Sociodemographic inequalities in onset, mortality and prognosis among patients developing diabetic foot ulcers: a flexible parametric analysis

Aim: Inequalities in diabetic foot ulcer (DFU) outcomes are driven by several factors including sociodemographic factors. This study examined the intersectional risks of ethnicity, sex, and deprivation on DFU progression, which prior research often evaluated in isolation. Methods: A retrospective cohort study (2009 - 2024) of 2,125 patients at Lancashire Teaching Hospitals Trust utilized flexible parametric survival modelling. Models assessed DFU onset, overall mortality, and post-clinic prognostic survival, adjusting for demographics and comorbidities. Results: The most deprived patients presented significantly younger (median 64 vs. 73 years). Male sex accelerated DFU onset (HR: 1.24) and increased overall mortality risk (HR: 1.14). Black patients presented older with higher comorbidity burdens but paradoxically exhibited lower overall mortality risk (HR: 0.49). Deprivation heavily impacted life expectancy as the most deprived group showed higher mortality rates (HR: 0.73) and reduced 5-year prognostic survival (48.7% vs. 59.1%). Presence of comorbidities linearly increased overall mortality risk. Furthermore, severe deprivation caused greater overall life-years lost in men (4.0) than women (2.5). Conclusions: Patient outcomes with DFU are heavily influenced by cumulative demographic and socioeconomic factors. Effective management requires accessible, holistic care that actively accommodates these complex biosocial-economic realities.