In the UK, it is estimated that at any one time 6% of people with diabetes will have an active foot ulcer (Jones, 1998). The delayed healing, high probability of amputation and disability due to these ulcers have social and economic costs. Over 85% of major leg amputations initially begin with a foot ulcer (Foster and Edmonds, 2001; Lobmann et al, 2001).
The aims of this audit were as follows.
- To determine the percentage provision of specialist footwear to high-risk individuals with diabetes.
- To determine the duration of time any specialist footwear is worn.
- To determine the reasons for dissatisfaction with specialist footwear.
- To determine if a multidisciplinary approach increases patient choice regarding their footwear.
- To determine if a multidisciplinary approach reduces problems caused by footwear.
All adults with diabetes who had attended a podiatry clinic in North Derbyshire and had had a foot ulcer within the last 2 years comprised the population from which a sample was taken. Due to time and personnel constraints a random sample of the population was given a questionnaire to complete (70/350; see Appendix 1 for questionnaire). The questionnaire was based upon those currently published in the field of specialist footwear concerning concordance, choices given and patient opinion, and was aimed to gather this information for the North Derbyshire population (the questionnaire was based on those published by: Chantelau and Haage, 1994; Baker and Leatherdale, 1999; Philip, 2000; Williams and Meacher, 2001; Van de Weg, 2002).
Data from the returned questionnaires were analysed using a combination of descriptive statistics, chi-squared testing and Fisher’s tests.
Fifty-one completed questionnaires were received and used for data collection and analysis. There was no statistically significant difference between the ages of those who received specialist footwear and those who did not. A total of 20 individuals had had specialist footwear provided to them – ten of whom had one pair of specialist footwear, and the remainder had 2 or 3 pairs. Footwear was mainly supplied by three hospitals within North Derbyshire, although one individual had bought her own footwear from the US as she did not like the choice available in the UK. Two people had been prescribed specialist footwear from other hospitals prior to moving into the area.
Where specialist footwear is worn
Two individuals never wore their specialist footwear; seven only wore their footwear outdoors; and 11 individuals wore their footwear both indoors and outdoors.
How long footwear is worn for
Of the individuals with specialist footwear, 17 (85%) wore it for 5–6 days a week, 10 wore it for 5–6 hours per day and 10 for 3–4 hours a day. Two individuals never wore their footwear, 18 wore footwear outside, and 11 continued to wear it in the home. Chi-square testing determined that sex did not affect the amount of days per week or the number of hours per day that the footwear is worn.
Reasons for dissatisfaction with footwear
Fifteen individuals with specialist footwear had no problems with their footwear at all. The remaining five (all females) cited the following reasons for being dissatisfied and all were dissatisfied with fitting.
- Footwear was unsuitable for their activities.
- Footwear was uncomfortable.
- Footwear was too heavy.
- Footwear was too large and difficult to put on.
Choice regarding footwear
All individuals who had their footwear provided from the hospitals outside the area and from the Dales multidisciplinary clinic were given choices over style, colour, fastening and material. Individuals who received footwear from both the High Peak and Chesterfield orthotist clinics were given no choices.
Problems caused by specialist footwear
No problems were caused by any footwear supplied from the Dales multidisciplinary clinic or the High Peak orthotist clinic. Concerning footwear from the Chesterfield orthotist clinic, one respondent had foot ulceration, one had a blister, and one had a blister and an ulcer.
Although the author was surprised that the provision of footwear to high-risk individuals was only 39%, it is comparable to that of Neil (2002). Neil’s study indicated that 35% of individuals with peripheral neuropathy and diabetes were supplied with specialist footwear. There may be several reasons for this low number. Firstly, depending on local protocol, not all podiatrists can directly refer to an orthotist for specialist footwear to be provided. For example, in some parts of North and South Derbyshire podiatrists have to make an initial referral to a GP or diabetologist – it is then at their discretion as to whether an individual is referred or not, even if the podiatrist has recommended the appropriateness of specialist footwear for the individual. Secondly, time may also be an issue, but should not be an excuse.
The results of this study are similar to those of Baker and Leatherdale (1999), who found that 83.5% always wore their footwear.
In this audit 35% wore their specialist footwear for greater than 9 hours per day, and would be considered to be concordant by Chantelau and Haage’s (1994) standards: footwear worn for approximately 9.6 hours per day. The author believes that this highlights that further education should be provided to individuals to remind them that they should continue to wear this footwear indoors as well as outdoors. Also, additional choices of footwear suitable for in the home should be considered to raise the adherence rate further for individuals who are essentially housebound.
The concordance rates also compare favourably to previous studies: Knowles and Boulton (1996) found that only 22% of people regularly wore their specialist footwear and McCabe et al (1998) found that only 36% of patients claimed to wear specialist footwear at all times, and 27% never wore it. However, none of the above studies assessed the duration that specialist footwear was worn for, rather they assessed wear times through a more general basis with individuals stating whether they wore footwear regularly, sometimes or not at all. Each individual will have a different perception of what regularly wearing footwear means. Some individuals may term this as every day, others could interpret it as three times a week, therefore it is difficult to compare the results of this study to previous ones. Only a study by Armstrong (2001) looked at where footwear was worn, and Chantelau and Haage (1994) addressed the duration specialist footwear was worn.
