Gap analysis of diabetes-related foot disease management systems in Pacific Islands Countries and Territories

BACKGROUND

Pacific Island Countries and Territories (PICTs) are known to have high prevalence of Diabetes Mellitus and high incidence of diabetes-related foot disease. Diabetes-related foot disease can lead to lower limb amputation and is associated with poor outcomes, with increased morbidity and mortality. The purpose of this study was to gain a better understanding of diabetes-related foot disease management in selected countries in PICTs and to identify potential barriers in management of diabetes-related foot disease management in the region.

METHODS

A cross-sectional survey was sent to eleven hospitals across six selected PICTs. The survey instrument was designed to provide an overview of diabetes-related foot disease (number of admissions, and number of lower limb amputations over 12 months) and to identify clinical services available within each institution. Two open-ended questions (free text responses) were included in the instrument to explore initiatives that have helped to improve management and treatment of diabetes-related foot diseases, as well as obstacles that clinicians have encountered in management of diabetes-related foot disease. The survey was conducted over 6 weeks.

RESULTS

Seven hospitals across four countries provided responses. Number of admissions and amputations related to diabetes-related foot disease were only reported as an estimate by clinicians. Diabetes-related foot disease was managed primarily by general medicine physician, general surgeon and/or orthopaedic surgeon in the hospitals surveyed, as there were no subspecialty services in the region. Only one hospital had access to outpatient podiatry. Common themes identified around barriers faced in management of diabetes-related foot disease by clinicians were broadly centred around resource availability, awareness and education, and professional development.

CONCLUSION

Despite the high prevalence of diabetes-related foot disease within PICTs, there appears to be a lack of functional multi-disciplinary foot services (MDFs). To improve the outcomes for diabetes-related foot disease patients in the region, there is a need to establish functional MDFs and engage international stakeholders to provide ongoing supports in the form of education, mentoring, as well as physical resources.

The financial burden of diabetes-related foot disease in Australia: a systematic review

BACKGROUND

Diabetes-related foot disease (DFD) is a common, costly, and severe complication of diabetes mellitus. DFD is associated with high rates of morbidity and mortality and poses a significant burden on patients, healthcare systems and society. While the detrimental impact of DFD is widely recognised, the precise financial implications of its management in Australia remain unclear due to inconsistent and inconclusive contemporary data. Therefore, the aim of this review was to identify, summarise and synthesise existing evidence to estimate the costs associated with DFD management in Australia.

METHODS

Searches were conducted in MEDLINE, Embase, AMED, CINAHL, Joanna Briggs Institute EBP, and the Cochrane Library from November 2011 to July 2023. Australian studies investigating costs associated with DFD management were eligible for inclusion. Two independent reviewers performed the study selection, data extraction and quality assessment steps. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) checklist was used to assess study quality. A descriptive analysis was performed due to limited existing evidence and large heterogeneity between study populations to conduct meta-analyses.

RESULTS

Three economic evaluations were included in the review. One study was rated as 'poor', one as 'very good' and one as 'excellent' when assessed against the CHEERS checklist. The estimated cost of DFD management varied between studies and comparisons were not possible due to the different methodological approaches and data sources. The studies were unable to provide an overall cost of DFD with respect to all aspects of care as they did not capture the multi-faceted level of care throughout the entire patient journey between sectors and over time.

CONCLUSION

There is limited contemporary evidence for the costs associated with DFD management within Australia, particularly related to direct costs and resource utilisation. Further research into the economic impact of DFD management is needed to inform optimisation of national service delivery and improve health outcomes for individuals with DFD in Australia. Integrating real-world data on impact of clinical interventions with parallel economic evaluation could be a valuable approach for future research, which would offer a more comprehensive understanding of the clinical and economic outcomes beyond solely model-based evaluations.

TRIAL REGISTRATION

PROSPERO Registration No. CRD42022290910.

The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration

BACKGROUND

Diabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD.

METHODS

This exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed.

RESULTS

Participants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. 'Patients have reduced travel burden' included that telehealth enabled Indigenous patients to stay on country. 'Patients had increased psychosocial support' covered the benefits of having health professionals who knew the patient present in consults. 'Improved access' incorporated how telehealth improved interprofessional relationship building and communication. 'Technological and equipment challenges' highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,'Lack of service communication to rural health professionals', highlighted the need for communication around service details.

CONCLUSION

Telehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.

Detection, management, and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

Trends in diabetes-related foot disease hospitalizations and amputations in Australia, 2010 to 2019

AIM

To determine trends in the incidence of hospitalizations and amputations for diabetes-related foot disease (DFD) in Australia.

