{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T11:15:06Z","timestamp":1783509306974,"version":"3.55.0"},"reference-count":31,"publisher":"MDPI AG","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,11]]},"abstract":"<jats:p>\n                    <jats:bold>Background:<\/jats:bold>\n                    Diabetic foot ulcers are a leading cause of major limb amputations in diabetic patients. Timely intervention through early diagnosis of vascular insufficiency and aggressive ulcer management may mitigate these risks. This study evaluated the relationship between early and delayed referral pattern and major amputation and the impact of the coronavirus disease (COVID) 2019 pandemic on associated rates.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Methods:<\/jats:bold>\n                    This retrospective cohort study analyzed records from type 2 diabetic patients over 30 years old with lower-extremity ulcers treated at Western Michigan Health clinics between June 1, 2018, and December 31, 2021. The study period was divided into pre-COVID (59 patients) and intra-COVID (92 patients) phases. Patients were followed until diabetic foot ulcer resolution, death, amputation, or loss to follow-up. Early referral was defined as within 4 weeks after ulcer diagnosis. Referral rates to specialists and the use of noninvasive studies such as the ankle-brachial index were examined.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Results:<\/jats:bold>\n                    Overall, 151 patients met the inclusion criteria. A total of 11 underwent major amputations, with a trend toward increased rates during the intra-COVID period. There was no significant difference in major amputation rates between early and delayed referrals. Although many of the major amputations had early referrals, this was likely due to late presentation. The study highlighted significant underutilization of noninvasive imaging, with only 37% of patients undergoing ankle-brachial index testing. Wound documentation inconsistencies and variability undermined the reliability of findings and patient treatment. No protocol was identified in ulcer management.\n                  <\/jats:p>\n                  <jats:p>\n                    <jats:bold>Conclusions:<\/jats:bold>\n                    Delayed referrals did not significantly affect major amputation rates, suggesting that factors other than referral timing may influence outcomes. The COVID-19 pandemic led to an increase in amputation rates, possibly owing to pandemic-related lapses in care. Underutilization of noninvasive vascular studies and lack of consistent treatment protocols represent missed opportunities for early intervention. Enhanced provider training, protocol-driven care, and consistent use of noninvasive vascular studies may help prevent major amputations.\n                  <\/jats:p>","DOI":"10.7547\/24-036","type":"journal-article","created":{"date-parts":[[2025,12,16]],"date-time":"2025-12-16T14:40:03Z","timestamp":1765896003000},"source":"Crossref","is-referenced-by-count":0,"title":["Impact of COVID-19 Pandemic on Diabetic Foot Ulcer Management in Kalamazoo, Michigan"],"prefix":"10.3390","volume":"115","author":[{"given":"Mason","family":"Gonzales","sequence":"first","affiliation":[{"name":"Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tucker","family":"Morris","sequence":"additional","affiliation":[{"name":"Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nikoli","family":"Nickson","sequence":"additional","affiliation":[{"name":"Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Young","sequence":"additional","affiliation":[{"name":"Department of Biomedical Informatics, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Krishna","family":"Jain","sequence":"additional","affiliation":[{"name":"Center for Clinical Research, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI."}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","reference":[{"key":"B1","unstructured":"US Centers for Disease Control and Prevention: National diabetes statistics report. Available at: https:\/\/www.cdc.gov\/diabetes\/php\/data-research\/?CDC_AAref_Val=https:\/\/jwww.cdc.gov\/diabetes\/pdfs\/data\/statistics\/national-diabetes-statistics-report.pdf. Accessed June 12, 2023."