Building a scalable diabetic limb preservation program: four steps to success

Diabetic foot in primary and tertiary (DEFINITE) Care: A health services innovation in coordination of diabetic foot ulcer (DFU) Care within a healthcare cluster - 18-month results from an observational population health cohort study

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.

Community-engaged research in vascular surgery: An approach to decrease amputation disparities and effect population-level change

Community-engaged research (CEnR) is a powerful tool to create sustainable and effective change in health outcomes. CEnR engages community members as equal partners, amplifying their voices and priorities by including them throughout the research process. Such engagement increases the relevance and meaning of research, improves the translation of research findings into sustainable health policy and practice, and ultimately enhances mutual trust among academic, clinical, and community partners for ongoing research partnership. There are a number of key principles that must be considered in the planning, design, and implementation of CEnR. These principles are focused on inclusive representation and participation, community empowerment, building community capacity, and protecting community self-determination. Although vascular surgeons may not be equipped to address these issues from the ground up by themselves, they should work with a team who can help them incorporate these elements into their CEnR project designs and proposals. This may be best accomplished by collaborating with researchers and community-based organizations who already have this expertise and have established social capital within the community. This article describes the theory and principles of CEnR, its relevance to vascular surgeons, researchers, and patients, and how using CEnR principles in vascular surgery practice, research, and outreach can benefit our patient population, with a specific focus on reducing disparities related to amputation.

Tackling diabetic foot: limb salvage during the COVID-19 pandemic

PURPOSE

Lower extremity amputation resulting from diabetic foot ulcer, with neuropathic and/or ischemic etiologies, remains a devastating and costly complication of diabetes mellitus. This study evaluated changes in care delivery of diabetic foot ulcer patients during the COVID-19 pandemic. A longitudinal assessment evaluating the ratio of major lower extremity amputation to minor lower extremity amputations after implementation of novel strategies to combat access restrictions was compared to the pre-COVID-19 era.

METHODS

The ratio of major to minor lower extremity amputation (i.e. the high-to-low ratio) was assessed at two academic institutions, the University of Michigan, and University of Southern California, in a population of patients with diabetes who had direct access to multidisciplinary foot care clinics in the 2 years prior to the pandemic and the first 2 years of the COVID-19 pandemic.

RESULTS

Patient characteristics and volumes including patients with diabetes and those with a diabetic foot ulcer were similar between eras. In addition, inpatient diabetic foot-related admissions were similar, but were suppressed by government shelter in placed mandates and subsequent COVID-19 variants surges (e.g. delta, omicron). In the control group, the Hi-Lo ratio increased every 6 months by an average of 11.8%. Meanwhile, following STRIDE implementation during the pandemic, the Hi-Lo ratio reduced by (-)11% (p < 0.001) and doubled limb salvage efforts as compared to the baseline era. The reduction of the Hi-Lo ratio was not influenced significant by patient volumes or inpatient admissions for foot infections.

CONCLUSION

These findings signify the importance of podiatric care in the at-risk diabetic foot population. Through strategic planning and rapid implementation of at-risk diabetic foot ulcer triage, multidisciplinary teams were able to maintain accessible care during the pandemic which resulted in a reduction of amputations. Furthermore, this manuscript highlights the value of the Hi-Lo ratio as an indicator of institutional limb salvage efforts.

Socioecological model-based design and implementation principles of lower limb preservation programs as partners for limb-loss rehabilitation programs- A mini-review

People with lower limb loss, especially of dysvascular etiology, are at substantial risk for both ipsilateral and contralateral reamputation. Additionally, while not as well documented for reamputation, there is recognition that amputation incidence is influenced by not only sociodemographic factors such as sex, race, socioeconomic status, but also by system factors such as service access. A systems strategy to address this disparity within the field of limb-loss rehabilitation is for Limb-loss Rehabilitation Programs (LRP) to partner with medical specialists, mental health professionals, and Limb Preservation Programs (LPP) to provide comprehensive limb care. While LPPs exist around the nation, design principles for such programs and their partnership role with LRPs are not well established. Using a socioecological model to incorporate hierarchical stakeholder perspectives inherent in the multidisciplinary field of limb care, this review synthesizes the latest evidence to focus on LPP design and implementation principles that can help policymakers, healthcare organizations and limb-loss rehabilitation and limb-preservation professionals to develop, implement, and sustain robust LPP programs in partnership with LRPs.

