The impact of socio-economic disadvantage on rates of hospital separations for diabetes-related foot disease in Victoria, Australia

Assessment, diagnosis and management characteristics of people with acute Charcot neuro-osteoarthropathy in a regional Australian health service: A 3-year retrospective audit

OBJECTIVE

Acute Charcot neuro-osteoarthropathy (CN) is highly destructive, causing bone and joint damage that can result in devastating structural changes to the foot. The objective of this study was to determine the characteristics of assessment, diagnosis and management of people with acute CN attending a large regional Australian health service.

DESIGN

Three-year retrospective medical record audit.

SETTING

Large regional health service with catchment area of >250 000 people in regional Australia.

PARTICIPANTS

People with acute CN who attended emergency, orthopaedic clinics or High Risk Foot Clinic (HRFC).

MAIN OUTCOME MEASURES

Participant characteristics and acute CN assessment, diagnosis and management characteristics. Trends in characteristics were investigated according to rurality as measured by the Modified Monash Model (MMM) scale.

RESULTS

Seventeen participants (20 presentations) of acute CN were identified. Mean age was 57.1 ± 10.8 years, with 11 female participants. Median duration to seek help was 31 (IQR 14-47) days. Total Contact Casting was undertaken for 85% of cases, with those who resided in MMM1-2 regions experienced significantly shorter time to TCC therapy compared to those residing in MMM3-7 regions (U = 3.0, p < 0.01). Resolution of acute CN with or without deformity occurred in 70% of cases.

CONCLUSIONS

Those who lived in smaller regional and rural communities were more likely to experience delayed access to gold standard treatment for acute CN. Regional models of care for acute CN should include activities to improve the knowledge of people at risk of acute CN about the condition and upskill regional health professionals for timely and local TCC therapy.

Experiences and impact of a rural Australian high-risk foot service: A multiple-methods study

OBJECTIVE

Most podiatry-led high-risk foot services (HRFS) in Australia are located in metropolitan areas or large regional centres. In rural areas, where there are limited specialist services, individuals with diabetes-related foot ulceration are more likely to undergo amputation. This study aimed to explore clinicians' perceptions of a recently implemented HRFS in rural New South Wales, Australia, and compare trends of amputation and hospitalisation prior to and post-implementation of the service.

SETTING

Rural HRFS in Tamworth, New South Wales, Australia.

PARTICIPANTS

Health professionals working within the HRFS were recruited to participate.

DESIGN

This was a multiple-methods study. For the qualitative arm, semi-structured interviews were conducted, which were analysed using a reflexive thematic approach. The quantitative arm of the study utilised a retrospective analytic design which applied an interrupted time series to compare amputation and hospitalisation trends pre- and post-implementation of the HRFS utilising diagnostic and procedural ICD codes.

RESULTS

The qualitative arm of the study derived three themes: (1) navigating the divide, (2) rural community and rural challenges and (3) professional identity. Results of the interrupted time series indicate that there was a downward trend in major amputations following implementation of the HRFS; however, this was not statistically significant.

CONCLUSION

Clinicians were aware of the inequity in DFD outcomes between rural and metropolitan areas and were committed to improving outcomes, particularly with respect to First Nations peoples. Future research will explore service use and amputation rates in the longer term to further evaluate this specialised multidisciplinary care in a rural community.

Implication of Peripheral Neuropathy on Unplanned Readmissions in Patients Hospitalized for Complicated Diabetic Foot Disease

Introduction. Unplanned readmissions are common following discharge in patients after hospitalization for diabetic foot disease (DFD) complications. The aim of this study was to identify factors associated with readmissions in these high-risk patients, treated in a multidisciplinary setting and the implication of measures that could effectively reduce readmission rates. Methods. Patients presenting with DFDs admitted between 2015 and 2017 were studied retrospectively in a single-centre patient database. The demographics and clinical comorbidities were analyzed and comparison was made between 2 groups: patients readmitted within 30 days of discharge and those who did not require readmission. Multivariate analysis was performed to identify risk factors associated with readmissions. Results. In total, 340 patients were included. The unplanned readmission rate was 10.9%. More than half of readmissions (71%) were related to wound deterioration and infection. In the readmission group, the patients had lower body mass index, higher rate of osteomyelitis, lower rate of debridement, and evidence of peripheral vascular disease below the knee in the index admissions but these were not significant. In the multivariate analysis, peripheral neuropathy was the only significant risk associated with unplanned readmissions (odds ratio: 2.78, 95% confidence interval: 1.23-6.29, P = .014). Conclusion. This study demonstrates a significant association between peripheral neuropathy and unplanned readmissions. The implications of this nonmodifiable risk factor in reducing readmissions include all levels of patient care delivery such as adequate preparation for discharge and transition back into the community. Recognition and education in successful long-term offloading of insensate diabetic feet may help reduce rates of unplanned readmission.