},{"key":"B2","series-title":"Diabetes in America","first-page":"409","article-title":"Lower extremity foot ulcers and amputations in diabetes","author":"Reiber GE","year":"1995","unstructured":"Reiber GE, Boyko EJ, Smith DG: \u201cLower extremity foot ulcers and amputations in diabetes,\u201d in Diabetes in America, 2nd Ed, edited by MI Harris, C Cowie, MP Stern, p 409, National Diabetes Information Clearinghouse, Bethesda, MD, 1995."},{"key":"B3","series-title":"Diabetes Care","first-page":"513","article-title":"Pathways to diabetic limb amputation. Basis for prevention","volume":"13","author":"Pecoraro RE","year":"1990","unstructured":"Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13: 513, 1990."},{"key":"B4","series-title":"World J Clin Cases","first-page":"1684","article-title":"Diabetic foot ulcer: a comprehensive review of pathophysiology and management modalities","volume":"11","author":"Raja JM","year":"2023","unstructured":"Raja JM, Maturana MA, Kayali S, et al: Diabetic foot ulcer: a comprehensive review of pathophysiology and management modalities. World J Clin Cases 11: 1684, 2023."},{"key":"B5","series-title":"Foot Ankle Int","first-page":"716","article-title":"Clinical characteristics and outcome in 223 diabetic patients with deep foot infections","volume":"18","author":"Eneroth M","year":"1997","unstructured":"Eneroth M, Apelqvist J, Stenstr\u00f6m A: Clinical characteristics and outcome in 223 diabetic patients with deep foot infections. Foot Ankle Int 18: 716, 1997."},{"key":"B6","series-title":"J Wound Care","first-page":"186","article-title":"Delayed referral of patients with diabetic foot ulcers across Europe: patterns between primary care and specialised units","volume":"27","author":"Manu C","year":"2018","unstructured":"Manu C, Lacopi E, Bouillet B, et al: Delayed referral of patients with diabetic foot ulcers across Europe: patterns between primary care and specialised units. J Wound Care 27: 186, 2018."},{"key":"B7","series-title":"PLoS One","first-page":"e0177176","article-title":"Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: a retrospective cohort study","volume":"12","author":"Smith-Str\u00f8m H","year":"2017","unstructured":"Smith-Str\u00f8m H, Iversen MM, Igland J, et al: Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: a retrospective cohort study. PLoS One 12: e0177176, 2017."},{"key":"B8","series-title":"Angiology","first-page":"242","article-title":"Factors associated with ulcer healing and quality of life in patients with diabetic foot ulcer","volume":"68","author":"Spanos K","year":"2017","unstructured":"Spanos K, Saleptsis V, Athanasoulas A, et al: Factors associated with ulcer healing and quality of life in patients with diabetic foot ulcer. Angiology 68: 242, 2017."},{"key":"B9","series-title":"Bone Jt Open","first-page":"93","article-title":"How we managed elective, urgent, and emergency orthopedic surgery during the COVID-19 pandemic: the Milan metropolitan area experience","volume":"1","author":"Giorgi PD","year":"2020","unstructured":"Giorgi PD, Gallazzi E, Capitani P, et al: How we managed elective, urgent, and emergency orthopedic surgery during the COVID-19 pandemic: the Milan metropolitan area experience. Bone Jt Open 1: 93, 2020."},{"key":"B10","series-title":"J Vasc Surg","first-page":"772","article-title":"The impact of the COVID-19 pandemic on vascular surgery practice in the United States","volume":"73","author":"Mouawad NJ","year":"2021","unstructured":"Mouawad NJ, Woo K, Malgor RD, et al: The impact of the COVID-19 pandemic on vascular surgery practice in the United States. J Vasc Surg 73: 772, 2021."},{"key":"B11","series-title":"BMC Fam Pract","first-page":"208","article-title":"Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia","volume":"21","author":"Coma E","year":"2020","unstructured":"Coma E, Mora N, M\u00e9ndez L, et al: Primary care in the time of COVID-19: monitoring the effect of the pandemic and the lockdown measures on 34 quality of care indicators calculated for 288 primary care practices covering about 6 million people in Catalonia. BMC Fam Pract 21: 208, 2020."