Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation

Predictors of limb saving in diabetic foot ulcer

Objectives

This study was aimed to determine the various factors which could serve as predictor of saving of lower limb from amputation in patients with diabetic foot ulcer (DFU).

Method

This three-year retrospective study was conducted in the Diabetes and Endocrinology Unit of Hayatabad Medical complex Peshawar, Pakistan. Demographic, clinical, laboratory and radiological information of the diabetic patients with DFU admitted between January 2020 to December 2022 was retrieved from the hospital files. Information regarding initial and final decision regarding amputation and the outcome of the ulcer was also recorded.

Results

A total of 502 patients of diabetes mellitus (DM) with DFU were included in the study, of whom there were 279 (55.6%) males and 223 (44.4%) females. The mean age of the study population, mean duration of DM and mean HbA1c were 55.2 ± 9.8 years, 13.7 ± 6.7 years and 11.2 ± 2.4 %, respectively. Patients who had an amputation of their lower limbs had an increased age (p= 0.034), raised total leucocyte count (TLC) (p= <0.001), higher HbA1c (p= 0.025), had osteomyelitis (p= <0.001), and had a higher-grade ulcer (p= <0.001). On binary logistic regression analysis, ulcer grade (OR=7.4, p= <0.001), osteomyelitis (OR=11.8, p= <0.001), and initial decision of no amputation at the time of admission (OR=33.6, p=<0.001) were independently associated with the lower limb salvage.

Conclusion

DFU which were of grade I to II, had no evidence of osteomyelitis and for which an initial decision was of no amputation were more likely to be salvaged.

Challenges and opportunities in the management of type 2 diabetes in patients with lower extremity peripheral artery disease: a tailored diagnosis and treatment review

Lower extremity peripheral artery disease (PAD) often results from atherosclerosis, and is highly prevalent in patients with type 2 diabetes mellitus (T2DM). Individuals with T2DM exhibit a more severe manifestation and a more distal distribution of PAD compared to those without diabetes, adding complexity to the therapeutic management of PAD in this particular patient population. Indeed, the management of PAD in patients with T2DM requires a multidisciplinary and individualized approach that addresses both the systemic effects of diabetes and the specific vascular complications of PAD. Hence, cardiovascular prevention is of the utmost importance in patients with T2DM and PAD, and encompasses smoking cessation, a healthy diet, structured exercise, careful foot monitoring, and adherence to routine preventive treatments such as statins, antiplatelet agents, and angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. It is also recommended to incorporate glucagon-like peptide-1 receptor agonists (GLP-1RA) and sodium-glucose cotransporter-2 inhibitors (SGLT2i) in the medical management of patients with T2DM and PAD, due to their demonstrated cardiovascular benefits. However, the specific impact of these novel glucose-lowering agents for individuals with PAD remains obscured within the background of cardiovascular outcome trials (CVOTs). In this review article, we distil evidence, through a comprehensive literature search of CVOTs and clinical guidelines, to offer key directions for the optimal medical management of individuals with T2DM and lower extremity PAD in the era of GLP-1RA and SGLT2i.

How multidisciplinary clinics may mitigate socioeconomic barriers to care for chronic limb-threatening ischemia

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.

Multidisciplinary management of diabetic foot infection associated with improved 8-year overall survival

AIMS

Diabetic foot syndrome is a global challenge best managed through multidisciplinary collaboration. This study aimed to investigate the effect of a systematic multidisciplinary team (MDT) on the overall survival and major amputation-free survival of hospitalized patients with diabetic foot infection (DFI).

METHODS

This retrospective cohort study was conducted at Tampere University Hospital. Cohorts of hospitalized patients with DFI before and after the initiation of multidisciplinary wound ward were compared after an 8-year follow-up.

RESULTS

Kaplan-Meier analysis revealed significantly higher overall survival in the post-MDT cohort (37.8 % vs 22.6 %, p < 0.05) in 8-year follow-up. Similarly, major amputation-free survival was superior in this cohort (31.8 % vs 16.9 %, p < 0.05). Additionally, early major amputation was associated with inferior overall survival (35.1 % vs 12.0 %, p < 0.05). In a multivariable Cox-regression analysis cohort (hazard ratio [HR] 1.38, 95 % confidence interval [CI95%] 1.01-1.87), early amputation (HR 1.64, CI95% 1.14-2.34) and diagnosed peripheral artery disease (HR 2.23, CI95% 1.61-3.09), congestive heart failure (HR 2.13, CI95% 1.47-3.08), or moderate kidney disease (HR 1.95, CI95% 1.34-2.84) were identified as significant risk factors affecting overall survival.

