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