A model to estimate cost-savings in diabetic foot ulcer prevention efforts

Cost-effectiveness of temperature monitoring to help prevent foot ulcer recurrence in people with diabetes: A multicenter randomized controlled trial

AIMS

Diabetes-related foot ulcers are common, costly, and frequently recur. Multiple interventions help prevent these ulcers. However, none of these have been prospectively investigated for cost-effectiveness. Our aim was to evaluate the cost-effectiveness of at-home skin temperature monitoring to help prevent diabetes-related foot ulcer recurrence.

MATERIALS AND METHODS

Multicenter randomized controlled trial. We randomized 304 persons at high diabetes-related foot ulcer risk to either usual foot care plus daily at-home foot skin temperature monitoring (intervention) or usual care alone (control). Primary outcome was cost-effectiveness based on foot care costs and quality-adjusted life years (QALY) during 18 months follow-up. Foot care costs included costs for ulcer prevention (e.g., footwear, podiatry) and for ulcer treatment when required (e.g., consultation, hospitalisation, amputation). Incremental cost-effectiveness ratios were calculated for intervention versus usual care using probabilistic sensitivity analysis for willingness-to-pay/accept levels up to €100,000.

RESULTS

The intervention had a 45% probability of being cost-effective at a willingness-to-accept of €50,000 per QALY lost. This resulted from (non-significantly) lower foot care costs in the intervention group (€6067 vs. €7376; p = 0.45) because of (significantly) fewer participants with ulcer recurrence(s) in 18 months (36% vs. 47%; p = 0.045); however, QALYs were (non-significantly) lower in the intervention group (1.09 vs. 1.12; p = 0.35), especially in those without foot ulcer recurrence (1.09 vs. 1.17; p = 0.10).

CONCLUSIONS

At-home skin temperature monitoring for diabetes-related foot ulcer prevention compared with usual care is at best equally cost-effective. The intervention resulted in cost-savings due to preventing foot ulcer recurrence and related costs, but this came at the expense of QALY loss, potentially from self-monitoring burdens.

Patients, carers and healthcare providers' perspectives on a patient-owned surveillance system for diabetic foot ulcer care: A qualitative study

Objective

Digital health has recently gained a foothold in monitoring and improving diabetes care. We aim to explore the views of patients, carers and healthcare providers (HCPs) regarding the use of a novel patient-owned wound surveillance application as part of outpatient management of patients with diabetic foot ulcers (DFUs).

Methods

Semi-structured online interviews were conducted with patients, carers and HCPs in wound care for DFUs. The participants were recruited from a primary care polyclinic network and two tertiary hospitals in Singapore, within the same healthcare cluster. Purposive maximum variation sampling was used to select participants with differing attributes to ensure heterogeneity. Common themes relating to the wound imaging app were captured.

Results

A total of 20 patients, 5 carers and 20 HCPs participated in the qualitative study. None of the participants have used a wound imaging app before. Regarding a patient-owned wound surveillance app, all were open and receptive to the system and workflow for use in DFU care. Four major themes emerged from patients and carers: (1) technology, (2) application features and usability, (3) feasibility of using the wound imaging application and (4) logistics of care. Four major themes were identified from HCPs: (1) attitudes towards wound imaging app, (2) preferences regarding functionality, (3) perceived challenges for patients/carers and (4) perceived barriers for HCPs.

Conclusion

Our study highlighted several barriers and facilitators from patients, carers and HCPs regarding the use of a patient-owned wound surveillance app. These findings demonstrate the potential of digital health and areas to improve and tailor a DFU wound app suitable for implementation in the local population.

Health economics of diabetic foot ulcer and recent trends to accelerate treatment

Diabetic foot ulcer is a preventable complication of diabetes that imposes a significant burden on the community. It leads to amputation and increased disability if left untreated and thus bears profound implications on the individual, the community and the health system at large. Diabetic foot (DF) is an area of research interest where interdisciplinary researchers are trying to elucidate the best strategy to halt the progression of chronic diabetic wounds. It is an area where tissue engineering research is making a strong impact through the use of scaffolds and skin substitutes for diabetic wound healing. This review aims at discussing the geographical health economics, its impact on healing and factors influencing financial costs of DFU. The upcoming economic and clinical impacts due to disease outbreak such as the 2020 COVID-19 has also been discussed. Finally, it will discuss novel therapy available with emphasis on skin tissue engineering scaffolds with a cost-benefit analysis. The review aims at promoting better management of people with diabetes with emphasis on emerging treatments and technologies.