CONCLUSIONS

After systematic MDT approach we found improved long-term overall and major amputation-free survival. Multidisciplinary approach is therefore highly recommended for managing patients hospitalized for DFI.

Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome

The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26 weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.

Effect of a multidisciplinary team approach on the management of diabetic foot ulcers on the Central Coast: A review of the Gosford Hospital High-Risk Foot Clinic

This retrospective cohort study aims to assess whether the implementation of a multidisciplinary approach in the Gosford Hospital High-Risk Foot Clinic improved outcomes of diabetic foot ulcers. Ulceration is a common foot complication of diabetes mellitus and greatly increases patient morbidity and mortality. Patients who attended at least one appointment at the Gosford Hospital High-Risk Foot Clinic in 2017 or 2019 were identified through the Gosford Hospital Podiatry department's records. The 2017 and 2019 cohorts were compared on measures of ulcer healing, incidence of amputation, incidence of vascular intervention and surgical debridement, percentage of patients admitted to hospital due to complications and use of systemic antibiotic therapy. Sixty-one patients in 2017 and 59 patients in 2019 met inclusion criteria, and from them, 207 ulcers were included. Between 2017 and 2019, there was a 6.2-week reduction in time to 100% ulcer healing in 2019 (p = 0.021), and 10.1% more ulcers healed within 52 weeks (p = 0.22, 95% confidence interval [CI] [-5.9%, 25.5%]). Whilst there was no significant difference in incidence of patients receiving amputation, there was an increased absolute number of amputations in 2019. Implementation of a multidisciplinary approach at the Gosford Hospital High-Risk Foot Clinic led to improvements in diabetic foot ulcer healing.

A novel Canadian multidisciplinary acute care pathway for people hospitalised with a diabetic foot ulcer

This manuscript describes the implementation and initial evaluation of a novel Canadian acute care pathway for people with a diabetic foot ulcer (DFU). A multidisciplinary team developed and implemented an acute care pathway for patients with a DFU who presented to the emergency department (ED) and required hospitalisation at a tertiary care hospital in Canada. Processes of care, length of stay (LOS), and hospitalisation costs were considered through retrospective cohort study of all DFU hospitalizations from pathway launch in December 2018 to December 2020. There were 82 DFU-related hospital admissions through the ED of which 55 required invasive intervention: 28 (34.1%) minor amputations, 16 (19.5%) abscess drainage and debridement, 6 (7.3%) lower extremity revascularisations, 5 (6.1%) major amputations. Mean hospital LOS was 8.8 ± 4.9 days. Mean hospitalisation cost was $20 569 (±14 143): $25 901 (±15 965) when surgical intervention was required and $9279 (±7106) when it was not. LOS and hospitalisation costs compared favourably to historical data. An acute care DFU pathway can support the efficient evaluation and management of patients hospitalised with a DFU. A dedicated multidisciplinary DFU care team is a valuable resource for hospitals in Canada.

Fast-Access Multidisciplinary Approach to Management of Diabetic Foot Ulcers: The Diabetic Rapid Evaluation and Lower Limb Amputation Management (DREAM) Clinic

Background

Diabetic foot ulcers (DFUs) are debilitating to the patient and costly for the healthcare system. We set up the Diabetic Rapid Evaluation and lower limb Amputation Management (DREAM) clinic with the aim of providing early directed specialist care to patients with DFUs. With early management, we hope to treat DFUs in its early stages, reducing the need for and associated morbidity of major and minor lower limb amputations.

Objectives

We evaluated the outcomes of the fast-access DREAM clinic with multi-disciplinary evaluation for patients with DFUs. Outcomes include time from the point of referral to DREAM clinic evaluation, amputation rates and wound healing rates.