Evolution of WIfI: Expansion of WIfI Notation After Intervention

Nearly a decade ago, the Society for Vascular Surgery (SVS)'s wound, ischemia, and foot Infection (WIfI) classification was first developed to help assess overall limb threat. However, managing conditions such as diabetic foot ulcer and chronic limb-threatening ischemia can be complex. For instance, certain investigative findings might initially be pending such as the level of ischemia or extent of infection before the final classification is established. In addition, wounds evolve rapidly, and the current classification does not allow for tracking their progression over time during treatment. Therefore, we propose a supplemental consistent notation for scoring WifI re-assessment during treatment of a threatened limb inspired by the cancer staging before and after neoadjuvant treatment classification system. Thus, we describe the re-scoring system and how to use it. Our suggestion supports a coherent method to longitudinally communicate characteristics of a threatened limb. This has potential to support high quality interdisciplinary, patient-centered care and enhance the use of this classification in research. Further work is required to validate this modification of a common language of risk.

How to build a limb salvage program

Patients with chronic limb-threatening ischemia (CLTI) are medically complex and continue to experience high rates of amputation, despite improved diagnosis and treatment. Limb salvage programs and multidisciplinary teams provide comprehensive patient care and have been associated with reduced amputation rates. Recent societal guidelines suggest the adoption of limb salvage programs to improve care of patients with CLTI. In this article, we describe the critical components of a limb salvage program and outline the following steps to aid in their construction: community and institution assessment, formation of a multidisciplinary team, provision of patient care, and monitoring outcomes and processes refinement.

Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study

Present guidelines recommend a multidisciplinary team (MDT) approach to diabetic foot ulcer (DFU) care, but relevant data from Asia are lacking. We aim to evaluate the clinical and economic outcomes of an MDT approach in a lower extremity amputation prevention programme (LEAPP) for DFU care in an Asian population. We performed a case-control study of 84 patients with DFU between January 2017 and October 2017 (retrospective control) vs 117 patients with DFU between December 2017 and July 2018 (prospective LEAPP cohort). Comparing the clinical outcomes between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 vs 9.5 days, P < .001), increase in outpatient podiatry follow-up (33% vs 76%, P < .001), decrease in 1-year minor amputation rate (14% vs 3%, P = .007), and decrease in 1-year major amputation rate (9% vs 3%, P = .05). Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86m (SGD $2.5m) for patients within the LEAPP cohort. In conclusion, similar to the data from Western societies, an MDT approach in an Asian population, via a LEAPP for patients with DFU, demonstrated a significant reduction in minor and major amputation rates, with annualised cost avoidance of USD $1.86m.

Structure, processes, and initial outcomes of The Ottawa Hospital Multi-Specialist Limb-Preservation Clinic and Programme: A unique-in-Canada quality improvement initiative

In 2017, The Ottawa Hospital initiated a unique-in-Canada quality improvement initiative by opening a novel, multi-specialist limb-preservation clinic. We sought to describe the structure, processes, and initial outcomes of the clinic and evaluate whether it is achieving its mandate of providing high-quality wound clinical care, education, and research. We conducted a descriptive prospective cohort study alongside a nested study of 162 clinic patients requiring serial assessments. There have been 1623 visits, mostly (72.2%) from outpatients. During 17.8% of visits, patients were evaluated by >1 specialist. Therapies provided most often included negative-pressure wound therapy (32.7%), biological wound dressings (21.6%), and total contact casting (18.5%). Furthermore, 1.2% underwent toe/ray amputations or skin grafting in clinic and 22.8% were initiated on antimicrobials. Mixed-effects models suggested that mean wound volumes for those requiring serial assessments decreased by 1.6 (95% confidence interval = -0.86 to -2.27) cm³ between visits. The clinic provided seven rotations to vascular surgery, infectious diseases, dermatology, and palliative care physicians; three nursing preceptorships; and two educational workshops. It also initiated provincial and national vascular health and wound care research initiatives. This study may be used to guide development of other limb-preservation clinics and programmes. Findings support that our programme is achieving its mandate.

