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Lusendi FM, Vanherwegen AS, Doggen K, Nobels F, Matricali GA. Evidence-based interventions for identifying candidate quality indicators to assess quality of care in diabetic foot clinics: a scoping review. BMC Public Health 2024; 24:996. [PMID: 38600498 PMCID: PMC11005120 DOI: 10.1186/s12889-024-18306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 03/07/2024] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND Foot ulcers in people with diabetes are a serious complication requiring a complex management and have a high societal impact. Quality monitoring systems to optimize diabetic foot care exist, but a formal and more evidence-based approach to develop quality indicators (QIs) is lacking. We aimed to identify a set of candidate indicators for diabetic foot care by adopting an evidence-based methodology. METHODS A systematic search was conducted across four academic databases: PubMed, Embase CINAHL and Cochrane Library. Studies that reported evidence-based interventions related to organization or delivery of diabetic foot care were searched. Data from the eligible studies were summarized and used to formulate process and structure indicators. The evidence for each candidate QI was described in a methodical and transparent manner. The review process was reported according to the "Preferred Reported Items for Systematic reviews and Meta-Analysis" (PRISMA) statements and its extension for scoping reviews. RESULTS In total, 981 full-text articles were screened, and 322 clinical studies were used to formulate 42 candidate QIs. CONCLUSIONS An evidence-based approach could be used to select candidate indicators for diabetic foot ulcer care, relating to the following domains: wound healing interventions, peripheral artery disease, offloading, secondary prevention, and interventions related to organization of care. In a further step, the feasibility of the identified set of indicators will be assessed by a multidisciplinary panel of diabetic foot care stakeholders.
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Affiliation(s)
- Flora Mbela Lusendi
- Health Services Research, Sciensano, Rue Juliette Wytsmanstraat 14, Brussels, 1050, Belgium.
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium.
| | - An-Sofie Vanherwegen
- Health Services Research, Sciensano, Rue Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
| | - Kris Doggen
- Health Services Research, Sciensano, Rue Juliette Wytsmanstraat 14, Brussels, 1050, Belgium
| | - Frank Nobels
- Multidisciplinary Diabetic Foot Clinic, Onze-Lieve-Vrouwziekenhuis, Aalst, Belgium
| | - Giovanni Arnoldo Matricali
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Multidisciplinary Diabetic Foot Clinic, University Hospital Leuven, Leuven, Belgium
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Lusendi FM, Vanherwegen AS, Nobels F, Matricali GA. A multidisciplinary Delphi consensus to define evidence-based quality indicators for diabetic foot ulcer care. Eur J Public Health 2024; 34:253-259. [PMID: 38276880 PMCID: PMC10990505 DOI: 10.1093/eurpub/ckad235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Valid measures to assess quality of care delivered to patients with diabetes suffering from diabetic foot ulcer (DFU) are scarce. This study aimed to achieve consensus on relevant and feasible quality indicators (QIs) among stakeholders involved in DFU care and was conducted as the second part of a Belgian QI selection study that sought to identify QIs for DFU care. METHODS A stakeholder panel, including caregivers from primary care and specialized disciplines active in diabetic foot care as well as a patient organization representative, was recruited. By using the RAND/UCLA Appropriateness Method, stakeholders were asked to rate a list of 42 candidate evidence-based indicators for appropriateness through a 9-point Likert scale. QIs were classified based on the median ratings and the disagreement index, calculated by the inter-percentile range adjusted for symmetry. RESULTS At the end of a three-phase process, 17 QIs were judged as appropriate. Among them, five were not previously described, covering the following topics: integration of wound care specialty in the multidisciplinary team, systematic evaluation of the nutritional status of the patient, administration of low-density lipoprotein-cholesterol lowering medication and protocolized care (implementation of care and prevention management protocols). CONCLUSIONS The identified evidence-based QIs provide an assessment tool to evaluate and monitor quality of care delivered to DFU patients. Future research should focus on their complementarity with the existing QIs and their implementation in clinical practice.