Design

Patients presenting with DFU to the DREAM clinic were enrolled. A podiatrist made the first assessment, followed by immediate specialist consultation with Endocrinologists, Vascular surgeons or Orthopaedic surgeons as required.

Methods

Data on baseline demographics and DFU characteristics were collected. Outcomes evaluated were wound healing at 12 weeks, wound salvage rates, time to DREAM clinic access and time to specialist referral.

Results

Sixty-eight patients were enrolled, with 57.3% males, and mean age of 63 ± 13.0 years. Majority of ulcers were classified as neuropathic (41.3%) and located at the digits (40%). At 12-weeks follow-up, 1 had undergone major amputation, 9 minor amputations and 4 surgical debridements. The median time to DREAM clinic evaluation from first presentation was 3 days (IQR 7). Eleven (16.2%) required >1 specialist consult. Twenty (29.4%) were hospitalised for treatment. Twelve underwent revascularisation within 4 days (IQR 3.5). Twenty-four patients (35.3%) continued podiatry follow-up, having 28 DFUs in which 20 (71.4%) healed within 12 weeks.

Conclusion

The fast-access multidisciplinary DREAM clinic shows promising outcomes with lower major amputation rates and exemplary DFU healing outcomes.

Surgical amputation for patients with diabetic foot ulcers: A Chinese expert panel consensus treatment guide

BACKGROUND

Diabetic foot disease is a serious complication of diabetes mellitus. Patients with diabetes mellitus have a 25% lifetime risk for developing a foot ulcer, and between 14% and 24% of patients require a major or minor lower limb amputation due to severe gangrene. However, decisions concerning whether to amputate or whether to perform a major or minor lower limb amputation, and how best to determine the amputation plane remain unclear.

METHODS

To consolidate the current literature with expert opinion to make recommendations that will guide surgical amputation for patients with diabetic foot ulcers. A total of 23 experts experienced in surgical treatment of patients with diabetic foot ulcers formed an expert consensus panel, and presented the relevant evidence, discussed clinical experiences, and derived consensus statements on surgical amputation for patients with diabetic foot ulcers. Each statement was discussed and revised until a unanimous consensus was achieved.

RESULTS

A total of 16 recommendations for surgical amputation for patients with diabetic foot ulcers were formulated. The experts believe that determination of the amputation plane should be comprehensively evaluated according to a patient's general health status, the degree of injury, and the severity of lower limb vasculopathy. The Wagner grading system and the severity of diabetic lower extremity artery disease are important criteria when determining the degree of amputation. The severity of both diabetic foot infection and systemic underlying diseases are important factors when considering appropriate treatment. Moreover, consideration should also be given to a patient's socioeconomic status. Given the complexities of treating the diabetic foot, relevant issues in which consensus could not be reached will be discussed and revised in future.

CONCLUSION

This expert consensus could be used to guide doctors in clinical practice, and help patients with diabetic foot ulcers gain access to appropriate amputation treatment.

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.

National Rates of Lower Extremity Amputation in People With and Without Diabetes in a Multi-Ethnic Asian Population: a Ten Year Study in Singapore

OBJECTIVE

Population level data from Asia on amputation rates in people with and without diabetes are extremely limited. Hence it is unclear how the rising diabetes prevalence in Asia has affected the amputation burden. The present study examined national amputation rates in people with and without diabetes in Singapore from 2008 to 2017 in the context of increasing diabetes prevalence and health system changes.

METHODS

This was a retrospective observational study using national population data for ages 16 - 100 years obtained from the Ministry of Health Singapore administrative datasets. Age sex standardised major and toe/ray amputation rates per 100 000 people with diabetes and per 100 000 people without diabetes were calculated. Rates were calculated overall and in each ethnic group (Chinese, Malay, Indian, Others), with trends over time calculated using joinpoint trend analysis. In addition, age specific rates, relative risk (RR) of amputation in diabetics compared with non-diabetics and proportion of amputations in the population attributable to diabetes were also calculated.

