The role of interdisciplinary team approach in the management of the diabetic foot: a joint statement from the Society for Vascular Surgery and the American Podiatric Medical Association

A multidisciplinary Delphi consensus to define evidence-based quality indicators for diabetic foot ulcer care

BACKGROUND

Valid measures to assess quality of care delivered to patients with diabetes suffering from diabetic foot ulcer (DFU) are scarce. This study aimed to achieve consensus on relevant and feasible quality indicators (QIs) among stakeholders involved in DFU care and was conducted as the second part of a Belgian QI selection study that sought to identify QIs for DFU care.

METHODS

A stakeholder panel, including caregivers from primary care and specialized disciplines active in diabetic foot care as well as a patient organization representative, was recruited. By using the RAND/UCLA Appropriateness Method, stakeholders were asked to rate a list of 42 candidate evidence-based indicators for appropriateness through a 9-point Likert scale. QIs were classified based on the median ratings and the disagreement index, calculated by the inter-percentile range adjusted for symmetry.

RESULTS

At the end of a three-phase process, 17 QIs were judged as appropriate. Among them, five were not previously described, covering the following topics: integration of wound care specialty in the multidisciplinary team, systematic evaluation of the nutritional status of the patient, administration of low-density lipoprotein-cholesterol lowering medication and protocolized care (implementation of care and prevention management protocols).

CONCLUSIONS

The identified evidence-based QIs provide an assessment tool to evaluate and monitor quality of care delivered to DFU patients. Future research should focus on their complementarity with the existing QIs and their implementation in clinical practice.

The Opportunity for Impactful Integration of Vascular and Podiatric Care

BACKGROUND

The importance of collaboration between vascular and podiatric surgeons has been well-established. High-level partnerships are integral to the development of multidisciplinary programs and wound care centers, ultimately resulting in improved patient outcomes. This vascular-podiatric integration is not universal, however, and podiatric surgery may not be aligned within a vascular surgery division at many institutions. As one such institution, we reviewed our single-center experience in order to identify opportunities for the impactful integration of vascular-podiatric patient care.

METHODS

Institutional electronic medical records were retrospectively reviewed for all procedures performed by vascular surgeons at a high volume, safety-net academic medical center. Data were collected on all primary and additional procedures, current procedural terminology (CPT) codes, case type (elective, urgent, emergent), surgeon specialty, and date/time of the procedures performed. CPT codes were linked to the Centers for Medicare & Medicaid Services' Physician Fee Schedule to estimate the work relative value unit (wRVU) per procedure.

RESULTS

From 2018 to 2022, vascular surgeons performed a total of 12,206 operations, of which 1102 (9.9%) involved podiatric procedures. The most common vascular-performed podiatry procedures performed were toe amputations (38.1%, n = 420), transmetatarsal foot amputations (20.1%, n = 222), and ankle/foot debridement (16.2%, n = 178). Foot/ankle-specific procedures were identified as the primary procedure in 726 (65.9%) cases and as the adjunct procedure in 376 (34.1%) cases. A substantial proportion of podiatric procedures occurred on an urgent (n = 278, 25.2%) or emergent (n = 28, 2.5%) basis. A total of 163 (14.8%) cases occurred after hours (either before 0600 or after 1800), and 133 (12.1%) cases were performed on a holiday or weekend. Procedure-specific revenue included 4243.39 wRVU for primary procedures and 2108.08 wRVU for additional procedures performed.

CONCLUSIONS

We report our single-center experience in which vascular surgeons provide a significant proportion of podiatric procedures. Our study underscores the potential for integrating podiatric surgeons within a vascular surgical division and presents opportunities for collaboration and enhanced patient care.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: a national multicenter study

BACKGROUND AND PURPOSE

The lack of timely foot care among individuals with diabetics often lead to ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening practices among patients with type 2 diabetes in various cities across Iran.