Habitual Physical Activity of People with or at Risk of Diabetes-Related Foot Complications

Regular physical activity is an important component of diabetes management. However, there are limited data on the habitual physical activity of people with or at risk of diabetes-related foot complications. The aim of this study was to describe the habitual physical activity of people with or at risk of diabetes-related foot complications in regional Australia. Twenty-three participants with diabetes from regional Australia were recruited with twenty-two participants included in subsequent analyses: no history of ulcer (N = 11) and history of ulcer (N = 11). Each participant wore a triaxial accelerometer (GT3X+; ActiGraph LLC, Pensacola, FL, USA) on their non-dominant wrist for 14 days. There were no significant differences between groups according to both participant characteristics and physical activity outcomes. Median minutes per day of moderate-to-vigorous physical activity (MVPA) were 9.7 (IQR: 1.6-15.7) while participants recorded an average of 280 ± 78 min of low-intensity physical activity and 689 ± 114 min of sedentary behaviour. The sample accumulated on average 30 min of slow walking and 2 min of fast walking per day, respectively. Overall, participants spent very little time performing MVPA and were largely sedentary. It is important that strategies are put in place for people with or at risk of diabetes-related foot complications in order that they increase their physical activity significantly in accordance with established guidelines.

Factors influencing diabetes-related foot ulcer healing in Australian adults: A prospective cohort study

OBJECTIVE

Diabetes-related foot ulceration (DFU) is a common limb-threatening condition, which is complex and subsequently challenging to manage. The aim of this study was to determine the contribution of a range of clinical and social factors to the healing of diabetes-related foot ulceration in an Australian population.

RESEARCH DESIGN AND METHODS

This was a prospective cohort study of individuals with diabetes-related foot ulceration (DFU). Age, sex, medical history, medications, dietary supplementation (e.g. vitamin C intake) and smoking history were elicited at baseline. The index of relative socio-economic disadvantage (IRSD) was calculated. The Australian Eating Survey and International Physical Activity Questionnaire-short were administered. Wound history, size, grade, time to healing and infection were captured and monitored over 6 months. Logistic regression was performed to determine the relationship between healing and diet quality, toe systolic pressure, wound size at, IRSD, infection and previous amputation.

RESULTS

A total of 117 participants were included. The majority were male n = 96 (82%), socio-economically disadvantaged (mean IRSD 965, SD 60), and obese (BMI 36 kg/m2 , SD 11) with a long history of diabetes (20 years, SD 11). Wounds were predominantly neuropathic (n = 85, 73%) and classified 1A (n = 63, 54%) on the University of Texas wound classification system with few infections (n = 23, 16%). Dietary supplementation was associated with 4.36 increased odds of healing (95% 1.28-14.84, p = 0.02), and greater levels of socio-economic advantage were also associated with increased odds of healing (OR 1.01, 95% CI 1.01-1.02, p = 0.03).

CONCLUSIONS

In this cohort study of predominantly neuropathic, non-infected DFU, individuals who had greater levels of socio-economic advantage had significantly greater odds of DFU healing. Diet quality was poor in most participants, with individuals taking supplementation significantly more likely to heal.

Comparing opioid types in the persistence of opioid use following surgical admission: a study protocol for a retrospective observational linkage study comparing tapentadol and oxycodone in Australia

INTRODUCTION

Each year, an estimated two million Australians commence opioids, with 50 000 developing longer-term (persistent) opioid use. An estimated 3%-10% of opioid-naïve patients prescribed opioids following surgery develop persistent opioid use. This study will compare rates of persistent opioid use between two commonly used postoperative opioids, oxycodone and tapentadol, to understand if initial postoperative opioid type is important in determining longer-term outcomes.

METHODS AND ANALYSIS

A retrospective data linkage study that analyses administrative data from hospital and community pharmacies. Data will be obtained from at least four pharmacies that service large hospitals with comparable supplies of oxycodone and tapentadol. The study will include at least 6000 patients who have been dispensed a supply of oxycodone or tapentadol to take home following their discharge from a surgical ward. The primary outcome measure will be persistent opioid use at 3 months postdischarge for opioid naïve people who receive either immediate release tapentadol or immediate release oxycodone. Hierarchical logistic regression models will be used to predict persistent opioid use, controlling for covariates including comorbidities.

ETHICS AND DISSEMINATION

Ethics approval has been obtained through the Monash University Human Research Ethics Committee (29977). We will present project findings in a peer-reviewed journal article, in accordance with the REporting of studies Conducted using Observational Routinely-collected health Data statement.