RESULTS

Between 2008 and 2017, the database included 3.6 million unique individuals, of whom 75% were Chinese, 8.6% Malay, 7.9% Indian, and 8.4% Others. Of those, 413 486 (11%) had diabetes. Major amputation rates in people with diabetes remained stable (2008: 99.5/100 000; 2017: 95.0/100 000 people with diabetes, p = .91) as did toe/ray amputation rates. Rates in people without diabetes were substantially lower, with major amputation rates decreasing significantly (2008: 3.0/100 000; 2017: 2.1/100 000 people without diabetes, 3% annual reduction, p = .048). Diabetes related amputation rates were highest in Malays and lowest in Chinese. Diabetes related major amputation rates declined significantly among Chinese (3.1% annual reduction, p < .038). While the RR for amputations in diabetes remained stable, the proportion of major amputations attributable to diabetes increased from 63.6% in 2008 to 81.7% in 2017 (3% annual increase, p = .003).

CONCLUSION

Diabetes related major and toe/ray amputation rates have remained stable but relatively high in Singapore compared with other countries, and the proportion of amputations attributable to diabetes has increased over time. More research is needed to understand the aetiopathological, sociocultural, and health system factors that may underlie the continued high rates of diabetes related amputations in this population.

Demographics and outcomes of inpatients with diabetic foot ulcers treated conservatively and surgically in a metropolitan hospital network

AIMS

To describe the demographics of patients with diabetic foot ulcers (DFU) and their impact on inpatient management. Secondary outcomes identified relationships of treatment modality with mortality, length of hospital admission, readmissions and post-admission care.

METHODS

Retrospective cohort study including patients with DFU admitted to a hospital network in Melbourne, Australia from 2016 to 2018. Medical records were manually reviewed for acute admission with DFU as a major presenting diagnosis; incidental ulcers and traumatic amputations were excluded. Amputations distal and proximal to the ankle were labelled 'minor' and 'major' respectively. Patients were followed until October 31, 2019.

RESULTS

Of 338 patients, 21 and 148 had major and minor amputations, and 169 were managed conservatively. 94% had ≥1 microvascular and/or macrovascular complication. Conservative management (7 days) was associated with a shorter length of stay (major 18, minor 10 days, p < 0.001). Readmission rates were not significantly different. Mortality was greatest (38%) and survival time shortest (999 days) after major amputation than after either other treatment. Other factors associated with mortality were age and a history of coronary artery disease.

CONCLUSIONS

Early identification and multi-disciplinary management of DFU is essential to reduce the significant morbidity and mortality associated with amputation in these complex patients.

Impact of dedicated infectious disease teamwork on the treatment and prognosis of patients with diabetic foot infection

OBJECTIVE

The aim was to develop and evaluate the impact of a new model in which the infectious disease (ID) physician and pharmacist work together to treat diabetic foot infections (DFIs).

METHODS

A quasi-experimental before-after study was conducted. The medical charts of inpatients with DFI admitted between April 1, 2017 and March 31, 2018 were reviewed retrospectively (control group, n = 30). Inpatients diagnosed with DFI between April 1, 2018 and March 31, 2019 were enrolled prospectively as the intervention group and received treatment through dedicated ID teamwork (intervention group, n = 35).

RESULTS

The distribution of infection severity and levels of metabolic criteria were similar in the two groups. Compared with the control group, the intervention group received adequate initial empirical treatment more frequently (96.8% vs 43.5%, p < 0.001) and had a shorter median duration of fever (1 day vs 7.5 days, p < 0.001). Rates of healing and relapse within 6 months were similar in the two groups, although the intervention group showed more sites of osteomyelitis (p = 0.036) and a higher percentage of polymicrobial infections (48.6% vs 10.0%, p = 0.001).

CONCLUSION

The early and full participation of ID physicians and pharmacists in the treatment of DFI facilitated targeted antimicrobial treatment and improved patient outcomes.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers

OBJECTIVE

Multiple single-center studies have reported significant reductions in major amputations among patients with diabetic foot ulcers after initiation of multidisciplinary teams. The purpose of this study was to assess the association between multidisciplinary teams (ie, two or more types of clinicians working together) and the risk of major amputation and to compile descriptions of these diverse teams.