METHODS

The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, and diabetic foot self-care (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow's 60-Second Screen.

RESULTS

The study included 1094 diabetic patients with, with a majority being female (64.8%) and married (92.5%). The average age of the participants was 57.6 ± 10.21 (mean ± SD), and the mean duration of diabetes was 11.56 ± 7.41 years. Based on Inlow's 60-Second Screen criteria, 58% of the patients should undergo yearly foot ulcer screening, 47% exhibited peripheral neuropathy, and 37% were found to have inappropriate footwear.

CONCLUSION

The high prevalence of peripheral neuropathy observed in approximately half of the participants across different regions of Iran underscores the importance of continuous patient education regarding foot care and appropriate footwear. Furthermore, regular foot ulcer screenings, following the recommended intervals outlined in Inlow's screening protocol, should be implemented to effectively manage diabetic foot complications.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: A national multicenter study.. [DOI: 10.21203/rs.3.rs-2880691/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and Purpose Lack of timely foot care in diabetics result in ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening of patients suffering from diabetes around the country of Iran. Methods The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, diabetic foot self-care situation (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow’s 60-Second Screen. Results Participants were 1094 diabetic patients. Most of the participants were female (64.8%) and married (92.5%) with the average age of 57.6 ± 10.21 (mean ± SD). The mean duration of DM was 11.56 ± 7.41 years. According to the Inlow’s 60-Second Screen criteria, 58% of patients should have foot ulcer screened yearly and 47% of the patients had peripheral neuropathy, 37% of population had inappropriate foot wear. Conclusion Considering the prevalence of peripheral neuropathy among about than half of participants in this study across Iran, it is essential to have continuous patients’ education about foot care and foot wear. Additionally, foot ulcer screening would be performed in recommended interval of Inlow screen.

Bottom-up approach to build a 'precision' risk factor classification for diabetic foot ulcer healing. Proof-of-concept

AIMS

Diabetic foot ulcers (DFU) have a complex multifactorial pathophysiology. It is crucial to identify essential prognostic variables to streamline therapeutic actions and quality-of-care audits. Although SINBAD and University of Texas (UT), the most frequently used prognostic classification systems, were prospectively validated, not all individual parameters were shown to have consistent associations with healing. In this study, we used a bottom-up approach relying on robust methods to identify independent predictors of DFU healing.

METHODS

1,664 DFU patients were included by 34 Belgian diabetic foot clinics (DFCs). Twenty-one patient- and foot-related characteristics were recorded at presentation. Predictors of healing were identified using multivariable Cox proportional hazard regression. Multivariable models were built using backward regression with multiple imputation of missing values and bootstrapping.

RESULTS

Five essential independent variables were identified: presentation delay, history of minor amputation, ulcer location, surface area and ischemia. This 5 variable-model showed a better performance compared to models based on existing classification systems.

CONCLUSIONS

A bottom-up approach was used to build a prognostic classification for DFU healing based on large databases. It offers new insights and allows to tailor the classification to certain clinical settings. These 5 parameters could be used as a 'precision classification' for specialized DFCs.

Team-Based Care in Patients with Chronic Limb-Threatening Ischemia

PURPOSE OF REVIEW

Team-based care has been proposed as a tool to improve health care delivery, especially for the treatment of complex medical conditions. Chronic limb-threatening ischemia (CLTI) is a complex disease associated with significant morbidity and mortality which often involves the care of multiple specialty providers. Coordination of efforts across the multiple physician specialists, nurses, wound care specialists, and administrators is essential to providing high-quality and efficient care. The aim of this review is to discuss the multiple facets of care of the CLTI patient and to describe components important for a team-based care approach.

RECENT FINDINGS

Observational studies have reported improved outcomes when using a team-based care approach in the care of the patients with CLTI, including reduction in mean wound healing times, decreasing rate of amputations, and readmissions. Team-based care can streamline care of CLTI patients by raising awareness, facilitating early recognition, and providing prompt vascular assessment, revascularization, and surveillance. This approach has the potential to improve patient outcomes and reduce downstream health care costs.