The results of this study are comparable to previous studies which investigated where patients wore footwear. Armstrong’s study (2001) found that 85% of a population of high-risk individuals wore footwear outdoors; with only 15% continuing to wear this inside the home.
Concordance with wearing specialist footwear varies; younger individuals appear to wear the footwear for more days a week, however a larger study is needed to confirm this. This could reflect the change in activity levels for people post-retirement. Additional ranges of specialist footwear may be useful so that individuals will have specialist footwear suitable to their activities.
The causes of dissatisfaction with footwear in this audit were similar to those given by patients in previous studies (Fisher and McLellan, 1989; Lord and Foulston, 1989). One in twenty found their specialist footwear unsuitable for activities, uncomfortable, too heavy, too large or did not fit properly.
Concerning appearance of the footwear all men found this to be acceptable; three of the ten women with specialist footwear did not like the appearance of the footwear provided, resulting in two of them not wearing footwear. The author believes that this is due to women’s focus upon wearing more fashionable footwear.
Sadly the appearance of women’s footwear is falling short of expectations. On questioning regarding the acceptability of appearance in this study, 30% of women found the appearance unacceptable. This is comparable to results in a study undertaken by Bas van de Weg (2002) who found cosmetic dissatisfaction was indicated by 40% of people with diabetes. Also in Knowles and Boulton’s 1996 study the female participants were less satisfied with the appearance of the footwear provided than male subjects. This highlights the need for a screening process prior to individuals attending a footwear clinic, so that people can see the type of footwear which is available to them. Pre-screening has been shown to be valuable by Williams and Meacher (2001) who found that those who had an awareness of the type of footwear they were likely to receive from the footwear clinic were more accepting of it.
Questionnaire responses show that a multidisciplinary approach to supplying and fitting specialist footwear improves the patient’s choice. Previous studies have indicated that people with diabetes wish to have more control over the shoes that they are being supplied with (Fisher, 1989; Newson et al, 1992). Newson et al’s study indicated that a multidisciplinary approach involving the person with diabetes would not only increase the patient’s choice, but also satisfaction and concordance.
Williams and Meacher (2001) compared patient choice with footwear supplied from either a multidisciplinary or a ‘traditional’ footwear clinic. Only 70% in the traditional clinic were offered choices regarding the style and colour of their footwear, compared to 100% in the multidisciplinary clinic.
The footwear supplied from the multidisciplinary clinic also caused no problems when wearing, whereas five individuals supplied from a ‘traditional’ footwear clinic had problems with blistering, ulceration or both. One individual developed ulceration, one a blister and one a blister and ulceration; in total 15% of the population with specialist footwear. These findings are similar to those of previous studies. Fisher found that the footwear had rubbed sores or ulcers in 7 out of the 39 individuals.
Data pertaining to when the trauma occurred to the feet was not gathered from participants in this study, thus, the author is unable to determine whether problems were caused due to ill-fitting footwear or from another mechanism. This will, however, be included in further audits.
If problems had arisen within the first month after the specialist footwear was fitted this could indicate that the footwear did not accommodate the patient’s foot properly (Baker and Leatherdale, 1999). Problems arising months later could indicate that new footwear was required or existing footwear would need repair (Lord and Lewis, 1998).
The fact that problems do occur emphasises the importance of professional and patient scrutiny of specialist footwear. Previously, the importance of early review of footwear after dispensation to reduce the risk of problems caused by ill-fitting has been recognised (Chantelau et al, 1990). Education is essential to enable people with diabetes to confidently recognise warning signs upon their feet, and know who to contact if problems arise.
One of the advantages of the multidisciplinary footwear clinic is that the podiatrist is also involved with the routine care of high-risk individuals with diabetes; therefore as the clinician has an extended knowledge base in footwear and high-risk patient management, potential problems can be avoided as more frequent checks are made.
Only 39% of respondents did have specialist footwear. Although this compares favourably with previous studies which benchmarked current provision of specialist footwear, it is not acceptable.
The benefits of a multidisciplinary clinic are indicated by this audit. Individuals who had their footwear provided by a multidisciplinary clinic were given greater input into the decision-making process regarding their footwear, and the footwear supplied to the individuals who had completed the questionnaire caused no problems. These results may be attributed to more in-depth scrutiny of the footwear and emphasis of education by the multidisciplinary clinic at the time of fitting, dispensing and at subsequent follow up.
Clinicians treating high-risk individuals need to have their attention brought to the importance of specialist footwear as an ulcer prevention strategy, and also to the importance of re-evaluating the footwear at every contact point with that individual.