Remote Diabetic Foot Temperature Monitoring for Early Detection of Diabetic Foot Ulcers: A Cost-Effectiveness Analysis

BACKGROUND

Foot temperature monitoring for the prevention and early detection of diabetic foot ulcers (DFU) is evidence-based and recommended in clinical practice. However, easy-to-use remote monitoring tools have been lacking, thereby preventing widespread adoption.

OBJECTIVE

To evaluate the cost-effectiveness of remote foot temperature monitoring (RFTM) (Siren's Neurofabric™ Diabetic socks) in addition to standard of care (SoC) versus SoC alone for early detection of DFU with diabetic neuropathy and a moderate to high risk of DFU.

METHODS

A payer perspective decision-tree analysis was conducted to compare expected DFU occurrence and subsequent amputation rates and costs between treatment strategies over one year. Inputs in the model were sourced from publicly available literature and relevant health technology assessments. One-way sensitivity analyses were performed for each model variable.

RESULTS

In the base-case scenario, RFTM plus SoC was a dominant strategy compared to SoC alone. RFTM plus SoC was associated with cost savings of $38,593 per additional ulcer avoided versus SoC alone, and $8027 per patient per year on average compared to SoC alone. These results were highly robust to one-way sensitivity analysis; all scenarios remained dominant if compliance was ≥13%.

CONCLUSION

RFTM is a cost-effective addition to SoC in patients with diabetic neuropathy at a moderate-to-high risk of DFU and subsequent amputation. Further, reduction in DFU and associated complications may result in improvements in the patient's quality of life and mental health. Future studies are needed to evaluate the compliance and reduction of DFU occurrence in patients on RFTM.

Healthcare disparities in vascular surgery: A critical review

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care.

Is Reconstruction of Unstable Midfoot Charcot Neuroarthropathy Cost Effective from a US Payer's Perspective?

BACKGROUND

Charcot neuroarthropathy is a morbid and expensive complication of diabetes that can lead to lower extremity amputation. Current treatment of unstable midfoot deformity includes lifetime limb bracing, primary transtibial amputation, or surgical reconstruction of the deformity. In the absence of a widely adopted treatment algorithm, the decision to pursue more costly attempts at reconstruction in the United States continues to be driven by surgeon preference.

QUESTIONS/PURPOSES

To examine the cost effectiveness (defined by lifetime costs, quality-adjusted life-years [QALYs] and incremental cost-effectiveness ratio [ICER]) of surgical reconstruction and its alternatives (primary transtibial amputation and lifetime bracing) for adults with diabetes and unstable midfoot Charcot neuroarthropathy using previously published cost data.

METHODS

A Markov model was used to compare Charcot reconstruction and its alternatives in three progressively worsening clinical scenarios: no foot ulcer, uncomplicated (or uninfected) ulcer, and infected ulcer. Our base case scenario was a 50-year-old adult with diabetes and unstable midfoot deformity. Patients were placed into health states based on their disease stage. Transitions between health states occurred annually using probabilities estimated from the evidence obtained after systematic review. The time horizon was 50 cycles. Data regarding costs were obtained from a systematic review. Costs were converted to 2019 USD using the Consumer Price Index. The primary outcomes included the long-term costs and QALYs, which were combined to form ICERs. Willingness-to-pay was set at USD 100,000/QALY. Multiple sensitivity analyses and probabilistic analyses were performed to measure model uncertainty.