METHODS

We searched PubMed, Scopus, Cumulative Index to Nursing and Allied Health, and Cochrane Central Register of Controlled Trials from inception through May 24, 2019 for studies reporting the association between multidisciplinary teams and major amputation rates for patients with diabetic foot ulcers. We included original studies if ≥50% of the patients seen by the multidisciplinary team had diabetes, they included a control group, and they reported the effect of a multidisciplinary team on major amputation rates. Studies were excluded if they were non-English language, abstracts only, or unpublished. We used the five-domain Systems Engineering Initiative for Patient Safety Model to describe team composition and function and summarized changes in major amputation rates associated with multidisciplinary team care. A meta-analysis was not performed because of heterogeneity across studies, their observational designs, and the potential for uncontrolled confounding (PROSPERO No. 2017: CRD42017067915).

RESULTS

We included 33 studies, none of which were randomized trials. Multidisciplinary team composition and functions were highly diverse. However, four elements were common across teams: teams were composed of medical and surgical disciplines; larger teams benefitted from having a "captain" and a nuclear and ancillary team member structure; clear referral pathways and care algorithms supported timely, comprehensive care; and multidisciplinary teams addressed four key tasks: glycemic control, local wound management, vascular disease, and infection. Ninety-four percent (31/33) of studies reported a reduction in major amputations after institution of a multidisciplinary team.

CONCLUSIONS

Multidisciplinary team composition was variable but reduced major amputations in 94% of studies. Teams consistently addressed glycemic control, local wound management, vascular disease, and infection in a timely and coordinated manner to reduce major amputation for patients with diabetic foot ulcerations. Care algorithms and referral pathways were key tools to their success.

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis

Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower extremity amputations (LEAs), but there is heterogeneity between team members and interventions. Podiatrists have been suggested as “gatekeepers” for the prevention and management of DFUs. The purpose of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a systematic review of available literature. Data’s heterogeneity about DFU outcomes made it impossible for us to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for MDTs that include podiatry. We found statistical significance in favour of an MDT approach including podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54–0.89, I² = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23–0.90, I² = 67%, P < 0.02). Our systematic review, with a standard search strategy, is the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for DFU management. Our observations support the literature that MDTs including podiatrists have a positive effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in team approach in daily practice and in published literature.

Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with diabetes: A systematic review & meta-analysis

AIMS

To determine the pooled effectiveness of multidiscipinary care teams (MCTs) in reducing major amputation rates in adults with diabetes.

METHODS

A systematic review and meta-analysis was performed, searching databases MEDLINE, EMBASE, Google Scholar, Cochrane Library, and Clinicaltrials.gov thru October 2018. We included only before-after studies comparing amputation rates before and after the implementation of a MCT for the prevention of major amputation in adults with diabetes. Our primary outcome was relative risk of major amputation. Risk ratios and 95% confidence intervals were calculated using a fixed effects model.

RESULTS

Twenty studies met the inclusion criteria. Nine studies were included in the meta-analysis, and eleven were included in a qualitative analysis. Exposure to a MCT resulted in a protective effect ranging from a RR of 0.44 [p-value < 0.00001 (95% CI 0.38, 0.51) I² = 67%] to a RR of 0.61 [p-value < 0.0001, (95% CI 0.50, 0.75) I² = 0%] after sensitivity analysis, and remained robust in qualitative analysis.

CONCLUSIONS

Healthcare systems can expect a 39-56% amputation rate reduction after implementing an MCT amputation prevention program. These findings may justify the use of additional resources needed for program implementation by helping healthcare systems predict the anticipated benefit these teams have on "possible limbs saved".

FUNDING

None.

Identification of potential plantar ulceration among diabetes patients using plantar soft tissue stiffness

This study investigates the relationship between plantar tissue stiffness and selected parameters, including age, diabetes mellitus (DM) duration, body mass index (BMI), and HbA_1c level. 70 diabetes patients with no foot problems were recruited. The plantar soft tissue at the 2nd sub-metatarsal head (MTH) pad was examined using the novel indentation system developed. The stiffness constant, K, was used to describe the tissue stiffness. The four factors (age, DM duration, BMI, and HbA_1c level) were plotted against the plantar tissue stiffness. The scatter plots revealed that a higher plantar tissue stiffness was usually associated with (1) BMI>25  kgm^-2, (2) HbA_1c score >10% (86 mmol/mol), and (3) DM duration >10 years. The three risk criteria were further evaluated using the binary classification test. The predictions were reported to be fairly accurate and reliable in detecting stiffened tissues. The study has successfully identified the strong association of BMI, HbA_1c, and DM duration with the plantar tissue properties. Special attention should be given to the high risk group with BMI>25 kgm^-2, HbA_1c score >10% (86 mmol/mol), and DM duration >10 years. The high diagnostic odds ratio attained suggests its potential usefulness in helping clinicians to diagnose diabetic foot more efficiently.

