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Izumi Y, Onishi H, Lavery LA. Health professionals involved in diabetic foot and their tasks in a country without podiatrists: From a Japanese Nationwide Survey. Wound Repair Regen 2024. [PMID: 39007520 DOI: 10.1111/wrr.13205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 07/01/2024] [Indexed: 07/16/2024]
Abstract
Although there are no podiatrists in 85% of countries worldwide, how diabetic foot is managed in those countries is still unknown. We sought to identify the health professionals involved in diabetic foot and their tasks in Japan, where no podiatrists exist. This cross-sectional study used the Japanese Nationwide Survey on Foot Ulcer Management dataset, consisting of 249 medical doctors and 680 allied health professionals. The types of health professionals involved in the diabetic foot were identified, and the tasks performed by each professional were compared within subgroups (medical doctors and allied health professionals). We found that the primary medical doctors involved in diabetic foot care in Japan were plastic surgeons (33.5%), dermatologists (21%), cardiovascular/vascular surgeons (15.2%), and cardiologists (12.1%). Nurses were the main allied health professionals (80%), and the rest consisted of prosthetists/orthotists (7.6%), physical/occupational therapists (5.9%), and clinical engineering technologists (3.6%). Medical doctors performed tasks related to their specialties significantly more than others (p < 0.001); however, they also engaged in tasks outside of their specialty, such as plastic surgeons performing preventive foot care (72%). Among allied health professionals, clinical engineering technologists performed more vascular assessments (p < 0.001), and half were engaged in wound management, preventive foot care, and self-foot care education. In conclusion, the type and proportion of health professionals in our study differed from those in countries with podiatrists, and many performed tasks outside their specialties. This is the first nationwide cross-sectional study of diabetic foot care in a country without podiatrists and is unique in examining multiple specialists/professionals in one study.
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Affiliation(s)
- Yuki Izumi
- Department of International Cooperation for Medical Education, Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hirotaka Onishi
- Department of International Cooperation for Medical Education, Research Center for Medical Education, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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Campbell DB, Gutta G, Sobol CG, Atway SA, Haurani MJ, Chen XP, Rowe VL, Stacy MR, Go MR. How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia. J Vasc Surg 2024:S0741-5214(24)01212-6. [PMID: 38906429 DOI: 10.1016/j.jvs.2024.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/13/2024] [Accepted: 05/15/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE Although multidisciplinary clinics improve outcomes in chronic limb-threatening ischemia (CLTI), their role in addressing socioeconomic disparities is unknown. Our institution treats patients with CLTI at both traditional general vascular clinics and a multidisciplinary Limb Preservation Program (LPP). The LPP is in a minority community, providing expedited care at a single facility by a consistent team. We compared outcomes within the LPP with our institution's traditional clinics and explored patients' perspectives on barriers to care to evaluate if the LPP might address them. METHODS All patients undergoing index revascularization for CLTI from 2014 to 2023 at our institution were stratified by clinic type (LPP or traditional). We collected clinical and socioeconomic variables, including Area Deprivation Index (ADI). Patient characteristics were compared using χ2, Student t, or Mood median tests. Outcomes were compared using log-rank and multivariable Cox analysis. We also conducted semi-structured interviews to understand patient-perceived barriers. RESULTS From 2014 to 2023, 983 limbs from 871 patients were revascularized; 19.5% of limbs were treated within the LPP. Compared with traditional clinic patients, more LPP patients were non-White (43.75% vs 27.43%; P < .0001), diabetic (82.29% vs 61.19%; P < .0001), dialysis-dependent (29.17% vs 13.40%; P < .0001), had ADI in the most deprived decile (29.38% vs 19.54%; P = .0061), resided closer to clinic (median 6.73 vs 28.84 miles; P = .0120), and had worse Wound, Ischemia, and foot Infection (WIfI) stage (P < .001). There were no differences in freedom from death, major adverse limb event (MALE), or patency loss. Within the most deprived subgroup (ADI >90), traditional clinic patients had earlier patency loss (P = .0108) compared with LPP patients. Multivariable analysis of the entire cohort demonstrated that increasing age, heart failure, dialysis, chronic obstructive pulmonary disease, and increasing WIfI stage were independently associated with earlier death, and male sex was associated with earlier MALE. Ten traditional clinic patients were interviewed via convenience sampling. Emerging themes included difficulty understanding their disease, high visit frequency, transportation barriers, distrust of the health care system, and patient-physician racial discordance. CONCLUSIONS LPP patients had worse comorbidities and socioeconomic deprivation yet had similar outcomes to healthier, less deprived non-LPP patients. The multidisciplinary clinic's structure addresses several patient-perceived barriers. Its proximity to disadvantaged patients and ability to conduct multiple appointments at a single visit may address transportation and visit frequency barriers, and the consistent team may facilitate patient education and improve trust. Including these elements in a multidisciplinary clinic and locating it in an area of need may mitigate some negative impacts of socioeconomic deprivation on CLTI outcomes.