},{"key":"B12","series-title":"Int Wound J","first-page":"63","article-title":"Effects of the COVID\u201019 pandemic on the outcome and mortality of patients with diabetic foot ulcer","volume":"20","author":"Rubin G","year":"2023","unstructured":"Rubin G, Feldman G, Dimri I, et al: Effects of the COVID\u201019 pandemic on the outcome and mortality of patients with diabetic foot ulcer. Int Wound J 20: 63, 2023."},{"key":"B13","series-title":"Ann Fam Med","first-page":"63","article-title":"Impact of the COVID-19 pandemic on primary health care disease incidence rates: 2017 to 2020","volume":"20","author":"Sis\u00f3-Almirall A","year":"2022","unstructured":"Sis\u00f3-Almirall A, Kostov B, S\u00e1nchez E, et al: Impact of the COVID-19 pandemic on primary health care disease incidence rates: 2017 to 2020. Ann Fam Med 20: 63, 2022."},{"key":"B14","series-title":"Diabetes Care","first-page":"1288","article-title":"Risk factors for foot infections in individuals with diabetes","volume":"29","author":"Lavery LA","year":"2006","unstructured":"Lavery LA, Armstrong DG, Wunderlich RP, et al: Risk factors for foot infections in individuals with diabetes. Diabetes Care 29: 1288, 2006."},{"key":"B15","series-title":"Scand J Infect Dis","first-page":"497","article-title":"The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds","volume":"45","author":"Mutluoglu M","year":"2013","unstructured":"Mutluoglu M, Sivrioglu AK, Eroglu M, et al: The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds. Scand J Infect Dis 45: 497, 2013."},{"key":"B16","series-title":"Diabetologia","first-page":"747","article-title":"Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE study","volume":"51","author":"Prompers L","year":"2008","unstructured":"Prompers L, Schaper N, Apelqvist J, 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 51: 747, 2008."},{"key":"B17","series-title":"Fed Pract","first-page":"16","article-title":"Management of diabetic foot ulcers: a review","volume":"33","author":"Frykberg RG","year":"2016","unstructured":"Frykberg RG, Banks J: Management of diabetic foot ulcers: a review. Fed Pract 33: 16, 2016."},{"key":"B18","series-title":"J Vasc Surg","first-page":"1433","article-title":"A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers","volume":"71","author":"Musuuza J","year":"2020","unstructured":"Musuuza J, Sutherland BL, Kurter S, et al: A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. J Vasc Surg 71: 1433, 2020."},{"key":"B19","series-title":"Aust J Gen Pract","first-page":"250","article-title":"The diabetic foot ulcer","volume":"49","author":"Reardon R","year":"2020","unstructured":"Reardon R, Simring D, Kim B, et al: The diabetic foot ulcer. Aust J Gen Pract 49: 250, 2020."},{"key":"B20","series-title":"J Diabetes Sci Technol","first-page":"792","article-title":"Near infrared wound monitor helps clinical assessment of diabetic foot ulcers","volume":"4","author":"Neidrauer M","year":"2010","unstructured":"Neidrauer M, Zubkov L, Weingarten MS, et al: Near infrared wound monitor helps clinical assessment of diabetic foot ulcers. J Diabetes Sci Technol 4: 792, 2010."},{"issue":"suppl 3","key":"B21","series-title":"J Vasc Surg","first-page":"23S","article-title":"Toe and flow: essential components and structure of the amputation prevention team","volume":"52","author":"Rogers LC","year":"2010","unstructured":"Rogers LC, Andros G, Caporusso J, et al: Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg 52(suppl 3): 23S, 2010."},{"key":"B22","series-title":"Diabet Med","first-page":"526","article-title":"Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers","volume":"6","author":"Apelqvist J","year":"1989","unstructured":"Apelqvist J, Castenfors J, Larsson J, et al: Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers. Diabet Med 6: 526, 1989."},{"key":"B23","series-title":"Diabetes Care","first-page":"84","article-title":"A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems","volume":"24","author":"Oyibo SO","year":"2001","unstructured":"Oyibo SO, Jude EB, Tarawneh I, et al: A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes Care 24: 84, 2001."