Disparities in Advanced Peripheral Arterial Disease Presentation by Socioeconomic Status

Background

Diabetes and peripheral arterial disease (PAD) often synergistically lead to foot ulceration, infection, and gangrene, which may require lower limb amputation. Worldwide there are disparities in the rates of advanced presentation of PAD for vulnerable populations. This study examined rates of advanced presentations of PAD for unemployed patients, those residing in low Index of Economic Resources (IER) areas, and those in rural areas of Australia.

Methods

A retrospective study was conducted at a regional tertiary care centre (2008–2018). To capture advanced presentations of PAD, the proportion of operative patients presenting with complications (gangrene/ulcers), the proportion of surgeries that are amputations, and the rate of emergency to elective surgeries were examined. Multivariable logistic regression adjusting for year, age, sex, Charlson Comorbidity Index, and sociodemographic variables was performed.

Results

In the period examined, 1115 patients underwent a surgical procedure for PAD. Forty-nine per cent of patients had diabetes. Following multivariable testing, the rates of those requiring amputations were higher for unemployed (OR 1.99(1.05–3.79), p = 0.036) and rural patients (OR 1.83(1.21–2.76), p = 0.004). The rate of presentation with complications was higher for unemployed (OR 7.2(2.13–24.3), p = 0.001), disadvantaged IER (OR 1.91(1.2–3.04), p = 0.007), and rural patients (OR 1.73(1.13–2.65), p = 0.012). The rate of emergency to elective surgery was higher for unemployed (OR 2.32(1.18–4.54), p = 0.015) and rural patients (OR 1.92(1.29–2.86), p = 0.001).

Conclusions

This study found disparities in metrics capturing delayed presentations of PAD: higher rates of presentations with complications, higher amputation rates, and increased rates of emergency to elective surgery, for patients of low socioeconomic status and those residing in rural areas. This suggests barriers to appropriate, effective, and timely care exists for these patients.

The Effect of Structured Exercise Compared with Education on Neuropathic Signs and Symptoms in People at Risk of Neuropathic Diabetic Foot Ulcers: A Randomized Clinical Trial

Background and Objectives: Lifestyle interventions such as exercise prescription and education may play a role in the management of peripheral neuropathy in people with diabetes. The aim of this study was to determine the effect of undertaking an exercise program in comparison with an education program on the signs and symptoms of peripheral neuropathy in people with diabetes at risk of neuropathic foot ulceration. Materials and Methods: Twenty-four adult participants with diabetes and peripheral neuropathy were enrolled in this parallel-group, assessor blinded, randomised clinical trial. Participants were randomly allocated to one of two 8-week lifestyle interventions, exercise or education. The primary outcome measures were the two-part Michigan Neuropathy Screening Instrument (MNSI) and vibratory perception threshold (VPT). Secondary outcome measures included aerobic fitness, balance and lower limb muscular endurance. Results: Participants in both lifestyle interventions significantly improved over time for MNSI clinical signs (MD: -1.04, 95% CI: -1.68 to -0.40), MNSI symptoms (MD: -1.11, 95% CI: -1.89 to -0.33) and VPT (MD: -4.22, 95% CI: -8.04 to -0.40). Although the interaction effects did not reach significance, changes in values from pre to post intervention favoured exercise in comparison to control for MNSI clinical signs (MD -0.42, 95% CI -1.72 to 0.90), MNSI clinical symptoms (MD -0.38, 95% CI -1.96 to 1.2) and VPT (MD -4.22, 95% CI -12.09 to 3.65). Conclusions: Eight weeks of exercise training or lifestyle education can improve neuropathic signs and symptoms in people with diabetes and peripheral neuropathy. These findings support a role for lifestyle interventions in the management of peripheral neuropathy.

Social determinants of diabetes-related foot disease among older adults in New South Wales, Australia: evidence from a population-based study

BACKGROUND

Diabetes-related foot is the largest burden to the health sector compared to other diabetes-related complications in Australia, including New South Wales (NSW). Understanding of social determinants of diabetes-related foot disease has not been definitive in Australian studies. This study aimed to investigate the social determinants of diabetes-related foot disease in NSW.

METHODOLOGY

The first wave of the 45 and Up Study survey data was linked with NSW Admitted Patient Data Collection, Emergency Department Data Collection, and Pharmaceutical Benefits Scheme data resulting in 28,210 individuals with diabetes aged 45 years and older in NSW, Australia. Three outcome variables were used: diabetes-related foot disease (DFD), diabetic foot ulcer (DFU), and diabetic foot infection (DFI). They were classified as binary, and survey logistic regression was used to determine the association between each outcome measure and associated factors after adjusting for sampling weights.