METHODS

We included 70,766 people with type 1, and 1,087,706 with type 2 diabetes from the Australian diabetes registry from 2010 to 2019, linked to hospital admissions databases. Trends in age-adjusted incidence were summarized as annual percent changes (APC).

RESULTS

In people with type 1 diabetes, total DFD hospitalizations increased from 20.8 to 30.5 per 1,000 person-years between 2010 and 2019 (APC: 5.1% (95% CI: 3.5, 6.8)), including increases for ulceration (13.3% (2.9, 24.7)), osteomyelitis (5.6% (2.7, 8.7)), peripheral arterial disease (7.7% (3.7, 11.9)), and neuropathy (8.7% (5.5, 12.0)). In people with type 2 diabetes, DFD hospitalizations changed from 18.6 to 24.8 per 1,000 person-years between 2010 and 2019 (APC: 4.5% (3.6, 5.4); 2012-2019), including increases for ulceration (8.7% (4.0, 13.7)), cellulitis (5.4% (3.7, 7.0)), osteomyelitis (6.7% (5.7, 7.7)), and neuropathy (6.9% (5.2, 8.5)). Amputations were stable in type 1, whereas in type 2, above knee amputations decreased (-6.0% (-9.1, -2.7). Adjustment for diabetes duration attenuated the magnitude of most increases, but many remained significant.

CONCLUSIONS

DFD hospitalizations increased markedly in Australia, mainly driven by ulceration and neuropathy, highlighting the importance of managing DFD to prevent hospitalizations.

Australian guideline on prevention of foot ulceration: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

BACKGROUND

There are no current Australian guidelines on the prevention of diabetes-related foot ulceration (DFU). A national expert panel aimed to systematically identify and adapt suitable international guidelines to the Australian context to create new Australian evidence-based guidelines on prevention of first-ever and/or recurrent DFU. These guidelines will include for the first-time considerations for rural and remote, and Aboriginal and Torres Strait Islander peoples.

METHODS

The National Health and Medical Research Council procedures were followed to adapt suitable international guidelines on DFU prevention to the Australian health context. This included a search of public databases after which the International Working Group on the Diabetic Foot (IWGDF) prevention guideline was deemed the most appropriate for adaptation. The 16 IWGDF prevention recommendations were assessed using the ADAPTE and GRADE systems to decide if they should be adopted, adapted or excluded for the new Australian guideline. The quality of evidence and strength of recommendation ratings were re-evaluated with reference to the Australian context. This guideline underwent public consultation, further revision, and approval by national peak bodies.

RESULTS

Of the 16 original IWGDF prevention recommendations, nine were adopted, six were adapted and one was excluded. It is recommended that all people at increased risk of DFU are assessed at intervals corresponding to the IWGDF risk ratings. For those at increased risk, structured education about appropriate foot protection, inspection, footwear, weight-bearing activities, and foot self-care is recommended. Prescription of orthotic interventions and/or medical grade footwear, providing integrated foot care, and self-monitoring of foot skin temperatures (contingent on validated, user-friendly and affordable systems becoming available in Australia) may also assist in preventing DFU. If the above recommended non-surgical treatment fails, the use of various surgical interventions for the prevention of DFU can be considered.

CONCLUSIONS

This new Australian evidence-based guideline on prevention of DFU, endorsed by 10 national peak bodies, provides specific recommendations for relevant health professionals and consumers in the Australian context to prevent DFU. Following these recommendations should achieve better DFU prevention outcomes in Australia.

Australian guideline on management of diabetes-related foot infection: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

BACKGROUND

Diabetes-related foot infections cause substantial morbidity and mortality, both globally and in Australia. There is a need for up-to-date evidence-based guidelines to ensure optimal management of patients with diabetes-related foot infections. We aimed to identify and adapt high quality international guidelines to the Australian context to become the new Australian evidence-based guideline for people with a diabetes-related foot infection.

METHODS

Following Australian National Health and Medical Research Council (NHMRC) procedures we identified the 2019 International Working Group on the Diabetic Foot (IWGDF) guidelines as suitable for adaptation to the Australian context. Guidelines were screened, assessed and judged by an expert panel for the Australian context using the guideline adaptation frameworks ADAPTE and Grading of Recommendations Assessment, Development and Evaluation (GRADE). Judgements led to recommendations being adopted, adapted or excluded, with additional consideration regarding their implementation, monitoring and future research for the Australian context. Clinical pathways were then developed to assist implementation.

RESULTS

Of 36 original diabetes-related foot infection IWGDF sub-recommendations, 31 were adopted, four were adapted and one was excluded. Adaption was primarily undertaken due to differences or clarification of the sub-recommendations' intended population. One sub-recommendation was excluded due to substantial differences in judgements between the panel and IWGDF and unacceptable heterogeneity of the target population. Therefore, we developed 35 evidence-based sub-recommendations for the Australian context that should guide best practice diagnosis and management of people with diabetes-related foot infection in Australia. Additionally, we incorporated these sub-recommendations into two clinical pathways to assist Australian health professionals to implement these evidence-based sub-recommendations into clinical practice. The six guidelines and the full protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/ .