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Affiliation(s)
- Drayson B Campbell
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Goutam Gutta
- The Ohio State University College of Medicine, Columbus, OH; Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Carly G Sobol
- Division of Vascular Surgery, Department of Surgery, University of Wisconsin, Madison, WI
| | - Said A Atway
- Department of Orthopaedics, The Ohio State University College of Medicine, Columbus, OH
| | - Mounir J Haurani
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Xiaodong P Chen
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Mitchel R Stacy
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH; Center for Regenerative Medicine, The Research Institute at Nationwide Children's Hospital, Columbus, OH
| | - Michael R Go
- Division of Vascular Diseases and Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
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Chuter V, Schaper N, Hinchliffe R, Mills J, Azuma N, Behrendt CA, Boyko EJ, Conte MS, Humphries M, Kirksey L, McGinigle KC, Nikol S, Nordanstig J, Rowe V, David R, van den Berg JC, Venermo M, Fitridge R. Performance of non-invasive bedside vascular testing in the prediction of wound healing or amputation among people with foot ulcers in diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3701. [PMID: 37493206 DOI: 10.1002/dmrr.3701] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION The presence of peripheral artery disease (PAD) confers a significantly increased risk of failure to heal and major lower limb amputation for people with diabetes-related foot ulcer (DFU). Determining performance of non-invasive bedside tests for predicting likely DFU outcomes is therefore key to effective risk stratification of patients with DFU and PAD to guide management decisions. The aim of this systematic review was to determine the performance of non-invasive bedside tests for PAD to predict DFU healing, healing post-minor amputation, or need for minor or major amputation in people with diabetes and DFU or gangrene. METHODS A database search of Medline and Embase was conducted from 1980 to 30 November 2022. Prospective studies that evaluated non-invasive bedside tests in patients with diabetes, with and without PAD and foot ulceration or gangrene to predict the outcomes of DFU healing, minor amputation, and major amputation with or without revascularisation, were eligible. Included studies were required to have a minimum 6-month follow-up period and report adequate data to calculate the positive likelihood ratio (PLR) and negative likelihood ratio for the outcomes of DFU healing, and minor and major amputation. Methodological quality was assessed using the Quality in Prognosis Studies tool. RESULTS From 14,820 abstracts screened 28 prognostic studies met the inclusion criteria. The prognostic tests evaluated by the studies included: ankle-brachial index (ABI) in 9 studies; ankle pressures in 10 studies, toe-brachial index in 4 studies, toe pressure in 9 studies, transcutaneous oxygen pressure (TcPO2 ) in 7 studies, skin perfusion pressure in 5 studies, continuous wave Doppler (pedal waveforms) in 2 studies, pedal pulses in 3 studies, and ankle peak systolic velocity in 1 study. Study quality was variable. Common reasons for studies having a moderate or high risk of bias were poorly described study participation, attrition rates, and inadequate adjustment for confounders. In people with DFU, toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg were associated with a moderate to large increase in pretest probability of healing in people with DFU. Toe pressure ≥30 mmHg was associated with a moderate increase in healing post-minor amputation. An ABI using a threshold of ≥0.9 did not increase the pretest probability of DFU healing, whereas an ABI <0.5 was associated with a moderate increase in pretest probability of non-healing. Few studies investigated amputation outcomes. An ABI <0.4 demonstrated the largest increase in pretest probability of a major amputation (PLR ≥10). CONCLUSIONS Prognostic capacity of bedside testing for DFU healing and amputation is variable. A toe pressure ≥30 mmHg, TcPO2 ≥25 mmHg, and skin perfusion pressure of ≥40 mmHg are associated with a moderate to large increase in pretest probability of healing in people with DFU. There are little data available evaluating the prognostic capacity of bedside testing for healing after minor amputation or for major amputation in people with DFU. Current evidence suggests that an ABI <0.4 may be associated with a large increase in risk of major amputation. The findings of this systematic review need to be interpreted in the context of limitations of available evidence, including varying rates of revascularisation, lack of post-revascularisation bedside testing, and heterogenous subpopulations.
