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1. Introduction
Among the various chronic complications that are associated with diabetes mellitus, diabetic foot disease (DFD) is highly frequent, being associated with significant morbidity, mortality, and costs. DFD includes an array of medical conditions, mainly resulting from diabetic peripheral neuropathy and arterial disease, which can lead to foot ulceration. Diabetic foot ulceration may progress with wound infection, osteomyelitis, and, ultimately, amputation. As a result, DFD burden is significant, resulting in major economic consequences for patients, their families, and society.
The global prevalence of DFD varies between 3% in Oceania to 13% in North America, with a global average of 6.4% [1]. It has been estimated in 2015 that each year foot ulcers develop in 9.1 million to 26.1 million people with diabetes worldwide [2]. Furthermore, the incidence of diabetic foot is expected to increase due to the increasing trends in diabetes prevalence and prolonged life expectancy of diabetic patients. In developing countries, 25% of patients with diabetes will develop at least one foot ulcer during their lifetime [3]. More recent evidence suggest that the lifetime incidence of foot ulcers is even higher, between 19% and 34% [4].
Foot ulcers and amputation are more common in low and middle-income countries [5]. However, in such a setting, evidence on the epidemiology of DFD is still lacking. The first comprehensive study of DFD in Brazil, the Brazilian Cooperative Study on Ulcer, Severe Peripheral Neuropathy and Amputation (BRAZUPA), conducted from 2012-2014, evaluated 1055 diabetic individuals in order to gather data on the current situation of foot at risk throughout the nation. A quarter (25.3%) of patients referred previous foot of ulcer, 13.7% amputation (of which 17.3% major amputations), and 5.3% reported history of more than one amputation [6].
A recent review of the economic consequences of diabetic foot lesions indicate that despite the different methods that were used, significant evidence from the literature confirm the substantial economic consequences of diabetic foot lesions [7]. Healthcare costs are five times higher in diabetic individuals with foot ulcers when compared to without foot ulcers [8]. These costs are mainly related to hospitalization, which is more frequent in diabetic individuals with DFD, but also healthcare costs of the clinical management of outpatients with DFD.
Limited evidence is available on the costs of...