RESULTS

The prevalence of DFD, DFU and DFI were 10.8%, 5.4% and 5.2%, respectively, among people with diabetes. Multivariate analyses revealed that the common factors associated with DFD, DFU and DFI were older age (75 years or more), male, single status, background in English speaking countries, and coming from lower-income households (less than AUD 20,000 per year). Furthermore, common lifestyle and health factors associated with DFD, DFU, and DFI were low physical activity (< 150 min of moderate-to-vigorous physical activity per week), history of diabetes for over 15 years, and having cardiovascular disease.

CONCLUSION

Our study showed that about 1 in 10 adults with diabetes aged 45 years and older in NSW reported DFD. Interventions, including the provision of related health services aimed at reducing all forms of DFD in NSW, are recommended to target older individuals with a long history of diabetes, and coming from lower-income households.

Prevalence and Burden of Diabetes-Related Foot Disease in New South Wales, Australia: Evidence from the 45 and Up Study Survey Data Linked with Health Services Data

Diabetes-related foot disease (DFD) is a major public health concern due to the higher risks of hospitalisation. However, estimates of the prevalence of DFD in the general population are not available in Australia. This study aims to estimate the prevalence of DFD and diabetes-related lower-extremity amputation (DLEA) among people aged 45 years and over in New South Wales (NSW), Australia. The NSW 45 and Up Study baseline survey data of 267,086 persons aged 45 years and over, linked with health services' administrative data from 2006 to 2012 were used in our study. Of these, 28,210 individuals had been diagnosed with diabetes, and our study identified 3035 individuals with DFD. The prevalence of DFD, diabetic foot ulcer (DFU), diabetic foot infection (DFI), diabetic gangrene (DG), and DLEA were 10.8% (95%CI: 10.3, 11.2), 5.4% (95% CI: 5.1, 5.8), 5.2% (95%CI: 4.9, 5.5), 0.4% (95%CI: 0.3, 0.5), and 0.9% (95%CI: 0.7, 1.0), respectively. DFD, DFU, DFI, DG, and DLEA were the most common among those who were older, born in Australia, from low-income households (<AUD 20,000), or were without private health insurance. Interventional messages to reduce all forms of DFD should target those who are from high-risk groups.

Factors influencing lower extremity amputation outcomes in people with active foot ulceration in regional Australia: A retrospective cohort study

Australia has the second highest rate of non-traumatic lower extremity amputation (LEA) globally. Australia's large geographical size is one of the biggest challenges facing limb preservation services and may be contributing to LEA. The aim of this study was to determine what factors contribute to the likelihood of LEA in people with active foot ulceration in regional Australia. This retrospective cohort study audited patients with active foot ulceration in a multidisciplinary high risk foot service (HRFS) in regional Australia. Neurological, vascular and wound characteristics were systematically extracted, along with demographic information. Participants were followed for at least 12 months until healing or LEA occurred. Correlations between LEA and clinical and demographic characteristics were assessed using the Pearson's product moment correlation coefficient and chi squared test for independence. Significant variables (p < 0.05) were included in the model. Direct logistic regression assessed the independent contribution of significantly correlated variables on the likelihood of LEA. Of note, 1876 records were hand screened with 476 participants (25%) meeting the inclusion criteria. Geographical distance from the HRFS, toe systolic pressure (TSP), diabetes and infection were all significantly correlated with LEA and included in the logistic regression model. TSP decrease of 1 mmHg (OR 1.02, 95% CI 1.01-1.03), increased geographical distance (1 km) from HRFS (OR 1.006, 95% CI 1.001-1.01) infection (OR 2.08, 95% CI 1.06-4.07) and presence of diabetes (OR 3.77, 95% CI 1.12-12.65) were all significantly associated with increased likelihood of LEA. HRFS should account for the disparity in outcomes between patients living in close proximity to their service, compared to those in rural areas. Optimal management of diabetes, vascular perfusion and control of infection may also contribute to preventing LEA in people with active foot ulceration.

Factors impacting the evidence-based assessment, diagnosis and management of Acute Charcot Neuroarthropathy: a systematic review

BACKGROUND

Acute Charcot Neuroarthropathy (CN) is a destructive condition that is characterised by acute fractures, dislocations and joint destruction in the weight-bearing foot. The acute phase is often misdiagnosed and can rapidly lead to devastating health outcomes. Early diagnosis and management of CN is imperative to attenuate progression of this condition. Consequently, timely evidence-based assessment, diagnosis and management of acute CN is imperative.