},{"key":"B24","series-title":"J Vasc Surg","first-page":"939","article-title":"The Society for Vascular Surgery lower extremity threatened limb classification system based on wound, ischemia, and foot infection (WIfI) correlates with risk of major amputation and time to wound healing","volume":"61","author":"Zhan LX","year":"2015","unstructured":"Zhan LX, Branco BC, Armstrong DG, et al: The Society for Vascular Surgery lower extremity threatened limb classification system based on wound, ischemia, and foot infection (WIfI) correlates with risk of major amputation and time to wound healing. J Vasc Surg 61: 939, 2015."},{"key":"B25","series-title":"JMIR Mhealth Uhealth","first-page":"e20203","article-title":"Factors impacting clinicians\u2019 adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care: qualitative case study","volume":"8","author":"Jacob C","year":"2020","unstructured":"Jacob C, Sanchez-Vazquez A, Ivory C: Factors impacting clinicians\u2019 adoption of a clinical photo documentation app and its implications for clinical workflows and quality of care: qualitative case study. JMIR Mhealth Uhealth 8: e20203, 2020."},{"key":"B26","series-title":"Int Wound J","first-page":"314","article-title":"Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement","volume":"11","author":"Khalil H","year":"2014","unstructured":"Khalil H, Cullen M, Chambers H, et al: Implementation of a successful electronic wound documentation system in rural Victoria, Australia: a subject of collaboration and community engagement. Int Wound J 11: 314, 2014."},{"key":"B27","series-title":"Br J Nurs","first-page":"1342","article-title":"The importance of wound documentation and classification","volume":"8","author":"Russell L","year":"1999","unstructured":"Russell L: The importance of wound documentation and classification. Br J Nurs 8: 1342, 1999."},{"key":"B28","series-title":"Cureus","first-page":"e21501","article-title":"Wagner\u2019s classification as a tool for treating diabetic foot ulcers: our observations at a suburban teaching hospital","volume":"14","author":"Shah P","year":"2022","unstructured":"Shah P, Inturi R, Anne D, et al: Wagner\u2019s classification as a tool for treating diabetic foot ulcers: our observations at a suburban teaching hospital. Cureus 14: e21501, 2022."},{"key":"B29","series-title":"J Vasc Surg Venous Lymphat Disord","first-page":"570","article-title":"Standardized care protocol and modifications to electronic medical records to facilitate venous ulcer healing","volume":"7","author":"Bitner J","year":"2019","unstructured":"Bitner J, Sachdev U, Hager ES, et al: Standardized care protocol and modifications to electronic medical records to facilitate venous ulcer healing. J Vasc Surg Venous Lymphat Disord 7: 570, 2019."},{"key":"B30","series-title":"Medicine (Baltimore","first-page":"e12319","article-title":"Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout","volume":"97","author":"Robinson KE","year":"2018","unstructured":"Robinson KE, Kersey JA: Novel electronic health record (EHR) education intervention in large healthcare organization improves quality, efficiency, time, and impact on burnout. Medicine (Baltimore) 97: e12319, 2018."},{"key":"B31","series-title":"BMC Health Serv Res","first-page":"503","article-title":"Training providers: beyond the basics of electronic health records","volume":"13","author":"Bredfeldt CE","year":"2013","unstructured":"Bredfeldt CE, Awad EB, Joseph K, et al: Training providers: beyond the basics of electronic health records. BMC Health Serv Res 13: 503, 2013."}],"container-title":["Journal of the American Podiatric Medical Association"],"original-title":[],"link":[{"URL":"https:\/\/japmaonline.org\/view\/journals\/apms\/115\/6\/24-036.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/japmaonline.org\/downloadpdf\/journals\/apms\/115\/6\/24-036.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/japmaonline.org\/downloadpdf\/journals\/apms\/115\/6\/24-036.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,8]],"date-time":"2026-07-08T10:20:28Z","timestamp":1783506028000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1930-8264\/115\/6\/24036"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,11]]},"references-count":31,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.7547\/24-036","relation":{},"ISSN":["8750-7315"],"issn-type":[{"value":"8750-7315","type":"print"}],"subject":[],"published":{"date-parts":[[2025,11]]}}}