Long-term Mortality among Patients with Chronic Ulcers
DOI:
https://doi.org/10.2340/00015555-3803Keywords:
skin ulcer, leg ulcer, peripheral arterial disease, sepsis, diabetes mellitusAbstract
Chronic ulcers cause a significant burden to patients and society. This study evaluated long-term mortality among patients with chronic ulcers diagnosed at a dermatology clinic between 1980 and 2010. The mortality risk and causes of death of 3,489 patients with ulcers were compared with a matched reference group of 10,399 individuals, and factors associated with increased mortality risk were examined. Long-term mortality was increased in patients with chronic ulcers (hazard ratio (HR) 1.74) and in both males and females (HR 1.99 and 1.62, respectively). Diabetes was the most relevant underlying cause of death (HR 8.98), and of the immediate causes of death, sepsis was strongly associated with mortality (HR 5.86). The mortality risk was highest among those with arterial ulcers (HR 2.85), but also increased in patients with atypical, mixed and venous leg ulcers. In conclusion, patients with chronic ulcers are at an increased mortality risk irrespective of age, sex and ulcer aetiology.
Downloads
References
Martin P, Nunan R. Cellular and molecular mechanisms of repair in acute and chronic wound healing. Br J Dermatol 2015; 173: 370-378.
DOI: https://doi.org/10.1111/bjd.13954
Kyaw BM, Järbrink K, Martinengo L, Car J, Harding K, Schmidtchen A. Need for improved definition of "chronic wounds" in clinical studies. Acta Derm Venereol 2018; 98: 157-158.
DOI: https://doi.org/10.2340/00015555-2786
Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provison of care. BMJ 1985; 290: 1855-1856.
DOI: https://doi.org/10.1136/bmj.290.6485.1855
Nelzén O, Bergqvist D, Lindhagen A. The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire. Br J Surg 1996; 83: 255-258.
DOI: https://doi.org/10.1002/bjs.1800830235
Graham ID, Harrison MB, Nelson EA, Lorimer K, Fischer A. Prevalence of lower-limb ulceration: a systematic review of prevalence studies. Adv Skin Wound Care 2003; 16: 305-316.
DOI: https://doi.org/10.1097/00129334-200311000-00013
Nussbaum SR, Carter MJ, Fife CE, DaVanzo J, Haught R, Nusgart M et al. An economic evaluation of the impact, cost, and Medicare policy implications of chronic nonhealing wounds. Value Health 2018; 21: 27-32.
DOI: https://doi.org/10.1016/j.jval.2017.07.007
Guest JF, Ayoub N, Mcllwraith T, Uchegbu I, Gerrish A, Weidlich D et al. Health economy burden that wounds impose on the National Health Service in the UK. BMJ Open 2015; 5: e009283.
DOI: https://doi.org/10.1136/bmjopen-2015-009283
United Nations, Department of Economic and Social Affairs, Population Division. World Population Ageing 2019: Highlights (ST/ESA/SER.A/430). 2019. [Accessed 2020 Sept 19]. Available from: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WorldPopulationAgeing2019-Highlights.pdf.
Heyer K, Herberger K, Protz K, Glaeske G, Augustin M. Epidemiology of chronic wounds in Germany: analysis of statutory health insurance data. Wound Repair Regen 2016; 24: 434-442.
DOI: https://doi.org/10.1111/wrr.12387
Moffatt CJ, Doherty DC, Smithdale R, Franks PJ. Clinical predictors of leg ulcer healing. Br J Dermatol 2010; 162: 51-58.
DOI: https://doi.org/10.1111/j.1365-2133.2009.09397.x
Guest JF, Vowden K, Vowden P. The health economic burden that acute and chronic wounds impose on an average clinical commissioning group/health board in the UK. J Wound Care 2017; 26: 292-303.
DOI: https://doi.org/10.12968/jowc.2017.26.6.292
Körber A, Klode J, Al-Benna S, Wax C, Schadendorf D, Steinstraesser L et al. Etiology of chronic leg ulcers in 31,619 patients in Germany analyzed by an expert survey. J Dtsch Dermatol Ges 2011; 9: 116-121.