Nationwide prevalence and clinical characteristics of inpatient diabetic foot complications: A Peruvian multicenter study

OBJECTIVE

To evaluate the burden of diabetic foot complications amongst inpatients in Peru.

MATERIALS AND METHODS

Cross-sectional multicenter study, performed in public hospitals, in one-day enrollment between October and December 2018.

RESULTS

We included 8346 patients from 39 national hospitals. Diabetic foot (DF) inpatient point prevalence was 2.8% (CI 95% 2.4-3.1), and DF point prevalence among Diabetes Mellitus (DM) inpatients was 18.9% (CI 95% 16.7-21.1). DF prevalence was higher in jungle and coastal hospitals than highlands ones, and there was no difference according to its care complexity level. Of the 234 patients with DF, 73% were males, age average was 62 ± 12 years, with DM mean time duration of 15 ± 9.9 years. Regarding to DF etiology, 91% and 68% had some degree of peripheral neuropathy and peripheral artery disease, respectively. According to the Infectious Diseases Society of America criteria, 61% presented moderate to severe infections, and 40% had bone involvement. Debridement within 48 h was performed in 36% of sepsis cases.

CONCLUSION

Peru has a substantial burden of DF disease, with a greater share of that burden falling on less equipped hospitals in the country's jungle and coastal regions. Interdisciplinary teams and pathways may improve the time of surgical debridement in the highest risk patients.

Steal syndrome from a superficial circumflex iliac perforator artery flap in a patient with a hypoplastic posterior tibial artery and severe diabetic peripheral artery disease

The use of free flaps in lower extremity reconstructive surgery has seen growing adoption for treating tissue loss in patients with diabetes mellitus and peripheral artery disease as a means for limb preservation. The superficial circumflex iliac perforator artery (SCIP) flap is one of the most commonly utilized flaps in foot reconstruction and has demonstrated benefits over amputation. Patients with impaired vascular and neurologic function are predisposed to complications following lower extremity reconstructive surgery, particularly ischemia in the angiosomes of the arteries used for flap anastomosis. We present the case of a patient who underwent successful SCIP flap reconstruction of the calcaneus but developed gangrene in the forefoot region supplied by a hypoplastic posterior tibial artery in subsequent months. The changes in tissue oxygenation and hemoglobin distribution of the foot are shown using spatial frequency domain imaging throughout the flap healing process and eventual tissue necrosis.

Struggling for normality: experiences of patients with diabetic lower extremity amputations and post-amputation wounds in primary care

Aim:

To explore the experiences of patients living with diabetic lower extremity amputation (DLEA) and its post-amputation wound in primary care.

Background:

DLEA, including both minor and major amputation, is a life-altering condition that brings numerous challenges to an individual’s life. Post-amputation physical wound healing is complicated and challenging because of wound dehiscence and prolonged healing times. Understanding patients’ experiences after DLEA with a post-amputation wound will enable healthcare professionals to develop interventions to assist patients in physical healing and psychosocial recovery.

Methods:

This study employs a qualitative design using interpretative phenomenological analysis (IPA). A purposive maximum variation sample of nine patients who had had lower extremity amputations and post-amputation wound attributed to diabetes in the previous 12 months was recruited from a primary care setting in Singapore. Semi-structured audio recorded one-to-one interviews with a duration of 45–60 min each were conducted between September 2018 and January 2019. The interviews were transcribed verbatim and analysed using IPA.

Findings:

The essential meaning of the phenomenon ‘the lived experiences for patients with DLEA and post-amputated wound’ can be interpreted as ‘struggling for “normality”’ which encompasses four domains of sense making: physical loss disrupted normality, emotional impact aggravated the disrupted normality, social challenges further provoked the disrupted normality, and attempt to regain normality. The study highlights the complex physical and psychosocial transition facing patients after DLEA before post-amputation wound closure. In primary care, an amputation, whether minor or major, is a life-altering experience that requires physical healing, emotional recovery, and social adaptation to regain normality. Patients living with DLEA and a post-amputation wound may benefit from an interdisciplinary team care model to assist them with physical and psychosocial adjustment and resume normality.