OBJECTIVE

To identify the factors that impact the delivery of evidence-based care in assessment, diagnosis and management of people with acute CN.

METHOD

Systematic searches were conducted in four databases to identify studies in English that included factors that impact the delivery of evidence-based care in the assessment, diagnosis and management of people with acute CN. Articles and consensus/guideline documents were assessed for inclusion by the researchers and disagreements were resolved through consensus. Additionally backward citation searching was used to source other potentially relevant documents. Information relevant to the research question was extracted and thematic analyses were performed using qualitative synthesis.

RESULTS

Thirty-two articles and four additional consensus/guideline documents were included for data extraction and analyses. Information related to the research question was of expert opinion using the National Health and Medical Research Council (NHMRC) Levels of Evidence guidelines. Themes explaining practices that deviated from evidence-based care in assessment, diagnosis and management of acute CN centred around patient, health professional and health organisation/environmental. Delay to diagnosis is particularly influenced by the patient's knowledge of when to seek help, practitioner knowledge in knowing how to recognise and refer for appropriate immediate care, confusion in imaging and offloading and geographical and local health service resources to appropriately manage the condition.

CONCLUSION

Individual and health professional awareness and geographical barriers are key challenges to the effective delivery of evidence-based assessment, diagnosis and management of people with acute CN. Acute CN represents a medical emergency warranting the need for expedited assessment, diagnosis and management by appropriately trained health professionals in the appropriate.

Geospatial mapping and data linkage uncovers variability in outcomes of foot disease according to multiple deprivation: a population cohort study of people with diabetes

AIMS/HYPOTHESIS

Our aim was to investigate the geospatial distribution of diabetic foot ulceration (DFU), lower extremity amputation (LEA) and mortality rates in people with diabetes in small geographical areas with varying levels of multiple deprivation.

METHODS

We undertook a population cohort study to extract the health records of 112,231 people with diabetes from the Scottish Care Information - Diabetes Collaboration (SCI-Diabetes) database. We linked this to health records to identify death, LEA and DFU events. These events were geospatially mapped using multiple deprivation maps for the geographical area of National Health Service (NHS) Greater Glasgow and Clyde. Tests of spatial autocorrelation and association were conducted to evaluate geographical variation and patterning, and the association between prevalence-adjusted outcome rates and multiple deprivation by quintile.

RESULTS

Within our health board region, people with diabetes had crude prevalence-adjusted rates for DFU of 4.6% and for LEA of 1.3%, and an incidence rate of mortality preceded by either a DFU or LEA of 10.5 per 10,000 per year. Spatial autocorrelation identified statistically significant hot spot (high prevalence) and cold spot (low prevalence) clusters for all outcomes. Small-area maps effectively displayed near neighbour clustering across the health board geography. Disproportionately high numbers of hot spots within the most deprived quintile for DFU (p < 0.001), LEA (p < 0.001) and mortality (p < 0.001) rates were found. Conversely, a disproportionately higher number of cold spots was found within the least deprived quintile for LEA (p < 0.001).

CONCLUSIONS/INTERPRETATION

In people with diabetes, DFU, LEA and mortality rates are associated with multiple deprivation and form geographical neighbourhood clusters.

The foot-health of people with diabetes in regional and rural Australia: baseline results from an observational cohort study

BACKGROUND

There is limited Australian epidemiological research that reports on the foot-health characteristics of people with diabetes, especially within rural and regional settings. The objective of this study was to explore the associations between demographic, socio-economic and diabetes-related variables with diabetes-related foot morbidity in people residing in regional and rural Australia.

METHODS

Adults with diabetes were recruited from non-metropolitan Australian publicly-funded podiatry services. The primary variable of interest was the University of Texas diabetic foot risk classification designated to each participant at baseline. Independent risk factors for diabetes-related foot morbidity were identified using multivariable analysis.

RESULTS

Eight-hundred and ninety-nine participants enrolled, 443 (49.3%) in Tasmania and 456 (50.7%) in Victoria. Mean age was 67 years (SD 12.7), 9.2% had type 1 diabetes, 506 (56.3%) were male, 498 (55.4%) had diabetes for longer than 10 years and 550 (61.2%) either did not know the ideal HbA1c target or reported that it was ≥7.0. A majority had peripheral neuropathy or worse foot morbidity (61.0%). Foot morbidity was associated with male sex (OR 2.42, 95% CI 1.82-3.22), duration of diabetes > 20 years (OR 3.25, 95% CI 2.22-4.75), and Tasmanian residence (OR 3.38, 95% CI 2.35-4.86).