DOI: https://doi.org/10.1111/j.1610-0387.2010.07535.x
Jockenhöfer F, Gollnick H, Herberger K, Isbary G, Renner R, Stücker M, et al. Aetiology, comorbidities and cofactors of chronic leg ulcers: retrospective evaluation of 1000 patients from 10 specialised dermatological wound care centers in Germany. Int Wound J 2016; 13: 821-828.
DOI: https://doi.org/10.1111/iwj.12387
Apollonio A, Antignani PL, Di Salvo M, Failla G, Guarnera G, Mosti G, et al. A large Italian observational multicentre study on vascular ulcers of the lower limbs (Studio Ulcere Vascolari). Int Wound J 2014; 13: 27-34.
DOI: https://doi.org/10.1111/iwj.12216
Isoherranen K, O'Brien JJ, Barker J, Dissemond J, Hafner J, Jemec GBE, et al. Atypical wounds. Best clinical practices and challenges. J Wound Care 2019; 28: 1-92.
DOI: https://doi.org/10.12968/jowc.2019.28.Sup6.S1
Kirsner RS, Vivas AC. Lower-extremity ulcers: diagnosis and management. Br J Dermatol 2015; 173: 379-390.
DOI: https://doi.org/10.1111/bjd.13953
Morton LM, Phillips TJ. Wound healing and treating wounds: differential diagnosis and evaluation of chronic wounds. J Am Acad Dermatol 2016; 74: 589-605.
DOI: https://doi.org/10.1016/j.jaad.2015.08.068
Renner R, Seikowski K, Simon JC. Association of pain level, health and wound status in patients with chronic leg ulcers. Acta Derm Venereol 2014; 94: 50-53.
DOI: https://doi.org/10.2340/00015555-1635
Nelzén O, Bergqvist D, Lindhagen A. Long-term prognosis for patients with chronic leg ulcers: a prospective cohort study. Eur J Vasc Endovasc Surg 1997; 13: 500-508.
DOI: https://doi.org/10.1016/S1078-5884(97)80179-7
Iversen MM, Tell GS, Riise T, Hanestad BR, Østbye T, Graue M, et al. History of foot ulcer increases mortality among individuals with diabetes: ten-year follow-up of the Nord-Trøndelag Health Study, Norway. Diabetes Care 2009; 32: 2193-2199.
DOI: https://doi.org/10.2337/dc09-0651
Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: more lethal than we thought? Adv Skin Wound Care 2005; 18: 367-372.
DOI: https://doi.org/10.1097/00129334-200509000-00010
Landi F, Onder G, Russo A, Bernabei R. Pressure ulcer and mortality in frail elderly people living in community. Arch Gerontol Geriatr 2007; 44: 217-223.
DOI: https://doi.org/10.1016/j.archger.2007.01.030
Zarchi K, Martinussen T, Jemec GBE. Wound healing and all-cause mortality in 958 wound patients treated in home care. Wound Repair Regen 2015; 23: 753-758.
DOI: https://doi.org/10.1111/wrr.12335
Kreft D, Keiler J, Grambow E, Kischkel S, Wree A, Doblhammer G. Prevalence and mortality of venous leg diseases of the deep veins: an observational cohort study based on German Health Claims Data. Angiology 2020; 71: 452-464.
DOI: https://doi.org/10.1177/0003319720905751
Kimpimäki T, Huotari-Orava R, Antonen J, Vaalasti A. Increased incidence of cutaneous vasculitic ulcers: 30-year results from a population-based retrospective study. Acta Derm Venereol 2017; 97: 653-654.
DOI: https://doi.org/10.2340/00015555-2608
Statistics Finland, Classification of causes of death. [Accessed 2020 Nov 22]. Available from: https://www.stat.fi/en/luokitukset/kuolinsyyt/kuolinsyyt_61_19960101/0/.
Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT, et al. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care 2012; 35: 2021-2027.
DOI: https://doi.org/10.2337/dc12-0200
Ghanassia E, Villon L, Thuan Dit Dieudonné JF, Boegner C, Avignon A, Sultan A. Long-term outcome and disability of diabetic patients hospitalized for diabetic foot ulcers: a 6.5-year follow-up study. Diabetes Care 2008; 31: 1288-1292.