Predictors of Major Adverse Limb Events after Open Forefoot Amputation in Patients with Chronic Limb-Threatening Ischemia

BACKGROUND

Management of patients with chronic limb-threatening ischemia (CLTI) and extensive foot necrosis presents a challenge for limb salvage. Our study evaluates preoperative risk factors that contributed to durability and efficacy of limb salvage after open transmetatarsal amputation (TMA) in patients with critical limb-threatening ischemia.

METHODS

We abstracted data from patients who underwent open TMA at Los Angeles County-University of Southern California Medical Center and Keck Hospital of University of Southern California from 2009 to 2018. Multivariable logistic regression analysis, adjusting for preoperative risk factors, was used to examine predictors of major adverse limb events (MALE). The aim was to evaluate outcomes following open TMA with MALE as the primary outcome. Our hypotheses were that outcomes would be worse for patients with foot infections and renal failure.

RESULTS

Forty-three open TMAs were done in 39 patients during the study period. The cohort had a mean age of 63 ± 11.6 years, 89% had a history of diabetes, 95% hypertension (HTN), 54% had end-stage renal disease (ESRD), and 26% were current smokers. MALE occurred in 39% of the cohort. Sex, race, indication, HTN, smoking status, and history of prior ipsilateral revascularization or minor amputations were not associated with MALE (P > 0.05). Multivariate logistic regression found ESRD to be an independent predictor of MALE (odds ratio 7.43, 95% confidence interval 1.12-49.17, P = 0.038) after adjusting for clinically significant covariates.

CONCLUSIONS

Open TMA provides acceptable rates of limb salvage for complex patients with CLTI. ESRD is an independent risk factor for MALE following open TMA in these patients. Vigilant follow-up is essential for this morbid patient population given poorer outcomes after forefoot amputation.

On the Cutting Edge: Wound Care for the Endovascular Specialist

Clinical outcomes in patients with critical limb ischemia (CLI) depend not only on endovascular restoration of macrovascular blood flow but also on aggressive periprocedural wound care. Education about this area of CLI therapy is essential not only to maximize the benefits of endovascular therapy but also to facilitate participation in the multidisciplinary care crucial to attaining limb salvage. In this article, we review the advances in wound care products and therapies that have granted the wound care specialist the ability to heal previously nonhealing wounds. We provide a primer on the basic science behind wound healing and the pathogenesis of ischemic wounds, familiarize the reader with methods of tissue viability assessment, and provide an overview of wound debridement techniques, dressings, hyperbaric therapy, and tissue offloading devices. Lastly, we explore emerging technology on the horizons of wound care.

'CPR for Feet' care bundle to improve foot assessment in inpatient diabetes

Aims

The Scottish Inpatient Diabetes Foot Audit conducted in 2013 revealed that 57% of inpatients had not had their feet checked on admission, 60% of those at risk did not have pressure relief in place and 2.4% developed a new foot lesion. In response, the Scottish Diabetes Foot Action Group launched the ‘CPR for Feet’ campaign. The aim of this project was to raise awareness of the ‘Check, Protect and Refer’ (CPR) campaign as well as improve the assessment and management of inpatients with diabetes.

Methods

A quality improvement project underpinned by Plan-Do-Study-Act (PDSA) methodology was undertaken. The first and second cycles focused on staff education and the implementation of a ‘CPR for Feet’ assessment checklist using campaign guidelines, training manuals and modules. The third and fourth cycles focused on staff feedback and the implementation of a ‘CPR for Feet’ care bundle.

Results

Baseline measurements revealed 28% of patients had evidence of foot assessment. Medical and nursing staff reported to be largely unaware of the ‘CPR for Feet’ campaign (13%). Fifty-two per cent of inpatients with diabetes had their feet assessed and managed correctly following the second PDSA cycle. After completion of the third and fourth PDSA this number improved further to 72% and all staff reported to be aware of the campaign.

Conclusions

The introduction of a ‘CPR for Feet’ care bundle improved the assessment of inpatients with diabetes.