Barriers and enablers to proper diabetic foot care amongst community dwellers in an Asian population: a qualitative study

BACKGROUND

Diabetic foot complications are common within Asian populations. They arise due to poor diabetic control and foot care. In this study, we aimed to identify the causes for proper and improper diabetic foot care.

METHODS

A qualitative study consisting of key informant interviews with 17 healthcare professionals, including doctors and various allied health workers, was conducted. Participants included had at least five years of caring for diabetic foot patients either in public institutions or private clinics. Data collected was analyzed via thematic analysis.

RESULTS

Diabetic patients were generally observed to have a mixture of proper and improper information and beliefs which eventually resulted in the extent of proper foot care. Factors which influenced the extent of proper and improper state of information and beliefs were classified into predisposing and precipitating factors. Predisposing factors were further categorised into modifiable factors (e.g., education level, socioeconomic status, social support) and non-modifiable factors (e.g., age, presence and severity of co-morbidities restricting ability to selfcare, past experiences). Precipitating factors were categorized into patient factors (e.g., degree of reception of information, presence of psychological barriers), provider factors (presence and degree of multi-disciplinary approach to care, presence of administrative inconveniences) and disease factors (presence of diabetic sensory neuropathy, complexity of disease process).

CONCLUSIONS

The extent of proper foot care amongst diabetic patients is influenced by numerous predisposing and precipitating factors. Further studies can look at further development of the described structure as well as quantitatively defining the various components and factors which make up the described system.

The financial burden of surgical and endovascular treatment of diabetic foot wounds

OBJECTIVE

The cost of treating diabetes-related disease in New Zealand is increasing and is expected to reach New Zealand dollars (NZD) 1.8 billion in 2021. The financial burden attached to the treatment of diabetic foot wounds is difficult to quantify and reported costs of treatment vary greatly in the literature. As of yet, no study has captured the true total cost of treating a diabetic foot wound. In this study, we investigate the total minimum cost of treating a diabetic foot ulcer at a tertiary institution.

METHODS

A retrospective audit of hospital and interhospital records was performed to identify adult patients with diabetes who were treated operatively for a diabetic foot wound by the department of vascular surgery at Auckland Hospital between January 2009 and June 2014. Costs from the patients' admissions and outpatient clinics from their first meeting to the achievement of a final outcome were tallied to calculate the total cost of healing the wound. The hospital's expenses were calculated using a fully absorbed activity-based costing methodology and correlated with a variety of demographic and clinical factors extracted from patients' electronic records using a general linear mixed model.

RESULTS

We identified 225 patients accounting for 265 wound episodes, 700 inpatient admissions, 815 outpatient consultations, 367 surgical procedures, and 248 endovascular procedures. The total minimum cost to the Auckland city hospital was NZD 10,217,115 (NZD 9,886,963 inpatient costs; NZD 330,152 outpatient costs). The median cost per wound episode was NZD 29,537 (NZD 28,491 inpatient costs; NZD 834 outpatient cost). Wound healing was achieved in 70% of wound episodes (average length of healing, 9 months); 19% of wounds had not healed before the patient's death. Of every 3.5 wound episodes, one required a major amputation. Wound treatment modality, particularly surgical management, was the strongest predictor of high resource utilization. Wounds treated with endovascular intervention and no surgical intervention cost less. Surgical management (indiscriminate of type) was associated with faster wound healing than wounds managed endovascularly (median duration, 140 vs 224 days). Clinical risk factors including smoking, ischemic heart disease, hypercholesterolemia, hypertension, and chronic kidney disease did not affect treatment cost significantly.

CONCLUSIONS

We estimate the minimum median cost incurred by our department of vascular surgery in treating a diabetic foot wound to be NZD 30,000 and identify wound treatment modality to be a significant determinant of cost. While readily acknowledging our study's inherent limitations, we believe it provides a real-world representation of the minimum total cost involved in treating diabetic foot lesions in a tertiary center. Given the increasing rate of diabetes, we believe this high cost reinforces the need for the establishment of a multidisciplinary diabetic foot team in our region.