CONCLUSIONS

A high proportion of the regional Australian clinical population with diabetes seen by the publicly-funded podiatric services in this study were at high risk of future limb threatening foot morbidity, and participants residing in Northern Tasmania are more likely to have worse diabetes-related foot morbidity than those from regional Victoria. Service models should be reviewed to ensure that diabetes-related foot services are appropriately developed and resourced to deliver interdisciplinary evidence-based care.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

PodCast: A rural and regional service model for podiatrist-led total contact casting

PROBLEM

Diabetes-related foot disease causes significant health system costs and is a leading cause of morbidity and disproportionately affects rural populations. Total contact casts or instant total contact casts are gold standard for management of foot ulcerations resulting from diabetes-related foot disease. The aim of this study was to evaluate the impact of a podiatrist-led casting service model within a rural and regional setting.

DESIGN

The implementation of the service model was evaluated over a 12-month period using a quality improvement approach, informed by multiple methods. Quantitative and qualitative methods were used.

SETTING

An outpatient high-risk foot clinic and community-based podiatry services within a large regional health service. The location was central Victoria, servicing rural communities within the Loddon Mallee region.

KEY MEASURES FOR IMPROVEMENT

Patient-related data included information relating to demographics, diabetes and foot pathologies. Service-related data included occasions of service, locations and the number and type of casts applied.

STRATEGIES FOR CHANGE

Upskilling podiatrists to provide the service in a safe, supportive and sustainable manner and ensuring the podiatrist-led casting service model was sufficiently adaptable for patients to access at the rural sites.

EFFECTS OF CHANGE

Increased access to total contact casts and instant total contact casts, comparable wound healing times to other studies and the model was able to be sustained.

LESSONS LEARNT

Podiatrist-led casting resulted in increased utilisation of total contact casts and instant total contact casts. The increased use of instant total contact casts in particular may help address the lack of uptake of this treatment for people with diabetes-related foot disease, thereby improving rural health outcomes.

Association between area-level socioeconomic status, accessibility and diabetes-related hospitalisations: a cross-sectional analysis of data from Western Victoria, Australia

OBJECTIVE

Hospitalisation rates for many chronic conditions are higher in socioeconomically disadvantaged and less accessible areas. We aimed to map diabetes hospitalisation rates by local government area (LGA) across Western Victoria, Australia, and investigate their association with socioeconomic status (SES) and accessibility/remoteness.

DESIGN

Cross-sectional study METHODS: Data were acquired from the Victorian Admitted Episodes Dataset for all hospitalisations (public and private) with a diagnosis of type 1 or type 2 diabetes mellitus during 2011-2014. Crude and age-standardised hospitalisation rates (per 1000 population per year) were calculated by LGA for men, women and combined data. Associations between accessibility (Accessibility/Remoteness Index of Australia, ARIA), SES (Index of Relative Socioeconomic Advantage and Disadvantage, IRSAD) and diabetes hospitalisation were investigated using Poisson regression analyses.

RESULTS

Higher LGA-level accessibility and SES were associated with higher rates of type 1 and type 2 diabetes hospitalisation, overall and for each sex. For type 1 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men incidence rate ratio [IRR]=2.14, 95% CI 1.64 to 2.80; women IRR=2.45, 95% CI 1.87 to 3.19; combined IRR=2.30, 95% CI 1.69 to 3.13; all p<0.05). Higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.25, 95% CI 1.09 to 1.43; women IRR=1.32, 95% CI 1.16 to 1.51; combined IRR=1.23, 95% CI 1.07 to 1.42; all p<0.05). Similarly, for type 2 diabetes, higher accessibility (ARIA category) was associated with higher hospitalisation rates (men IRR=2.49, 95% CI 1.81 to 3.43; women IRR=2.34, 95% CI 1.69 to 3.25; combined IRR=2.32, 95% CI 1.66 to 3.25; all p<0.05) and higher socioeconomic advantage (IRSAD decile) was also associated with higher hospitalisation rates (men IRR=1.15, 95% CI 1.02 to 1.30; women IRR=1.14, 95% CI 1.01 to 1.28; combined IRR=1.13, 95% CI 1.00 to 1.27; all p<0.05).

CONCLUSION

Our observations could indicate self-motivated treatment seeking, and better specialist and hospital services availability in the advantaged and accessible areas in the study region. The determinants for such variations in hospitalisation rates, however, are multifaceted and warrant further research.

Clinical decision support software for diabetic foot risk stratification: development and formative evaluation

Background

Identifying people at risk of developing diabetic foot complications is a vital step in prevention programs in primary healthcare settings. Diabetic foot risk stratification systems predict foot ulceration. The aim of this study was to explore the views and experiences of potential end users during development and formative evaluations of an electronic diabetic foot risk stratification tool based on evidence-based guidelines and determine the accuracy of the tool.