RESULTS

The most effective strategy for patients without foot ulcers was Charcot reconstruction, which resulted in an additional 1.63 QALYs gained and an ICER of USD 14,340 per QALY gained compared with lifetime bracing. Reconstruction was also the most effective strategy for patients with uninfected foot ulcers, resulting in an additional 1.04 QALYs gained, and an ICER of USD 26,220 per QALY gained compared with bracing. On the other hand, bracing was cost effective in all scenarios and was the only cost-effective strategy for patents with infected foot ulcers; it resulted in 6.32 QALYs gained and an ICER of USD 15,010 per QALY gained compared with transtibial amputation. As unstable midfoot Charcot neuroarthropathy progressed to deep infection, reconstruction lost its value (ICER USD 193,240 per QALY gained) compared with bracing. This was driven by the increasing costs associated with staged surgeries, combined with a higher frequency of complications and shorter patient life expectancies in the infected ulcer cohort. The findings in the no ulcer and uncomplicated ulcer cohorts were both unchanged after multiple sensitivity analyses; however, threshold effects were identified in the infected ulcer cohort during the sensitivity analysis. When the cost of surgery dropped below USD 40,000 or the frequency of postoperative complications dropped below 50%, surgical reconstruction became cost effective.

CONCLUSIONS

Surgeons aiming to offer both clinically effective and cost-effective care would do well to discuss surgical reconstruction early with patients who have unstable midfoot Charcot neuroarthropathy, and they should favor lifetime bracing only after deep infection develops. Future clinical studies should focus on methods of minimizing surgical complications and/or reducing operative costs in patients with infected foot ulcers.

LEVEL OF EVIDENCE

Level II, economic and decision analysis.

Risk assessments and structured care interventions for prevention of foot ulceration in diabetes: development and validation of a prognostic model

BACKGROUND

Diabetes-related foot ulcers give rise to considerable morbidity, generate a high monetary cost for health and social care services and precede the majority of diabetes-related lower extremity amputations. There are many clinical prediction rules in existence to assess risk of foot ulceration but few have been subject to validation.

OBJECTIVES

Our objectives were to produce an evidence-based clinical pathway for risk assessment and management of the foot in people with diabetes mellitus to estimate cost-effective monitoring intervals and to perform cost-effectiveness analyses and a value-of-information analysis.

DESIGN

We developed and validated a prognostic model using predictive modelling, calibration and discrimination techniques. An overview of systematic reviews already completed was followed by a review of randomised controlled trials of interventions to prevent foot ulceration in diabetes mellitus. A review of the health economic literature was followed by the construction of an economic model, an analysis of the transitional probability of moving from one foot risk state to another, an assessment of cost-effectiveness and a value-of-information analysis.

INTERVENTIONS

The effects of simple and complex interventions and different monitoring intervals for the clinical prediction rules were evaluated.

MAIN OUTCOME MEASURE

The main outcome was the incidence of foot ulceration. We compared the new clinical prediction rules in conjunction with the most effective preventative interventions at different monitoring intervals with a 'treat-all' strategy.

DATA SOURCES

Data from an electronic health record for 26,154 people with diabetes mellitus in one Scottish health board were used to estimate the monitoring interval. The Prediction Of Diabetic foot UlcerationS (PODUS) data set was used to develop and validate the clinical prediction rule.

REVIEW METHODS

We searched for eligible randomised controlled trials of interventions using search strategies created for Ovid® (Wolters Kluwer, Alphen aan den Rijn, the Netherlands), MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials. Randomised controlled trials in progress were identified via the International Standard Randomised Controlled Trial Number Registry and systematic reviews were identified via PROSPERO. Databases were searched from inception to February 2019.

RESULTS

The clinical prediction rule was found to accurately assess the risk of foot ulceration. Digital infrared thermometry, complex interventions and therapeutic footwear with offloading devices were found to be effective in preventing foot ulcers. The risk of developing a foot ulcer did not change over time for most people. We found that interventions to prevent foot ulceration may be cost-effective but there is uncertainty about this. Digital infrared thermometry and therapeutic footwear with offloading devices may be cost-effective when used to treat all people with diabetes mellitus regardless of their ulcer risk.

LIMITATIONS

The threats to the validity of the results in some randomised controlled trials in the review and the large number of missing data in the electronic health record mean that there is uncertainty in our estimates.