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Affiliation(s)
- Flora Mbela Lusendi
- Department of Epidemiology and Public Health, Health Services Research, Sciensano, Brussels, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - An-Sofie Vanherwegen
- Department of Epidemiology and Public Health, Health Services Research, Sciensano, Brussels, Belgium
| | - Frank Nobels
- Department of Internal Medicine-Endocrinology, Multidisciplinary Diabetic Foot Clinic, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Giovanni Arnoldo Matricali
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Multidisciplinary Diabetic Foot Clinic, University Hospital Leuven, Leuven, Belgium
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Bahrmann A, Wernecke J. Der geriatrische Patient mit diabetischem Fußsyndrom. DIABETOLOGE 2022. [DOI: 10.1007/s11428-022-00892-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Dörr S, Schlecht M, Chatzitomaris A, Weisser G, Lucke-Paulig L, Friedl A, Joachim R, Lobmann R. Predictive Effect of Inflammatory Response and Foot Ulcer
Localization on Outcome in Younger and Older Individuals with Infected Diabetic
Foot Syndrome. Exp Clin Endocrinol Diabetes 2020; 129:878-886. [DOI: 10.1055/a-1149-8989] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
AbstractThe diabetic foot syndrome (DFS) is the most important cause for non-traumatic
major amputation in adult individuals and actually one of the most frightening
events in diabetics’ life. Despite the often protracted treatment of
infected DFS at the end patients are often confronted with amputation. We
investigated 352 individuals with infected DFS in two age separated-groups.
Older individuals presented with significant worse renal function and lower
HbA1c on day of admittance. Most detected ulcers involved the plantar sides of
the metatarsal heads (MTH) and the toes. We saw an age-dependent translocation
of foot ulcers from plantar and hindfoot to the forefoot and toes. In average
every third wound provoked amputation, in the majority (94%) minor
amputations, only 1.9% major amputations occurred. Lesions of the
5th toe or its MTH and interdigital or interphalangeal joint
ulcers led to amputation in more than 60%. Worse renal function and WBC
above 11 tsd/µl were linked with higher amputation risk. But in
particular current scoring systems like SINBAD or Wagner-Armstrong scale and
thus finally clinician’s assessment of the wound situation gave a
substantial hint for subsequent amputation – regardless of age.
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Affiliation(s)
- Stefan Dörr
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Michael Schlecht
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Apostolos Chatzitomaris
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Gregor Weisser
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Lara Lucke-Paulig
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Alexander Friedl
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Regina Joachim
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
| | - Ralf Lobmann
- Departments of Endocrinology, Diabetology and Geriatrics, Stuttgart
General Hospital, Bad Cannstatt, Germany
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Bohn B, Grünerbel A, Altmeier M, Giesche C, Pfeifer M, Wagner C, Heise N, Best F, Fasching P, Holl RW. Diabetic foot syndrome in patients with diabetes. A multicenter German/Austrian DPV analysis on 33 870 patients. Diabetes Metab Res Rev 2018; 34:e3020. [PMID: 29726089 DOI: 10.1002/dmrr.3020] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Revised: 03/08/2018] [Accepted: 04/22/2018] [Indexed: 12/12/2022]
Abstract
AIMS The diabetic foot syndrome (DFS) is a serious complication in patients with diabetes increasing the risk for minor/major amputations. This analysis aimed to examine differences in diabetes patients with or without DFS stratified by type 1 (T1D) or type 2 diabetes (T2D). MATERIAL AND METHODS Adult patients (≥20y of age) with diabetes from the German/Austrian diabetes patients follow-up registry (DPV) were included. The cross-sectional study comprised 45 722 subjects with T1D (nDFS = 2966) and 313 264 with T2D (nDFS = 30 904). In DFS, minor/major amputations were analysed. To compare HbA1C , neuropathy, nephropathy, cardiovascular disease risk factors, and macrovascular complications between patients with or without DFS, regression models were conducted. Confounders: age, sex, diabetes duration. RESULTS In patients with DFS, a minor amputation was documented in 27.2% (T1D) and 25.9% (T2D), a major amputation in 10.2% (T1D) and 11.3% (T2D). Regression models revealed that neuropathy was more frequent in subjects with DFS compared with patients without DFS (T1D: 70.7 vs 29.8%; T2D: 59.4% vs 36.9%; both P < 0.0001). Hypertension, nephropathy, peripheral vascular disease, stroke, or myocardial infarction was more common compared with patients without DFS (all P < 0.0001). In T1D with DFS, a slightly higher HbA1C (8.11% vs 7.95%; P < 0.0001) and in T2D with DFS a lower HbA1C (7.49% vs 7.69%; P < 0.0001) was observed. CONCLUSIONS One third of the patients with DFS had an amputation of the lower extremity. Especially neuropathy or peripheral vascular disease was more prevalent in patients with DFS. New concepts to prevent DFS-induced amputations and to reduce cardiovascular risk factors before the occurrence of DFS are necessary.