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Affiliation(s)
- Vivienne Chuter
- School of Health Sciences, Western Sydney University, Campbelltown, Sydney, Australia
| | - Nicolaas Schaper
- Division of Endocrinology, Department of Internal Medicine, MUMC+, Maastricht, The Netherlands
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, University of Bristol, Bristol, UK
| | | | | | - Christian-Alexander Behrendt
- Department of Vascular and Endovascular Surgery, Asklepios Clinic Wandsbek, Asklepios Medical School, Hamburg, Germany
| | | | - Michael S Conte
- San Francisco (UCSF) Medical Centre, University of California, San Francisco, California, USA
| | | | | | | | - Sigrid Nikol
- Clinical and Interventional Angiology, Asklepios Klinik, St. Georg, Hamburg, Germany
| | | | - Vincent Rowe
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Jos C van den Berg
- CENTRO VASCOLARE TICINO Ospedale Regionale di Lugano, sede Civico and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Universitätsspital, Bern, Switzerland
| | - Maarit Venermo
- Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Robert Fitridge
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Cho NY, Tran Z, Bakhtiyar SS, Orellana M, Kronen E, Bowens N, Benharash P. Factors Associated With Early Amputation in Patients With Chronic Limb Threatening Ischemia. Am Surg 2023; 89:4111-4116. [PMID: 37212353 DOI: 10.1177/00031348231177945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Despite advancements in revascularization procedures, early amputation (EA) among patients with chronic limb threatening ischemia (CLTI) are still common. The present study evaluated clinical outcomes of patients with CLTI and factors associated with EA. METHODS The 2016-2019 Nationwide Readmission Database was queried to identify all adults (≥18 years) with CLTI of lower extremities undergoing limb salvage (LS) procedures. The primary outcome of the study was EA within 90 days of discharge. Secondary outcomes included infectious complication, length of stay (LOS), cumulative hospitalization cost and non-home discharge. RESULTS Of 103,703 patients who initially underwent surgical or endovascular revascularization, 10,439 (10.1%) subsequently underwent major amputation within 90 days of discharge. Following risk adjustment, factors associated with higher odds of EA were male sex, low-income quartile, tissue loss due to ulceration or gangrene, end-stage renal disease, and diabetes. Compared to those undergoing open revascularization, patients with endovascular limb salvage had a higher likelihood of having early amputation (AOR 1.41, 95% CI 1.31-1.51). Patients undergoing EA had greater odd of infectious complication, incremental LOS, incremental cost and non-home discharge. CONCLUSIONS We identified several risk factors to be associated with EA in patients with CLTI. These findings may supplement the objective performance goals for limb-related outcomes and facilitate institutional limb salvage programs.
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Affiliation(s)
- Nam Yong Cho
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Zachary Tran
- Department of Surgery, Loma Linda University Health, Loma Linda, CA, USA
| | | | - Manuel Orellana
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Elsa Kronen
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Nina Bowens
- Department of Surgery, Harbor-UCLA Medical Center, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Majumdar M, Lella S, Hall RP, Sumetsky N, Waller HD, McElroy I, Sumpio B, Feldman ZM, Kim Y, DeCarlo C, Warner M, Nuzzolo K, Kirshkaln A, Dua A. Utilization of Thromboelastography with Platelet Mapping to Predict Infection and Poor Wound Healing in Postoperative Vascular Patients. Ann Vasc Surg 2022; 87:213-224. [PMID: 35339591 DOI: 10.1016/j.avsg.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/13/2022] [Accepted: 03/14/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE/AIM Postoperative infection and wound dehiscence rates are higher than expected in peripheral artery disease and contribute significantly to limb loss and mortality. Microvascular pathology characterized by microthrombi and increased platelet aggregation have been cited as contributing factors to poor wound healing and infection. The emergence of viscoelastic assays, such as thromboelastography with platelet mapping (TEG-PM), have been utilized to identify prothrombotic states and may provide insight into a patient's microvascular coagulation profile. This prospective, observational study aimed to determine if TEG-PM could predict poor wound healing or infection following lower extremity revascularization. METHODS All patients undergoing revascularization between December 2020 and January 2022 were prospectively included and followed for wound complications or non-surgical site infections of the index limb. TEG-PM metrics at the first postoperative follow-up in the nonevent group was compared to the TEG-PM sample preceding the diagnosis of infection/dehiscence in the event group. Cox proportional hazards regression was used to model the predictive value of viscoelastic parameters. Cut-point analysis to determine high-risk groups was determined by performing receiver operating characteristic (ROC) curve analysis. RESULTS Of the 102 patients, 18.6% experienced infection/dehiscence. The TEG-PM sample analyzed in the event group was, on average, 19.5 days prior to the diagnosis of an event. The event group had significantly higher maximum clot amplitude (MA) [47.3mm±16.0 vs. 30.6mm±15.3, p<0.01], higher platelet aggregation [71.3%±27.7 vs. 31.2%±24.0, p<0.01] and lower platelet inhibition [28.7%±27.7 vs. 68.7%±24.1, p<0.01]. Cox PH analysis identified platelet aggregation as an independent and consistent predictor of infection [HR=1.04, 95% CI 1.03-1.06, p<0.01]. An optimal cut-point of >33.2mm MA, >46.6% platelet aggregation or <55.8% platelet inhibition identifies those with infection/dehiscence with 79.0-89.5% sensitivity. CONCLUSIONS These are the first data to provide a quantitative link between prothrombotic viscoelastic coagulation profiles with the development of infection/dehiscence. Based on the cut-points of >33.2mm MA, >46.6% platelet aggregation or <55.8% platelet inhibition, we recommend consideration of an enhanced antimicrobial or antithrombotic approach for these high risk groups.
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Affiliation(s)
- Monica Majumdar
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Srihari Lella
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Ryan P Hall
- Department of Surgery, Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Natalie Sumetsky
- Department of Epidemiology, University of Pittsburg, Pittsburg, PA
| | - Harold D Waller
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Imani McElroy
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Brandon Sumpio
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Zach M Feldman
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Young Kim
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Charles DeCarlo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Mary Warner
- Department of Surgery, Tufts Medical Center/Tufts University School of Medicine, Boston, MA
| | - Kathryn Nuzzolo
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Amanda Kirshkaln
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA
| | - Anahita Dua
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital/Harvard Medical School, Boston MA.
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