Optimising the quality and outcomes of treatments for diabetic foot infections

INTRODUCTION

Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients.

AREAS COVERED

We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.

Primary care referral to multidisciplinary high risk foot services - too few, too late

Background

To determine if patients with no contact with a multi-disciplinary team High Risk Foot Service (MDT-HRFS) had an increased rate of hospital admission for diabetes foot infection compared to patients with contact. Secondary aims were to report on clinical outcomes.

Methods

A retrospective study was conducted at a major tertiary referral hospital in metropolitan Sydney over 12 months. An ICD-10 search of the electronic medical record system and paper medical charts identified patients with diabetes mellitus (type 1 or type 2) and a primary admission for diabetes foot infection (DFI). Patients were categorised as having contact or no contact with an MDT-HRFS.

Results

One hundred ninety-six hospital admissions (156 patients) were identified with DFI over a 12-month period. Patients with no contact with a MDT-HRFS represented three quarters of admissions (no contact = 116, 74.7 % vs. contact = 40, 25.6 %, p = 0.0001) and presented with more severe infection (no contact = 39 vs. contact = 12). The odds of lower extremity amputation increased five-fold when both no contact and severe infection occurred in combination (no contact with severe infection and amputation = 34, 82.9 % vs. contact with severe infection and amputation = 7, 17.1 %, OR 4.9, 95 % CI 1.1–21.4, p = 0.037). Using estimates of both the contact and no contact population of people with diabetes and high-risk feet and assuming the risk of amputation was the same, than the number of expected amputations in the no contact group should have been 55, however the observed number was 77, 22 more than expected (p = 0.0001).

Conclusions

Patients with no contact with a MDT-HRFS represented the majority of admissions for DFIs to a tertiary referral hospital. This group on population estimates appears to be at high risk of amputation of the lower extremity and therefore early referral of this high-risk group might lower this risk.

Predictive factors for successful limb salvage surgery in diabetic foot patients

Background

The goal of salvage surgery in the diabetic foot is maximal preservation of the limb, but it is also important to resect unviable tissue sufficiently to avoid reamputation. This study aims to provide information on determining the optimal amputation level that allows preservation of as much limb length as possible without the risk of further reamputation by analyzing several predictive factors.

Methods

Between April 2004 and July 2013, 154 patients underwent limb salvage surgery for distal diabetic foot gangrene. According to the final level of amputation, the patients were divided into two groups: Patients with primary success of the limb salvage, and patients that failed to heal after the primary limb salvage surgery. The factors predictive of success, including comorbidity, laboratory findings, and radiologic findings were evaluated by a retrospective chart review.

Results

The mean age of the study population was 63.9 years, with a male-to-female ratio of approximately 2:1. The mean follow-up duration was 30 months. Statistical analysis showed that underlying renal disease, limited activity before surgery, a low hemoglobin level, a high white blood cell count, a high C-reactive protein level, and damage to two or more vessels on preoperative computed tomography (CT) angiogram were significantly associated with the success or failure of limb salvage. The five-year survival rate was 81.6% for the limb salvage success group and 36.4% for the limb salvage failure group.

Conclusion

This study evaluated the factors predictive of the success of limb salvage surgery and identified indicators for preserving as much as possible of the leg of a patient with diabetic foot. This should help surgeons to establish the appropriate amputation level for a case of diabetic foot and help prevent consecutive operations.

Reducing length of stay for acute diabetic foot episodes: employing an extended scope of practice podiatric high-risk foot coordinator in an acute foundation trust hospital

BACKGROUND

To enhance the acute management of people with diabetic foot disease requiring admission, an extended scope of practice, podiatric high-risk foot coordinator position, was established at the Great Western Hospital, Swindon in 2010. The focus of this new role was to facilitate more efficient and timely management of people with complex diabetic foot disease. The aim of this project was to investigate the impact of the podiatric high-risk foot coordinator role on length of stay, rate of re-admission and bed cost.