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Affiliation(s)
- Barbara Bohn
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Arthur Grünerbel
- Specialized Practice for Diabetes and Nutritional Medicine, Munich, Germany
| | | | - Carsten Giesche
- Clinic of Internal Medicine, Alexianer St. Hedwig Hospital, Berlin, Germany
| | | | | | - Nikolai Heise
- Alb Fils Kliniken, Helfenstein Clinic, Geislingen, Germany
| | - Frank Best
- Diabetes-Practice Dr. Best, Essen, Germany
| | - Peter Fasching
- 5th Medical Department, Wilhelminenspital, Vienna, Austria
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Neuropathy and Diabetic Foot Syndrome. Int J Mol Sci 2016; 17:ijms17060917. [PMID: 27294922 PMCID: PMC4926450 DOI: 10.3390/ijms17060917] [Citation(s) in RCA: 183] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulceration is a serious complication of diabetes mellitus worldwide and the most common cause of hospitalization in diabetic patients. The etiology of diabetic foot ulcerations is complex due to their multifactorial nature; in the pathophysiology of diabetic foot ulceration polyneuropathy is important. Proper adherence to standard treatment strategies and interdisciplinary cooperation can reduce the still high rates of major amputations.
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May M, Hahn S, Tonn C, Engels G, Hochlenert D. Decrease in (Major) Amputations in Diabetics: A Secondary Data Analysis by AOK Rheinland/Hamburg. J Diabetes Res 2016; 2016:6247045. [PMID: 26881254 PMCID: PMC4736381 DOI: 10.1155/2016/6247045] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2015] [Accepted: 12/02/2015] [Indexed: 12/02/2022] Open
Abstract
AIM In two German regions with 11.1 million inhabitants, 6 networks for specialized treatment of DFS were implemented until 2008. Data provided for accounting purposes was analysed in order to determine changes in the rate of diabetics requiring amputations in the years before and after the implementation. METHOD Data covering 2.9 million people insured by the largest insurance company between 2007 and 2013 was analysed by the use of log-linear Poisson regression adjusted for age, gender and region. RESULTS The rate of diabetics needing major amputations fell significantly by 9.5% per year (p < 0.0001) from 217 to 126 of 100,000 patients per year. The rate of diabetics needing amputations of any kind fell from 504 to 419 of 100,000 patients per year (p = 0.0038). DISCUSSION The networks integrate health care providers in an organised system of shared care. They educate members of the medical community and the general public. At the same time, a more general disease management program for people with diabetes was implemented, which may also have contributed to this decrease. At the end of the observation period, the rate of diabetics requiring amputations was still high. For this reason, further expansion of organised specialized care is urgently needed.
