What should be the world’s priorities for diabetic foot ulcers?

April 12, 2018

A new commentary paper authored by the world’s leading diabetic foot experts in one of the world’s leading diabetes journals has beautifully covered the current challenges and opportunities facing the world when it comes to diabetic foot ulcers.

Many of these authors will be very familiar as we have regularly summarized their pivotal work right here over the last years, including Professors Jeffcoate, Vileikyte, Boyko, Armstrong and Boulton.

When any of these authors writes a paper its worth reading. But when all five combine their thoughts into one leading commentary paper – and with Prof Boulton now also the President of the International Diabetes Foundation – it automatically becomes another unmissable classic diabetic foot paper.

So what did they cover in this new classic paper?

In short, this paper covers pretty much all we know about the clinical care of diabetic foot ulcers (DFU), research into DFUs, what we should know about DFUs and where the world should head when it comes to reducing the burden of DFUs. We simply cannot summarise this new classic paper and do it justice, so let us instead whet your appetite to read the full paper by outlining the topic headings it covers:

  1. Geographical differences in clinical outcome
  2. Current evidence base
  3. Primary Prevention: Reducing the incidence of new DFUs
  4. Failure of DFUs to heal promptly
  5. New ulceration after healing
  6. Improving well-being: The patient agenda
  7. Improving long-term survival
  8. Why is the evidence base so poor?
  9. Diabetic foot care has been traditionally neglected
  10. The complexity of the pathogenesis
  11. Improving the evidence base for clinical practice
  12. Randomised Controlled Trials
  13. Study population
  14. Control/comparator group: the components of “good standard care”
  15. Choice of outcome measure
  16. Blinding of outcome assessment
  17. Systematic reviews and meta-analyses
  18. The value of observational studies and systematic audit
  19. Future directions: New guidelines
  20. Evidence base for wound care treatments
  21. The structure of care

What was good or not so good about this paper?

We always like to summarise for you the limitations (‘what’s not so good’) and strengths (‘what’s good’) of any paper and this one is no different. So let’s get this out of the way now. This paper is a commentary paper, and like any commentary paper it is based on the expert opinions, narrative reviews and biases of the authors which is typically a limitation.  However, as you’ve probably gathered this is also a strength of this particular paper as these are the world’s leading experts when it comes to diabetic foot care, research and policies discussing what they think are the leading challenges and opportunities facing the world when it comes to diabetic foot disease.

Interestingly, the authors also cover a very handy quality appraisal tool to determine if diabetic foot studies are good or not so good. For any students, clinicians or researchers wanting to know how to assess the quality of a diabetic foot study this tool is a must. For those wanting additional info on how to use the tool please find it here in this full Lancet Diabetes and Endocrinology paper.

So what were their major conclusions?

The authors very nicely summarise what has been achieved in the world of diabetic foot disease to date:

“Much has been achieved in the last two decades with the incidence of major amputation being very much reduced, at least in some countries, but there is evidence that even more can be achieved. There is wide variation in the outcome of management, even in industrialized countries and those with nationalized health care systems – suggesting that many people do not receive optimal care.

And what were their major recommendations?

Well we are glad you asked. Again we will let the authors summarise this for you:

“Two broad strategies are key to improving overall outcome. The first is a major investment in the conduct of the high-quality clinical trials that are necessary to improve the evidence base for routine clinical care. The second is to ensure that those responsible for the design and delivery of care for people with DFUs comply with such evidence-based guidance as is available.”

“Available evidence suggests that very considerable improvements can accompany structural changes in the way professionals work and in the way that care is delivered. Available evidence suggests that such structural changes should focus on 1) the creation of clear pathways to enable early assessment of DFUs by a specialist multidisciplinary service and 2) the provision of structured surveillance and care for those who have had a DFU and are in remission after healing.

If communities embrace these initiatives, it should be possible to trigger substantial improvement in outcomes relating to DFUs. Care of the foot needs to metamorphose from a subspecialty to a “superspecialty” of diabetes.”

What does that mean for Australia?

If you think those recommendations sound familiar, perhaps it is because very similar recommendations were made in the Australian Diabetes-related Foot Disease Strategy 2018-2020, such as all people with diabetic foot disease need:

  1. Access to evidence-based healthcare from specialised interdisciplinary foot disease services
  2. Provision of safe quality care that adheres to evidence-based practice
  3. Major investments in high quality research and development to improve patient outcomes

If you don’t believe us, we strongly encourage you to compare this full Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers paper to the full Australian diabetes-related foot disease strategy 2018-2022 and we dare say you may just agree.

We hope this new paper will further convince you to not only join the Australian diabetic foot community, but now the world’s experts, in working together on these recommendations to end avoidable amputations in a generation. Now to convince the wider community … “watch this space” ;).