CONCLUSIONS

There is evidence that interventions to prevent foot ulceration are effective but it is not clear who would benefit most from receiving the interventions. The ulceration risk does not change over an 8-year period for most people with diabetes mellitus. A change in the monitoring interval from annually to every 2 years for those at low risk would be acceptable.

FUTURE WORK RECOMMENDATIONS

Improving the completeness of electronic health records and sharing data would help improve our knowledge about the most clinically effective and cost-effective approaches to prevent foot ulceration in diabetes mellitus.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016052324.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 62. See the NIHR Journals Library website for further project information.

SFDI biomarkers provide a quantitative ulcer risk metric and can be used to predict diabetic foot ulcer onset

AIMS

Annually, up to 4% of people with diabetes present with a chronic foot ulcer. Quantitative real-time testing to identify patients at risk for ulceration can guide preventative care. Here, we assess whether a non-invasive optical imaging technique, Spatial Frequency Domain Imaging (SFDI), can identify patients at the highest risk for ulceration and predict ulcer onset.

METHODS

We imaged 252 subjects with diabetes at Kaiser Permanente, Southern California. SFDI derived tissue biomarkers of microcirculation were compared between subjects with and without a history of ulceration, and subjects who did or did not develop ulcers after 1 year.

RESULTS

Feet of subjects at the highest risk (i.e. history of ulceration) had significantly lower hemoglobin in the papillary dermis (HbT₁), along with higher oxygenation (StO₂) due to poor extraction. These subjects also had more homogeneous hemoglobin spread in the reticular dermis (HbT₂) and tissue scattering (related to skin structure). Prediction based on HbT₁ and tissue scattering identified new ulcerations and performed with sensitivity/specificity of 68.8%/64.8% and 75.0%/69.1%, respectively.

CONCLUSION

These results show that SFDI hemoglobin distribution and oxygenation biomarkers provide a quantitative basis for ulcer risk stratification and ulcer onset prediction.

Meta-analyses of randomized controlled trials reporting the effect of home foot temperature monitoring, patient education or offloading footwear on the incidence of diabetes-related foot ulcers

AIM

The aim of this study was to perform an up-to-date systematic review and meta-analysis of randomized controlled trials (RCTs) examining the efficacy of home foot temperature monitoring, patient education and offloading footwear in reducing the incidence of diabetes-related foot ulcers.

METHODS

A literature search was performed using MEDLINE, PubMed, CINAHL, Scopus and Cochrane databases to identify relevant original studies. Meta-analyses were performed using intention-to-treat principals for worst (main analysis) and best (sub-analysis) case scenarios. Leave-one-out sensitivity analyses were used to assess the consistency of findings.

RESULTS

Of 7575 unique records, 17 RCTs involving 2729 participants were included. Four tested home foot temperature monitoring (n = 468), six examined patient education (n = 823) and seven assessed offloading footwear (n = 1438). Participants' who performed home foot temperature monitoring [odds ratio (OR) 0.51, 95% confidence interval (CI) 0.31 to 0.84; n = 468] and those provided offloading footwear (OR 0.48, 95% CI 0.29 to 0.80; n = 1438) were less likely to develop a diabetes-related foot ulcer. Patient education programmes did not significantly reduce diabetes-related foot ulcer incidence (OR 0.59, 95% CI 0.29 to 1.20; n = 823). Sensitivity analyses suggested that offloading footwear findings were consistent, but home foot temperature findings were dependent on the individual inclusion of one trial. All RCTs had either high or unclear risk of bias.

CONCLUSION

This meta-analysis suggests that offloading footwear is effective in reducing the incidence of diabetes-related foot ulcers. Home foot temperature monitoring also appears beneficial but larger trials are needed (PROSPERO registration no.: CRD42019135226).

Return on investment of the diabetes foot care clinical pathway implementation in Alberta, Canada

AIMS

Based on best practices, the diabetes foot care clinical pathway (DFCCP) has been developed and implemented in several clinics in Alberta, Canada. We performed a return on investment (ROI) analysis of this implementation.