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Affiliation(s)
- Melanie May
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich Ambulante Versorgung, Geschäftsbereich Selektivverträge, Kasernenstrasse 61, 40213 Düsseldorf, Germany
- *Melanie May:
| | - Sebastian Hahn
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich M-RSA/Finanzen/Controlling, Geschäftsbereich Controlling, Kasernenstrasse 61, 40213 Düsseldorf, Germany
| | - Claudia Tonn
- AOK Rheinland/Hamburg, Die Gesundheitskasse, Unternehmensbereich Ambulante Versorgung, Geschäftsbereich Selektivverträge, Kasernenstrasse 61, 40213 Düsseldorf, Germany
| | - Gerald Engels
- Chirurgische Praxis am Bayenthalgürtel, Bayenthalgürtel 45, 50968 Köln, Germany
- Ltd. Arzt Abteilung, Wundchirurgie St. Vinzenz Hospital Köln, Merheimer Strasse 221, 50733 Köln, Germany
| | - Dirk Hochlenert
- Centrum für Diabetologie, Endoskopie und Wundheilung, Merheimer Strasse 217, 50733 Köln, Germany
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Morbach S, Kersken J, Lobmann R, Nobels F, Doggen K, Van Acker K. The German and Belgian accreditation models for diabetic foot services. Diabetes Metab Res Rev 2016; 32 Suppl 1:318-25. [PMID: 26455588 DOI: 10.1002/dmrr.2752] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The International Working Group on the Diabetic Foot recommends that auditing should be part of the organization of diabetic foot care, the efforts required for data collection and analysis being balanced by the expected benefits. In Germany legislature demands measures of quality management for in- and out-patient facilities, and, in 2003, the Germany Working Group on the Diabetic Foot defined and developed a certification procedure for diabetic foot centres to be recognized as 'specialized'. This includes a description of management facilities, treatment procedures and outcomes, as well as the organization of mutual auditing visits between the centres. Outcome data is collected at baseline and 6 months on 30 consecutive patients. By 2014 almost 24,000 cases had been collected and analysed. Since 2005 Belgian multidisciplinary diabetic foot clinics could apply for recognition by health authorities. For continued recognition diabetic foot clinics need to treat at least 52 patients with a new foot problem (Wagner 2 or more or active Charcot foot) per annum. Baseline and 6-month outcome data of these patients are included in an audit-feedback initiative. Although originally fully independent of each other, the common goal of these two initiatives is quality improvement of national diabetic foot care, and hence exchanges between systems has commenced. In future, the German and Belgian accreditation models might serve as templates for comparable initiatives in other countries. Just recently the International Working Group on the Diabetic Foot initiated a working group for further discussion of accreditation and auditing models (International Working Group on the Diabetic Foot AB(B)A Working Group).
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Affiliation(s)
| | | | - Ralf Lobmann
- Department of Endocrinology, Diabetology and Geriatrics, Stuttgart General Hospital, Bad Cannstatt, Stuttgart, Germany
| | | | - Kris Doggen
- Scientific Institute of Public Health, OD Public Health and Surveillance, Brussels, Belgium
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Wernecke J, Gabel M, Lobmann R. Der geriatrische Patient mit diabetischem Fußsyndrom. DIABETOLOGE 2015. [DOI: 10.1007/s11428-014-1303-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Piaggesi A, Coppelli A, Goretti C, Iacopi E, Mattaliano C. Do you want to organize a multidisciplinary diabetic foot clinic? We can help. INT J LOW EXTR WOUND 2014; 13:363-70. [PMID: 25123372 DOI: 10.1177/1534734614545876] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The diabetic foot (DF) is a complex pathology involving the lower limb of 8 to 10 million people around the world, and its prevalence is rising, creating a dramatic need for effective therapeutic answers. The multidisciplinary DF clinic has been proposed as a model to fight this complication from the International Working Group on Diabetic Foot (IWGDF) inside a more articulated 3-level organization strategy. The organization and technical aspects of this strategy, together with the characteristics of each of the 3 levels have been analyzed and described in the article, together with the aims and limitations of each of the levels to cope with a 3-dimensional pathology involving systemic, local, and logistic aspects. The implementation of this model in Europe produced positive results measured so far in at least 2 nationwide experiences, in Germany and in Italy, and it should be taken in account whenever health policies apply to the DF issue.
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