Healthcare disparities in vascular surgery: A critical review

Health disparities in vascular surgical care have existed for decades. Persons categorized as Black undergo a nearly twofold greater risk-adjusted rate of leg amputations. Persons categorized as Black, Latinx, and women have hemodialysis initiated via autogenous fistula less often than male persons categorized as White. Persons categorized as Black, Latino, Latina, or Latinx, and women are less likely to undergo carotid endarterectomy for symptomatic carotid stenosis and repair of abdominal aortic aneurysms. New approaches are needed to address these disparities. We suggest surgeons use data to identify groups that would most benefit from medical care and then partner with community organizations or individuals to create lasting health benefits. Surgeons alone cannot rectify the structural inequalities present in American society. However, all surgeons should contribute to ensuring that all people have access to high-quality vascular surgical care.

Adequacy Between Canadian Clinical Guidelines and Recommendations Compared With International Guidelines for the Management of Diabetic Foot Ulcers

OBJECTIVES

Although quality of care in the prevention and management of diabetic foot ulceration (DFU) has improved with the use of comprehensive evidence-based clinical practice guidelines, disparities between national and international guidelines have been demonstrated in one study conducted in Western Pacific regions. Although there are challenges of systematic implementation of evidence-based care in some clinical settings, their applications have demonstrated positive outcomes on DFU-associated burdens in many countries. The aim of this study was to review and evaluate 3 Canadian clinical practice guidelines and recommendations (CPGRs) in comparison with the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines.

METHODS

Extraction of all 85 recommendations from the IWGDF guidelines was performed and 3 independent investigators used a rating recommendations adequacy method with descriptive statistics. The Appraisal of Guidelines REsearch & Evaluation (AGREE) II instrument was used for quality appraisal and reliability scores were noted using intraclass correlation coefficients.

RESULTS

The Wounds Canada CPGR had the higher adequacy with the IWGDF guidelines. However, its development method was poor to fair. The Registered Nurses' Association of Ontario CPGR was superior for its development and implementation strategies, but major gaps were found in all chapters. The Diabetes Canada CPGR obtained a good quality appraisal evaluation, but was not dedicated exclusively to DFU and some important recommendations were absent. Reliability scores of AGREE II were good between investigators (p<0.0001). Some disparities were noted between Canadian and international recommendations.

CONCLUSIONS

Some disparities were noted, future orientations for development should include various health-care professionals involved in the team approach, patient-oriented research, recommendations published along with their level of evidence and strength of recommendations (such as with the Grading of Recommendations, Assessment, Development and Evaluations system) and implementation strategies to enhance evidence-based practice in Canada.

Current Wound Care Education in Entry-Level Doctor of Physical Therapy Curricula

OBJECTIVE

To investigate how wound care instruction is currently delivered within entry-level doctor of physical therapy (DPT) educational curricula.

METHODS

An electronic survey was distributed to 226 DPT programs in the US. The questionnaire contained 27 questions about the characteristics of the wound care instruction as well as the credentials, clinical experience, and teaching experience of the instructors. Descriptive statistics were analyzed for each questionnaire item response.

MAIN RESULTS

The response rate was 22.1% (n = 50). The majority of respondents reported 10 to 29 contact hours of wound care instruction throughout the curriculum. More than half of the programs reported that their students completed a wound care observation in clinical settings. Forty-four percent of programs stated that their students had the opportunity to participate in a clinical rotation focused solely on wound care. All respondents reported that their wound care instructors were physical therapists. Of those instructors, most were seasoned clinicians, and 46% held a wound care-related certification.

CONCLUSIONS

Current entry-level DPT curricula provide physical therapy students with adequate contact hours in wound care and the opportunity for clinical experiences. The instructors are seasoned physical therapists, and nearly half of them hold advanced certification in the content area. Further studies are warranted to investigate how physical therapists practice in wound management in various clinical settings.