Methods

Formative evaluation of the risk tool occurred in five stages over an eight-month period and employed a mixed methods research design consisting of semi-structured interviews, focus group and participant observation, online survey, expert review, comparison to the Australian Guidelines and clinical testing.

Results

A total of 43 healthcare practitioners trialled the computerised clinical decision support system during development, with multiple software changes made as a result of feedback. Individual and focus group participants exposed critical design flaws. Live testing revealed risk stratification errors and functional limitations providing the basis for practical improvements. In the final product, all risk calculations and recommendations made by the clinical decision support system reflect current Australian Guidelines.

Conclusions

Development of the computerised clinical decision support system using evidence-based guidelines can be optimised by a multidisciplinary iterative process of feedback, testing and software adaptation by experts in modern development technologies.

High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study)

INTRODUCTION

The risk of diabetes mellitus is increasing worldwide, and is particularly high in Indigenous Australians. Complicated foot infection is one of the most common sequelae of diabetes. We describe the incidence and associations of Indigenous and non-Indigenous inpatients with diabetic foot infections at Royal Darwin Hospital.

METHODS

All adult Royal Darwin Hospital inpatients with diabetic foot infections were enrolled prospectively from September 2012 to November 2013. Incidence, demographics, microbiology, management and clinical outcomes were analysed by Indigenous status, and association with methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa.

RESULTS

There were 245 separate hospital admissions in 177 patients with an incidence of 79 admissions per 100,000 person years. Patients occupied a mean of 19.4 hospital beds each day. Compared to the non-Indigenous population, Indigenous patients had a greater incidence of admission (Rate Ratio (RR)=5.1, [95%CI=3.8, 7.0]), were younger (mean difference of 11.1 years; p<0.001), and more likely to undergo major and minor amputations (RR=4.1 [95%CI=1.6, 10.7], and 6.2 [95%CI=3.5, 11.1] respectively). Non-multiresistant methicillin resistant S. aureus was present in 44.7% of wounds from Indigenous patients versus 20.6% of non-Indigenous patients (Odds Ratio (OR)=3.1, [95%CI=1.5, 6.4]), whereas P. aeruginosa presence was significantly lower (15.8% versus 46.0%; OR=0.22; [95%CI=0.11, 0.45]). Methicillin resistant S. aureus or P. aeruginosa infections were associated with longer antibiotic courses and durations of stay.

CONCLUSIONS

This study highlights a rising burden of diabetic foot infections in the Top End of Australia, with a four-fold increase in bed days since 2002 and an overrepresentation in the Indigenous population.

Gender differences in the impact of poverty on health: disparities in risk of diabetes-related amputation

AIMS

To assess the combined impact of socio-economic status and gender on the risk of diabetes-related lower extremity amputation within a universal healthcare system.

METHODS

We conducted a population-based cohort study using administrative health databases from Ontario, Canada. Adults with pre-existing or newly diagnosed diabetes (N = 606 494) were included and the incidence of lower extremity amputation was assessed for the period 1 April 2002 to 31 March 2009. Socio-economic status was based on neighbourhood-level income groups, assigned to individuals using the Canadian Census and their postal code of residence.

RESULTS

Low socio-economic status was associated with a significantly higher incidence of lower extremity amputation (27.0 vs 19.3 per 10,000 person-years in the lowest (Q1) vs the highest (Q5) socio-economic status quintile. This relationship persisted after adjusting for primary care use, region of residence and comorbidity, and was greater among men (adjusted Q1:Q5 hazard ratio 1.41, 95% CI 1.30-1.54; P < 0.0001 for all male gender-socio-economic status interactions) than women (hazard ratio 1.20, 95% CI 1.06-1.36). Overall, the incidence of lower extremity amputation was higher among men than women (hazard ratio for men vs women: 1.87, 95% CI 1.79-1.96), with the greatest disparity between men in the lowest socio-economic status category and women in the highest (hazard ratio 2.39, 95% CI 2.06-2.77 and hazard ratio 2.30, 95% CI 1.97-2.68, for major and minor amputation, respectively).

CONCLUSIONS

Despite universal access to hospital and physician care, we found marked socio-economic status and gender disparities in the risk of lower extremity amputation among patients with diabetes. Men living in low-income neighbourhoods were at greatest risk.

Amputations and socioeconomic position among persons with diabetes mellitus, a population-based register study

OBJECTIVE

Low socioeconomic position is a known health risk. Our study aims to evaluate the association between socioeconomic position (SEP) and lower limb amputations among persons with diabetes mellitus.

DESIGN

Population-based register study.

