes after incident diabetic foot hospitalizations: A population cohort study


Giuseppe Seghieri*, Laura Policardo, Elisa Gualdani and Paolo Francesconi  


Background: Diabetic foot disease (DFD) is more prevalent among males and is associated with an excess-risk of cardiovascular events or mortality.

Aims: This study explores the risk of next cardiovascular events, renal failure and all-cause mortality after incident DFD hospitalizations, separately in males and females to detect any gender difference in a cohort of 322,140 persons with diabetes retrospectively followed-up through administrative data-sources in Tuscany, Italy over years 2011-2018.

Methods: The hazard ratio (HR) for incident adverse outcomes after first hospitalizations for DFD categorized as: major/minor amputations (No.=449;3.89%), lower limbs’ revascularizations (LLR: No.=2854;24.75%) and lower-extremity-arterial-disease (LEAD) with no procedures (LEAD-no proc: No.=6282;54.49%), was compared to risk of patients with background-DFD (ulcers, infections, Charcot-neuroarthropathy: No.=1,944;16.86%).

Results: DFD incidence-rate was higher among males compared to females [1.57(95% CI:1.54-1.61) vs. 0.97(0.94-1.00)/100,000p-years]. After DFD the overall risk of coronary artery disease was significantly associated to male gender and that of stroke to female gender. LEAD-no proc and LLR were associated with risk of stroke risk only in females and with coronary artery disease at a significantly higher extent among women. Incident renal failure was not associated with any DFD category. Amputations and LEAD-no proc, significantly predicted mortality risk only in females while LLR reduced such risk in both genders. Females had a greater risk of composite outcome (death or cardiovascular events). When compared with background-DFD the risk was by 34% higher after amputations [HR: 1.34(1.04-1.72)] and by 10% higher after LEAD-no proc: [HR:1.10(1.03-1.18)] for LEAD-no proc, overall confirming that after incident DFD more strictly associated with vascular pathogenesis females are burdened by a greater excess-risk of adverse events.

Conclusions: After incident DFD hospitalizations, females with DFD associated with amputations or with arterial disease are burdened by a greater excess risk of subsequent adverse cardiovascular events, compared with those with background DFD.


diabetic foot disease, lower extremity arterial disease, gender differences, atherosclerotic cardiovascular events, chronic kidney disease, mortality.


Epidemiology Unit, Agenzia Regionale Sanità, Florence, Epidemiology Unit, Agenzia Regionale Sanità, Florence, Epidemiology Unit, Agenzia Regionale Sanità, Florence, Epidemiology Unit, Agenzia Regionale Sanità, Florence

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