CONCLUSIONS

A new national guideline for the diagnosis and management of people with diabetes-related foot infections were successfully developed for the Australian context. In combination with simplified clinical pathway tools they provide an evidence-based framework to ensure best management of individuals with diabetes-related foot infections across Australia and highlight considerations for implementation and monitoring.

Guidelines development protocol and findings: part of the 2021 Australian evidence-based guidelines for diabetes-related foot disease

Background

Diabetes-related foot disease (DFD) is a leading cause of the Australian disease burden. The 2011 Australian DFD guidelines were outdated. We aimed to develop methodology for systematically adapting suitable international guidelines to the Australian context to become the new Australian evidence-based guidelines for DFD.

Methods

We followed the Australian National Health Medical Research Council (NHMRC) guidelines for adapting guidelines. We systematically searched for all international DFD guideline records. All identified records were independently screened and assessed for eligibility. Those deemed eligible were further assessed and included if scoring at least moderate quality, suitability and currency using AGREE II and NHMRC instruments. The included international guidelines had all recommendations extracted into six sub-fields: prevention, wound classification, peripheral artery disease, infection, offloading and wound healing. Six national panels, each comprising 6–8 multidisciplinary national experts, screened all recommendations within their sub-field for acceptability and applicability in Australia using an ADAPTE form. Where panels were unsure of any acceptability and applicability items, full assessments were undertaken using a GRADE Evidence to Decision tool. Recommendations were adopted, adapted, or excluded, based on the agreement between the panel’s and international guideline’s judgements. Each panel drafted a guideline that included all their recommendations, rationale, justifications, and implementation considerations. All underwent public consultation, final revision, and approval by national peak bodies.

Results

We screened 182 identified records, assessed 24 full text records, and after further quality, suitability, and currency assessment, one record was deemed a suitable international guideline, the International Working Group Diabetic Foot Guidelines (IWGDF guidelines). The six panels collectively assessed 100 IWGDF recommendations, with 71 being adopted, 27 adapted, and two excluded for the Australian context. We received 47 public consultation responses with > 80% (strongly) agreeing that the guidelines should be approved, and ten national peak bodies endorsed the final six guidelines. The six guidelines and this protocol can be found at: https://www.diabetesfeetaustralia.org/new-guidelines/

Conclusion

New Australian evidence-based guidelines for DFD have been developed for the first time in a decade by adapting suitable international guidelines. The methodology developed for adaptation may be useful for other foot-related conditions. These new guidelines will now serve as the national multidisciplinary best practice standards of DFD care in Australia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00533-8.

Diabetes-related foot disease research in Aotearoa New Zealand: a bibliometric analysis (1970-2020)

Background

The aim of this bibliometric study was to examine trends in the quality and quantity of published diabetes-related foot disease (DRFD) research in Aotearoa/New Zealand (NZ) over the past five decades.

Method

In July 2021, the Scopus® database was searched for DRFD-related publications (1970–2020) using predetermined search and inclusion criteria. Bibliometric data were extracted from Scopus® and Journal Citation Reports. Retrieved bibliometric indicators were analysed in Biblioshiny, an R Statistical Software interface and reported using descriptive statistics.

Results

Forty-seven DRFD-related articles were identified. The annual number of publications showed a significant upward trend increasing from one in 1988 to a peak of six in 2018 (P < 0.001). The majority of identified articles (n = 31, 66%) were published in the last decade (2011–2020). Basic/clinical research accounted for 87% (n = 41) of publications and 14 (30%) investigated the screening and/or prevention of DRFD. The average citation per article was 20.23 (range: 0–209) and the median impact factor was 4.31 (range, 1.82–79.32). Over a third of articles (36%) had an international authorship network. Funding was reported in 15 (32%) articles; 12 (26%) were supported by public national grants vs. three (6%) reporting industry-sponsorship.

Conclusion

DRFD articles authored by NZ researchers have increased over the past five decades. Despite NZ researchers having increased their global impact through collaborative networks, most of the research was classified as low-level evidence, with limited focus on Indigenous Māori and limited financial support and funding. Increased funding for interventional research is required to enable a higher level of evidence-based and practice-changing research to occur. With rates of diabetes-related amputations higher in Māori future research must focus on reducing inequalities in diabetes-related outcomes for Māori by specifically targeting the prevention and screening of DRFD in primary care settings in NZ.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00528-5.