METHOD

This study evaluated the difference in length of stay and rate of re-admission between an 11- month pre-pilot period (November 2008 to October 2009) and a 10-month pilot period (August 2010 to June 2011). The estimated difference in bed cost between the pre-pilot and pilot audits was also calculated. Inclusion criteria were restricted to inpatients admitted with a diabetic foot ulcer, gangrene, cellulitis or infection as the primary cause for admission. Eligible records were retrieved using ICD-10 (V9) coding via the hospital clinical audit department for the pre-pilot period and a unique database was used to source records for the pilot phase.

RESULTS

Following the introduction of the podiatric high-risk foot coordinator, the average length of stay reduced from 33.7 days to 23.3 days (mean difference 10.4 days, 95% CI 0.0 to 20.8, p = 0.050). There was no statistically significant difference in re-admission rate between the two study periods, 17.2% (95% CI 12.2% to 23.9%) in the pre-pilot phase and 15.4% (95% CI 12.0% to 19.5%) in the pilot phase (p = 0.820). The extrapolated annual cost saving following the implementation of the new coordinator role was calculated to be £234,000 for the 2010/2011 year.

CONCLUSIONS

This audit found that the extended scope of practice coordinator role may have a positive impact on reducing length of stay for diabetic foot admissions. This paper advocates the role of a podiatric high-risk foot coordinator utilising an extended scope of practice model, although further research is needed.

Clinical Outcomes of Below Knee Amputations in Diabetic Foot Patients

Introduction: This study aims to evaluate the predictive factors affecting the clinical outcome of Below Knee Amputations (BKA) performed in diabetic foot patients admitted to National University Hospital (NUH) Multi-Disciplinary Diabetic Foot Team. Materials and Methods: This is a prospective cohort study of 151 patients admitted to the Department of Orthopaedic Surgery, NUH, for Diabetic Foot Problems (DFP) from January 2006 to January 2010. All had undergone BKA performed by NUH Multi-Disciplinary Diabetic Foot Team. Statistical analyses (univariate and multivariate analysis with logistic regression) were carried out using SPSS version 18.0, for factors such as demographic data, diabetic duration and control, clinical findings and investigations, indications for surgery, preoperative investigations and evaluation, microbiological cultures, and these were compared to the clinical outcome of the patient. A good clinical outcome is defined as one not requiring proximal re-amputation and whose stump healed well within 6 months. The ability to ambulate with successful use of a prosthesis after 1 year was documented. Statistical significance was set at P <0.050. Results: Mean age of study population was 55.2 years with a male to female ratio of about 3:2. Mean follow up duration was 36 months. Of BKAs, 73.5% gave a good outcome. Univariate analysis showed that smoking, previous limb surgery secondary to diabetes, high Total White Count (TW), Erythrocyte Sedimentation Rate (ESR), C-Reactive Protein (CRP), Urea, Creatinine (Cr), Neutrophils, absence of posterior tibial and popliteal pulses, low Ankle Brachial Index (ABI) and Toe Brachial Index (TBI) were associated with poor clinical outcome. Multivariate analysis showed that high CRP, ESR, Neutrophils, absence of popliteal pulse and low ABI were associated with poor clinical outcome. Of patients, 50.3% attained mobility with prosthesis after 1 year. Mortality rate was 21.2% within 6 months of operation, with sepsis being the most significant cause of death. Conclusion: Success rate of BKA was 73.5%, with mortality rate being 21.2% within 6 months. In this cohort, 50.3% were able to attain eventual mobility with prosthesis after 1 year. Sepsis was the most significant cause of death. Markers of infection such as high CRP, ESR, neutrophils; and indicators of poor vascularity such as absence of popliteal pulse and low ABI were significantly associated with poor clinical outcome. Key words: Amputation, Diabetic foot, Epidemiology, Outcome assessment

Distal amputations for the diabetic foot

Minor amputations in diabetic patients with foot complications have been well studied in the literature but controversy still remains as to what constitutes successful or non-successful limb salvage. In addition, there is a lack of consensus on the definition of a minor or distal amputation and a major or proximal amputation for the diabetic population. In this article, the authors review the existing literature to evaluate the efficacy of minor amputations in this selected group of patients in terms of diabetic limb salvage and also propose several definitions regarding diabetic foot amputations.