Increasing diabetic foot service standards = Decreasing amputation rates
Last year we reported on a Lancet commentary article from Prof William Jeffcoate discussing large variations in regional diabetes-related amputation rates across England. This paper highlighted a huge data analysis showing the critical impact that regional diabetic foot services have on amputation rates.
Well Prof Jeffcoate has just published another commentary entitled, “reducing amputation in diabetes”. This time he highlights an article published in Diabetic Medicine by Richard Paisey and colleagues that investigated the link between key standards for diabetic foot services and major amputation rates.
In short, the authors identified 10 key standards for best practice diabetic foot services from the literature. They then audited 14 diabetic foot service areas within one South-West region of England (population ~5.5million) to see how many achieved these 10 key standards and also calculated the major diabetes-related amputation rates for these same 14 service areas. They then analysed the number of key standards each service area achieved along with major amputation rates to see if there was a link. They did this twice in two different time periods and both times there was a strong link.
So what were those 10 key standards we hear you say? They were:
- Education provided to patients at least annually
- Continuing professional development program provided to clinicians
- Adequate podiatry staffing levels in community & multidisciplinary Diabetic Foot Teams (MDFT)
- Formal MDFT clinic provided at least weekly
- Orthotist services provided within MDFT
- Urgent vascular services available to MDFT
- Foot assessments provided to in-patients with diabetes
- Clinical pathways documented for each patient’s care and communicated to each patient
- Clinical data recorded and monitored for patient with ulcers and amputations
- Administrative support provided for community podiatry and MDFT
The number of key standards achieved in different service areas ranged from 2 – 9, and the major diabetes-related amputation rates from 0.3 – 1.7 per 1,000 people with diabetes. So what was the link? They found that the fewer key standards a service area achieved the higher their major diabetes-related amputation rates was and vice versa. This relationship was not only statistically significant, but the number of key standards a service had predicted around 50-60% of their diabetes-related amputation rate. They were then able to group the services into categories based on key standards achieved:
- Green: >7 key standards had less than national average for diabetes-related amputation rates
- Amber: 6 key standards had national average for diabetes-amputation rates
- Red: <5 key standards had higher than national average for diabetes-amputation rates
While this study had many strengths – identifying the majority of patients with, or at risk of, diabetes-related foot disease and amputations; auditing nearly all clinicians who treated those patients in one large geographical region; interviewing patients and referring clinicians to confirm if standards were met – they did have limitations. Those limitations included: they had to calculate amputation rates in some cases from different data sources; they relied on modest samples of case notes, service documentation and patient, referring clinician and service interviews to confirm if standards were met.
The authors concluded, “peer reviews of diabetic foot services in the South-West region have shown a powerful correlation between major amputation incidence and service provision. Based on these findings we strongly recommend robust commissioning to provide and coordinate 10 key service provisions for diabetic foot care in all CCGs.” They also found that many of these key standards could be implemented without additional costs, and the standards that did need additional costs could be comfortably afforded with the costs saved from improved diabetes-related amputation rates, such as extra podiatry, orthoptist and vascular services.
Prof Jeffcoated concluded, “These findings are of fundamental importance and provide both clinicians and managers with the evidence and a toolkit to enable a major advance in the fight against this disabling, mutilating and deadly complication of diabetes.”
He then added a statement that we hope will resonate down under, “It seems inconceivable that those responsible for the provision of these (diabetic foot) services can continue to ignore the evidence now available and allow the inequalities of service provision (and, hence, sources of seemingly avoidable harm) to persist. Indeed, the point has now been reached where such inaction … is indefensible.”
Finally, Prof Jeffcoate made an interesting observation from their findings that they authors didn’t. He observed there was also a trend in decreased incidence of new diabetic foot ulcers with these increasing key standards. This finding links nicely to one of the other author observations that just having a MDFT with <5 other key elements was not sufficient to reduce high amputation rates and a more comprehensive regional service is required.
This suggests that to really drive down regional amputation rates, regions need to provide: best practice foot screening services for diabetes patients, prevention services for those found do be at risk of foot disease, MDFT for those found to have foot disease, and linking them all with clinical pathways. Sound familiar? That’s right these are exactly a few of the key recommendations in the Australian Diabetes-related Foot Disease Strategy 2018-2020 .
In conclusion, we dare say this study’s findings may form some of diabetic foot accreditation standards in the UK and perhaps Australia. On that note, we are excited to say we are working with the National Association of Diabetes Centres on the development of such Australian “Interdisciplinary Diabetic Foot Service Accreditation Standards” in 2018 … watch this space.
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The 2018 ‘What’s New in DFU‘ event series is only weeks away! These 3.5 hour event include a substantial selection of delicious food, alcoholic & non-alcoholic beverages, valuable networking time and a certificate of attendance that can be used towards your continued professional development. (subject to your governing/peak body)
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