METHODS

We used a cohort design comparing both cost and return (in terms of reduced health services utilization, HSU) between diabetes patients who were exposed and who were unexposed, to the intervention. We used a difference-in-difference approach and a propensity-score-matching technique to minimize biases due to differences in demographic and clinical characteristics between two cohorts. We used a 1-year time-horizon and converted all costs/savings to 2019 Canadian dollars (1 CA$ ~= 0.75 US$).

RESULTS

The intervention helped avoid $3500 in costs of HSU per patient-year. Subtracting the intervention cost of $500, the net benefit of intervention was $3000 (ranged $2400-$3700) per patient-year. The ROI ratio was estimated at 7.4 (ranged 6.1 to 8.8) meaning that every invested $1 returned $7.4 (ranged $6.1-$8.8) for the health system. The probability of intervention being cost-saving ranged from 99.5-100%.

CONCLUSIONS

The implementation of DFCCP in Alberta is cost-saving. A continuation of the pathway implementation at studied clinics and a spread to other clinics are recommended.

Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada

BACKGROUND

Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019.

METHODS

Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher's exact test or Chi-square test.

RESULTS

Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved.

CONCLUSION

Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.

The role of the platelet-to-lymphocyte ratio and neutrophil-to-lymphocyte ratio in the prediction of length and cost of hospital stay in patients with infected diabetic foot ulcers: A retrospective comparative study

OBJECTIVE

The aim of this study was to determine the role of new inflammatory markers, including the platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR), in the prediction of length and cost of hospital stay in patients with infected diabetic foot ulcers (DFUs).

METHODS

A total of 78 patients with DFUs who were admitted to our endocrinology clinic between January 2016 and July 2017 were included. Patients were then divided into three groups according to the Wagner DFU classification system: group 1: 18 patients with grade 2 DFU (11 men, 7 women; mean age = 57.5±7 years); group 2: 44 patients with grade 3 DFU (18 men, 26 women; mean age = 59.7±8.7 years); and group 3: 16 patients with grade 4 DFU (10 men, 6 women; mean age = 59.9±11.6 years). Laboratory findings were retrospectively obtained from hospital records; the PLR and NLR were calculated in all groups. Length and cost of hospital stay were recorded. Hospital costs were estimated in Turkish Lira (TL) based on the evaluation of glucose regulation, wound care, and antibiotic treatment.

RESULTS

The mean NLR was significantly lower in group 1 (2.8±0.9) than in group 2 (6.0±5.2; p=0.017) and group 3 (6.9±5.3; p=0.011). The mean PLR was significantly lower in group 1 (140.8±42.6) than in group 3 (222.1±95.5; p=0.006). The mean length of stay was 7.9±2.7 days in group 1, 15.0±8.9 days in group 2, and 12.5±8.9 days in group 3. The mean cost was 1,310.8±500 TL in group 1, 2,966.9±2105 TL in group 2, and 3,488.1±3603.1 TL in group 3. Length and cost of stay were both significantly lower in group 1 than in groups 2 and 3 (p=0.011 and p=0.002, respectively). Comparative results showed that the length and cost of hospital stay increased with increasing severity of DFUs. Furthermore, correlation analyses demonstrated no correlation of length of stay with PLR and NLR but an obvious correlation between cost of stay and PLR (r=0.412; p<0.001). Additionally, there was no correlation between cost of stay and NLR (r=0.158, p>0.05).

CONCLUSION

The PLR is inflammatory marker that can be measured by an inexpensive and easily accessible test and can aid in the prediction of length and cost of hospital stay in patients with DFUs.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Monitoring wound progression to healing in diabetic foot ulcers using three-dimensional wound imaging

AIM

3D wound imaging has provided clinicians with even greater wound measurement options. No data is available to guide clinicians as to which 3D measurements may yield the most reflective marker of wound progression to healing.

METHOD

A prospective pilot study was undertaken to assess the accuracy of five 3D wound measurements that best reflect metrics of interest to clinicians. Twenty-one diabetic foot ulcers were enrolled from initial ulcer presentation, through to healing. The relationship between mean wound healing measurement variables was examined using linear regression and Pearsons correlation coefficient, in addition to assessing clinician inter-rater reliability of measurements using Intra-class correlation coefficients (ICC).