SETTING

Finland, nationwide individual-level data.

PARTICIPANTS

All persons in Finland with any record of diabetes in the national health and population registers from 1991 to 2007 (FinDM II database).

METHODS

Three outcome indicators were measured: the incidence of first major amputation, the ratio of first minor/major amputations and the 2-year survival with preserved leg after the first minor amputation. SEP was measured using income fifths. The data were analysed using Poisson and Cox regression as well as age-standardised ratios.

RESULTS

The risk ratio of the first major amputation in the lowest SEP group was 2.16 (95% CI 1.95 to 2.38) times higher than the risk in the highest SEP group (p<0.001). The incidence of first major amputation decreased by more than 50% in all SEP groups from 1993 to 2007, but there was a stronger relative decrease in the highest compared with the lowest SEP group (p=0.0053). Likewise, a clear gradient was detected in the ratio of first minor/major amputations: the higher the SEP group, the higher the ratio. After the first minor amputation, the 2-year and 10-year amputation-free survival rates were 55.8% and 9.3% in the lowest and 78.9% and 32.3% in the highest SEP group, respectively.

CONCLUSIONS

According to all indicators used, lower SEP was associated with worse outcomes in the population with diabetes. Greater attention should be paid to prevention of diabetes complications, adherence to treatment guidelines and access to the established pathways for early expert assessment when diabetic complications arise, with a special attention to patients from lower SEP groups.

Impact of health-care accessibility and social deprivation on diabetes related foot disease

AIMS

To determine whether geography and/or social deprivation influences the occurrence of foot ulcers or amputations in patients with diabetes.

METHODS

A population-based cohort of people with diabetes (n = 15 983) were identified between 2004 and 2006. Community and hospital data on diabetes care, podiatry care and onset of ulceration and amputation was linked using a unique patient identifier, which is used for all patient contacts with health-care professionals. Postcode was used to calculate social deprivation and distances to general practice and hospital care.

RESULTS

Over 3 years' follow-up 670 patients with diabetes developed new foot ulcers (42 per 1000) and 99 proceeded to amputation (6 per 1000). The most deprived quintile had a 1.7-fold (95% CI 1.2-2.3) increased risk of developing a foot ulcer. Distance from general practitioner or hospital clinic and lack of attendance at community retinal screening did not predict foot ulceration or amputation. Previous ulcer (OR 15.1, 95% CI 11.6-19.6), insulin use (OR 2.7, 95% CI 2.1-3.5), absent foot pulses (5.9: 4.7-7.5) and impaired monofilament sensation (OR 6.5, 95% CI 5.0-8.4) all predicted foot ulceration. Previous foot ulcer, absent pulses and impaired monofilaments also predicted amputation.

CONCLUSION

Social deprivation is an important factor, especially for the development of foot ulcers. Geographical aspects such as accessibility to the general practitioner or hospital clinic are not associated with foot ulceration or amputation in this large UK cohort study.

The foot-health of people with diabetes in a regional Australian population: a prospective clinical audit

Background

There is limited understanding of the foot-health of people with diabetes in Australian regional areas. The aim of this study was to document the foot-health of people with diabetes who attend publically funded podiatric services in a regional Australian population.

Methods

A three month prospective clinical audit was undertaken by the publically-funded podiatric services of a large regional area of Victoria, Australia. The primary variables of interest were the University of Texas (UT) diabetic foot risk classification of each patient and the incidence of new foot ulceration during the study period. Age, gender, diabetes type, duration of diabetes and the podiatric service the patients attended were the other variables of interest.

Results

Five hundred and seventy six patients were seen during the three month period. Over 49% had a UT risk classification at a level at least peripheral neuropathy or more serious diabetes-related foot morbidity. Higher risk at baseline was associated with longer duration of diabetes (F = 31.7, p < 0.001), male gender (χ² = 40.3, p <0.001) and type 1 diabetes (χ² = 37.3, p <0.001). A prior history of foot pathology was the overwhelming predictor for incident ulceration during the time period (OR 8.1 (95% CI 3.6 to 18.2), p < 0.001).

Conclusions

The publically funded podiatric services of this large regional area of Australia deal with a disproportionally large number of people with diabetes at high risk of future diabetes-related foot complications. These findings may be useful in ensuring appropriate allocation of resources for future public health services involved in diabetic foot health service delivery in regional areas.

Setting the pace: the 2011 Australasian Podiatry Council conference

The 2011 Australasian Podiatry Council conference was held from April 26 to 29 in Melbourne, Victoria, Australia. This commentary provides a brief overview of the conference, including the speakers and topic areas covered, selected original research highlights, and award winning presentations.