DOI: https://doi.org/10.2337/dc07-2145
Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008; 51: 747-755.
DOI: https://doi.org/10.1007/s00125-008-0940-0
Chammas NK, Hill RLR, Edmonds ME. Increased mortality in diabetic foot ulcer patients: the significance of ulcer type. J Diabetes Res 2016; 2016: 2879809.
DOI: https://doi.org/10.1155/2016/2879809
Golomb BA, Dang TT, Criqui MH. Peripheral arterial disease: morbidity and mortality implications. Circulation 2006; 114: 688-699.
DOI: https://doi.org/10.1161/CIRCULATIONAHA.105.593442
Criqui MH, Langer RD, Fronek A, Feigelson HS, Klauber MR, McCann TJ et al. Mortality over a period of 10 years in patients with peripheral arterial disease. N Engl J Med 1992; 326: 381-386.
DOI: https://doi.org/10.1056/NEJM199202063260605
Wallace ZS, Fu X, Harkness T, Stone JH, Zhang Y, Choi H. All-cause and cause-specific mortality in ANCA-associated vasculitis: overall and according to ANCA type. Rheumatology (Oxford) 2020; 59: 2308-2315.
DOI: https://doi.org/10.1093/rheumatology/kez589
Arora A, Wetter DA, Gonzalez-Santiago TM, Davis MD, Lohse CM. Incidence of leukocytoclastic vasculitis, 1996 to 2010: a population-based study in Olmsted County, Minnesota. Mayo Clin Proc 2014; 89: 1515-1524.
DOI: https://doi.org/10.1016/j.mayocp.2014.04.015
Turesson C, Jacobsson L, Bergstrom U. Extra-articular rheumatoid arthritis: prevalence and mortality. Rheumatology (Oxford) 1999; 38: 668-674.
DOI: https://doi.org/10.1093/rheumatology/38.7.668
Voskuyl AE, Zwinderman AH, Westedt ML, Vandenbroucke JP, Breedveld FC, Hazes JM. The mortality of rheumatoid vasculitis compared with rheumatoid arthritis. Arthritis Rheum 1996; 39: 266-271.
DOI: https://doi.org/10.1002/art.1780390213
Langan SM, Groves RW, Card TR, Gulliford MC. Incidence, mortality, and disease associations of pyoderma gangrenosum in the United Kingdom: a retrospective cohort study. J Invest Dermatol 2012; 132: 2166-2170.
DOI: https://doi.org/10.1038/jid.2012.130
Rosella LC, Calzavara A, Frank JW, Fitzpatrick T, Donnelly PD, Henry D. Narrowing mortality gap between men and women over two decades: a registry-based study in Ontario, Canada. BMJ Open 2016; 6: e012564.
DOI: https://doi.org/10.1136/bmjopen-2016-012564
Escandon J, Vivas AC, Tang J, Rowland KJ, Kirsner RS. High mortality in patients with chronic wounds. Wound Repair Regen 2011; 19: 526-528.
DOI: https://doi.org/10.1111/j.1524-475X.2011.00699.x
Hansson C, Andersson E, Swanbeck G. A follow-up study of leg and foot ulcer patients. Acta Derm Venereol 1987; 67: 496-500.
Published
How to Cite
Issue
Section
Categories
License
Copyright (c) 2021 Jenni E. Salenius, Minna Suntila, Tiina Ahti, Heini Huhtala, Annikki Vaalasti, Teea T. Salmi, Teija Kimpimäki
![Creative Commons License](http://i.creativecommons.org/l/by-nc/4.0/88x31.png)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All digitalized ActaDV contents is available freely online. The Society for Publication of Acta Dermato-Venereologica owns the copyright for all material published until volume 88 (2008) and as from volume 89 (2009) the journal has been published fully Open Access, meaning the authors retain copyright to their work.
Unless otherwise specified, all Open Access articles are published under CC-BY-NC licences, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for non-commercial purposes, provided proper attribution to the original work.