RESULTS

Statistical analysis demonstrated a linear healing slope for each wound measurement as having a value greater than R 0.70 and a statistical significance of p = 0.0001. This suggests that all five wound measurements are useful prognostic markers of wound progression to healing. Low variability of measurements between users indicates good inter-observer reliability.

CONCLUSION

3D wound measurements demonstrate a linear correlation between the measurement and time to healing. This suggests they could be effective prognostic markers of a wounds progression to healing and closure. It may also provide important early identification of wounds not responding to standard care. Larger studies are required to validate our results.

Estimating the economic value of emerging technologies in chronic wound therapy

Estimating the economic value of emerging technologies in clinical medicine presents a number of problems. New technologies may have a limited clinical history, few supportive peer‐reviewed publications, and only anecdotal evidence as they enter the market and seek clinician approval and reimbursement from payers. Although clinical efficacy/effectiveness research is a minimal starting point for making the case for adoption of a product, establishing a competitive cost‐effectiveness position against other products and establishing the case for economic value must be made as well when presenting to health plans or other payers. Economic valuation methods have been well developed in the business community. Reviewed here are the components of a well‐crafted case for the economic value of a product in general and in the wound industry specifically, in a multidomain approach to demonstrate values using demographic, clinical, financial, operational, and intangible assessments.

Feasibility of a Low-Intensity, Technology-Based Intervention for Increasing Physical Activity in Adults at Risk for a Diabetic Foot Ulcer: A Mixed-Methods Study

BACKGROUND

Among adults with diabetes, 19-34% will develop a diabetic foot ulcer (DFU), which increases amputation risk and health care costs, and worsens quality of life. Regular physical activity, when increased gradually, may help prevent DFUs. In this mixed-methods study, we examined the feasibility of a low-intensity, technology-based behavioral intervention to increase activity in adults at risk for DFUs.

METHOD

Participants at risk for a DFU (n = 12; 66% female; mean age = 59.9 years) received four in-person exercise and behavioral counseling sessions over 2-3 weeks, supplemented with use of an activity monitor (to track steps) and text messages (to reinforce behavioral strategies) for an added 8 weeks. Pre- and postintervention assessments of accelerometer measured activity, daily mobility, and glycemic control (A1C) were completed. Treatment acceptability was assessed by questionnaire and via key informant interview.

RESULTS

The program appears feasible since all but one participant attended all four sessions, all used the activity monitor and all responded to text messages. Treatment acceptability (scale: 1 = very dissatisfied, 5 = extremely satisfied) was high; average item ratings were 4.79 (SD = 0.24). Participants increased their steps by an average of 881.89 steps/day (d = 0.66). A1C decreased on average by 0.33% (d = 0.23). Daily mobility did not change. Interview results suggest that participants perceived benefits from the intervention. Participant recommended improvements included providing more physical activity information, addressing pain, and intervention delivery in a podiatry clinic.

CONCLUSION

Individuals at risk for a DFU might benefit from a minimally intensive, technology-based intervention to increase their physical activity. Future research comparing the intervention to usual care is warranted.

Systematic review of community pharmacy-based and pharmacist-led foot care interventions for adults with type 2 diabetes

Background

To prevent diabetic foot disease, proper foot care is essential for early detection and treatment. Pharmacists are well suited to provide accessible foot care to adults with type 2 diabetes. Limited research has examined this role.

Methods

We conducted a systematic review of community pharmacy-based and pharmacist-led foot care interventions for adults with type 2 diabetes compared to usual care. Data sources included MEDLINE, EMBASE, the Cochrane Library, CINAHL, Academic Search Complete and Health Source: Nursing/Academic Edition and Google Scholar, plus Google and hand-searching. Original research studies reported in English, focused on community pharmacy-based or pharmacist-led foot care interventions were eligible for review. Participants were adults with type 2 diabetes. Studies were summarized narratively; pooled data were not possible.

Results

Seven studies were included in this review, 3 focusing on improving foot self-care behaviours and 4 on promoting foot examinations by the health care provider. Only 2 studies were randomized and were assessed as high quality. Six out of 7 studies reported significantly positive findings related to foot care practices.