Multidisciplinary Approach to PAD: Who's on Your Team?

The complexity of peripheral arterial disease (PAD) and its multiorgan involvement requires the utilization of a multispecialty team approach. Members of this team include a vascular specialty (interventional radiology, cardiology, and vascular surgery), podiatry, orthopedic surgery, primary care, infectious disease, endocrinology, plastic surgery, wound care nursing, and dietetics. A team approach has been proven to significantly improve patient outcomes as well as decreasing amputation rates. In order to promote collaboration and avoid duplication of care, the team can be broken down into three main pillars: medical management, wound care, and revascularization. A complete team approach is vital for this population, with an overall goal to treat all manifestations of the disease and prevent further progression and risk of major sequelae of the disease.

Multidisciplinary Care for Critical Limb Ischemia: Current Gaps and Opportunities for Improvement

Critical limb ischemia (CLI), defined as ischemic rest pain or nonhealing ulceration due to arterial insufficiency, represents the most severe and limb-threatening manifestation of peripheral artery disease. A major challenge in the optimal treatment of CLI is that multiple specialties participate in the care of this complex patient population. As a result, the care of patients with CLI is often fragmented, and multidisciplinary societal guidelines have not focused specifically on the care of patients with CLI. Furthermore, multidisciplinary care has the potential to improve patient outcomes, as no single medical specialty addresses all the facets of care necessary to reduce cardiovascular and limb-related morbidity in this complex patient population. This review identifies current gaps in the multidisciplinary care of patients with CLI, with a goal toward increasing disease recognition and timely referral, defining important components of CLI treatment teams, establishing options for revascularization strategies, and identifying best practices for wound care post-revascularization.

Using implementation science to help integrate preoperative evidence-based measures into practice for vascular surgery patients

The preoperative workup is a necessary and crucial evaluation for patients undergoing major vascular surgery. It is important to assess for likelihood of perioperative adverse events and then implement evidence-based measures to reduce identified medical comorbidities and improve the quality of patient care and outcomes after surgery. Although there are numerous opportunities to implement evidence-based processes during the preoperative period, there are many barriers that can prevent vascular surgeons from achieving these goals. This review will discuss how an implementation science-based approach can be used by members of the vascular surgery team to identify appropriate preoperative evidence-based interventions for diverse practice settings and to overcome barriers and allow integration of these interventions as part of the routine preoperative workup.

Diabetic foot ulcers: Part I. Pathophysiology and prevention

Diabetes mellitus is a serious, life-long condition that is the sixth leading cause of death in North America. Dermatologists frequently encounter patients with diabetes mellitus. Up to 25% of patients with diabetes mellitus will develop diabetic foot ulcers. Foot ulcer patients have an increased risk of amputation and increased mortality rate. The high-risk diabetic foot can be identified with a simplified screening, and subsequent foot ulcers can be prevented. Early recognition of the high-risk foot and timely treatment will save legs and improve patients' quality of life. Peripheral arterial disease, neuropathy, deformity, previous amputation, and infection are the main factors contributing to the development of diabetic foot ulcers. Early recognition of the high-risk foot is imperative to decrease the rates of mortality and morbidity. An interprofessional approach (ie, physicians, nurses, and foot care specialists) is often needed to support patients' needs.

