Stratification of Highest-Risk Patients with Chronic Skin Ulcers in a Stanford Retrospective Cohort Includes Diabetes, Need for Systemic Antibiotics, and Albumin Levels
Chronic nonsurgical skin wounds such as venous stasis and diabetic ulcers have been associated with a number of comorbid conditions; however, the strength of these associations has not been compared. We utilized the Stanford Translational Research Integrated Database Environment (STRIDE) system to identify a cohort of 637 patients with chronic skin ulcers. Preliminary analysis ( ) showed that 49.7% of the patients had a poor prognosis such as amputation or a nonhealing ulcer for at least a year. Factors significantly associated ( ) with these outcomes included diabetes mellitus, chronic kidney disease, peripheral neuropathy, peripheral arterial disease, and need for systemic antibiotics. Patients with poor outcomes also tended to have lower hemoglobin levels ( ), higher WBC levels ( ), and lower albumin levels ( ). On multivariate analysis, however, only diabetes mellitus (OR 5.87, 1.36–25.3), need for systemic antibiotics (OR 3.88, 1.06–14.2), and albumin levels (0.20 per unit, 0.07–0.60) remained significant independent predictors of poor wound-healing outcomes. These data identify patients at the highest risk for poor wound-healing and who may benefit the most from more aggressive wound care and treatment. 1. Introduction Chronic wounds cause a significant morbidity and financial expense in the United States, affecting 6.5 million patients with estimated treatment costs of $25 billion per year [1, 2]. Venous leg ulcers, the most common type of chronic skin wound, alone affect more than 1 million US citizens per year with an associated annual cost of $2.5 billion [3, 4]. Of these patients, only 50% effectively heal, affecting both quality of life and requiring long-term care. Moreover, in the diabetic population, numbering approximately 17 million patients in the United States, nonhealing foot ulcers can become life threatening if infected and confer a 15% increased risk of amputation compared to the general population [5–8]. A number of factors have been documented in the medical literature which predispose patients to poor wound healing. These include underlying diseases such as diabetes mellitus, venous insufficiency, peripheral arterial disease, tobacco smoking, low serum albumin, and inflammatory conditions (such as pyoderma gangrenosum) among others [8–15]. According to a recent report, chronic kidney disease (CKD), hypertension, and myocardial ischemia may also be associated with increased risk of developing foot ulcers including severe ulcers that necessitate amputation [16, 17]. Additionally, there are reports of higher rates of malnutrition
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