Discussion

An opportunity to influence foot care exists at each clinical encounter. Pharmacists are accessible health care practitioners and appropriate to provide a range of diabetes foot care interventions.

Conclusions

Seven studies examined community pharmacy-based and pharmacist-led foot care interventions for people with type 2 diabetes. Community pharmacies and pharmacists are capable of providing a variety of foot care interventions to patients with diabetes, helping detect problems early and leading to prompt intervention.

Diabetic foot infection: A critical complication

The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.

Comparing the Diagnostic Accuracy of Simple Tests to Screen for Diabetic Peripheral Neuropathy: Protocol for a Cross-Sectional Study

Background

Various tests are used to detect diabetic peripheral neuropathy by assessing sense perception in the feet. Tests vary in terms of time and resources required. Simple tests are those that can be conducted quickly and easily in primary care without laboratory equipment. There are some limitations to these simple tests, an example being the variable amplitude of the 128 Hz tuning fork. A new test, VibraTip (McCallan Medical, UK), might be a valuable alternative as it emits a consistent amplitude and may offer improved diagnostic accuracy.

Objective

The aims of this study are to estimate the diagnostic accuracy of the VibraTip device for diabetic peripheral neuropathy against the reference standard of sural nerve conduction velocity measurement, and to assess whether the VibraTip offers superior diagnostic accuracy to other routine tests based on vibration or touch.

Methods

The study will prospectively recruit adults with type 2 diabetes who are due to attend a routine follow-up clinic. A cross-sectional study design will be employed to assess the diagnostic accuracy of 5 standard index tests for peripheral neuropathy, including VibraTip. The reference test will be sural nerve conduction velocity measurement.

Results

Funding is being sought to conduct this research. The outcomes assessed will be the diagnostic accuracy of the 5 index tests against sural nerve conduction velocity measurement, including sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio. Receiver operating characteristic curves will be constructed and compared for each test.

Conclusions

This study will be the first within-study comparison of 5 simple tests for screening diabetic peripheral neuropathy and will address uncertainties in the potential benefits of using VibraTip in comparison with the other tests.

Views of Patients on Using mHealth to Monitor and Prevent Diabetic Foot Ulcers: Qualitative Study

Background

People with diabetes are at risk for diabetic foot ulcers (DFUs), which can lead to limb loss and a significant decrease in quality of life. Evidence suggests that mHealth can be an effective tool in diabetes self-management. mHealth presents an opportunity for the prevention and monitoring of DFUs. However, there is a paucity of research that explores its effectiveness in the DFU patient population, as well as the views and attitudes of these patients toward technology and mHealth.

Objective

This study aimed to explore the views, attitudes, and experiences of a diabetic patient population with or at risk of DFUs regarding technology, mHealth, and the diabetic foot.

Methods

We used a qualitative research approach using in-depth interviews with 8 patients with DFUs. Questions were structured around experience with technology, current health practices related to diabetic foot care, and thoughts on using an mHealth device that prevents and monitors DFUs. We transcribed and thematically analyzed all interviews.

Results

All patients had positive responses for an mHealth intervention aimed at preventing and monitoring DFUs. We found 4 themes in the data: diversity in use of technology, feet-checking habits, 2-way communication with health care professionals (HCPs), and functionality. There were varying levels of familiarity with and dependence on technology within this patient population. These relationships correlated with distinct generations found in North America, including baby boomers and Generation X. Furthermore, we found that most patients performed daily feet checks to monitor any changes in health. However, some did not perform feet checks prior to the development of a DFU. Patients expressed interest in 2-way communication with HCPs that would allow for easier appointment scheduling, sharing of medical data, decreased number of visits, and use of alerts for when medical attention is required. Patients also identified conditions of functionality for the mHealth intervention. These included consideration of debilitating complications because of diabetes, such as retinopathy and decreased mobility; ease of use of the intervention; and implementation of virtual communities to support continued use of the intervention.

Conclusions

Our patient population expressed an interest in mHealth for preventing and monitoring DFUs, although some participants were not frequent users of technology. mHealth continues to show potential in improving patient outcomes, and this study provides a foundation for designing interventions specific to a DFU population. Further research is needed to confirm these findings.