Inpatient management of diabetic foot disorders: a clinical guide

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Contemporary evaluation and management of the diabetic foot

Foot problems in patients with diabetes remain a major public health issue and are the commonest reason for hospitalization of patients with diabetes with prevalence as high as 25%. Ulcers are breaks in the dermal barrier with subsequent erosion of underlying subcutaneous tissue that may extend to muscle and bone, and superimposed infection is a frequent and costly complication. The pathophysiology of diabetic foot disease is multifactorial and includes neuropathy, infection, ischemia, and abnormal foot structure and biomechanics. Early recognition of the etiology of these foot lesions is essential for good functional outcome. Managing the diabetic foot is a complex clinical problem requiring a multidisciplinary collaboration of health care workers to achieve limb salvage. Adequate off-loading, frequent debridement, moist wound care, treatment of infection, and revascularization of ischemic limbs are the mainstays of therapy. Even when properly managed, some of the foot ulcers do not heal and are arrested in a state of chronic inflammation. These wounds can frequently benefit from various adjuvants, such as aggressive debridement, growth factors, bioactive skin equivalents, and negative pressure wound therapy. While these, increasingly expensive, therapies have shown promising results in clinical trials, the results have yet to be translated into widespread clinical practice leaving a huge scope for further research in this field.

Diabetic neuropathy status and the concerns in underserved rural communities: challenges and opportunities for diabetes educators

PURPOSE

The purpose of this study was to investigate the prevalence of diabetic peripheral neuropathy (DPN) and to identify at risk populations in medically underserved rural communities.

METHODS

A cross-sectional study was conducted in 816 type 2 diabetic patients from 5 rural Arkansas counties who attended a diabetes education program from 2005 to 2009. The data was collected through a survey questionnaire and from medical records. Univariate and multivariate analyses were conducted.

RESULTS

Of the 816 patients studied, 9.6% had a DPN diagnosis, and 43% reported peripheral neuropathy symptoms (PNS). Among the patients with PNS, 79% had not been diagnosed with DPN. Multivariate analyses found that being female, being white, having less than a college education, having a longer duration of diabetes, having a history of smoking, having a professional foot examination, and performing self foot examinations are associated with a higher risk for having DPN or PNS.

CONCLUSION

The study found that the prevalence of patients with PNS was high, and that DPN was alarmingly underdiagnosed in these underserved rural communities. The high prevalence of PNS and underdiagnosis of DPN could influence the development of severe foot complications like diabetic foot ulcer, and even possibly increase the risk of lower extremity amputation in these underserved communities. The at risk population identified by this study would be a resource to help diabetes educators develop targeted education and intervention programs in underserved rural communities.

Factors associated with presence and severity of toenail onychomycosis in patients with diabetes: a cross-sectional study

OBJECTIVE

To identify the factors associated with toenail onychomycosis in patients with diabetes.

METHODS

In this cross-sectional, observational study, the presence and severity (area of nail involvement and nail thickness) of toenail onychomycosis and related factors were examined. One hundred and thirteen patients with diabetes were surveyed at the Diabetic Foot Outpatient Clinic at the University hospital. Toenails of all patients enrolled in the survey were examined whether onychomycosis was present or absent by mycological examination. The severity of onychomycosis was assessed by clinical evaluation, using the area of nail involvement and the nail thickness.

RESULTS

Fifty eight (51.3%) patients had toenail onychomycosis. The presence of onychomycosis was significantly associated with not washing of feet every day (the unadjusted model, OR: 3.45, 95% CI: 1.24-9.65, P=0.018). The median area of nail involvement was 50.0% (range 5.0-100.0%). A larger area of involvement was significantly related to a lower toe brachial index (β=-67.46, P=0.040). The median nail thickness with onychomycosis was 1.14 mm (range 0.68-9.86 mm). Increasing thickness was significantly correlated with higher hemoglobin A(1)c levels (β=0.98, P=0.003).

CONCLUSIONS

This study suggested that daily washing of feet may reduce the risk of onychomycosis in patients with diabetes. This suggested that education regarding the importance of the washing of feet every day and support for continuous self-care might be effective in the prevention of onychomycosis in patients with diabetes. Furthermore, good control of blood glucose might prevent increasing nail thickness. This study may highlight importance of early nursing educational intervention to improve patients' daily life style for prevention of onychomycosis induced diabetic foot ulcers.