After staff, the largest single cost item in our clinic is diabetes footwear and insoles. Despite this, there is very little evidence for this expensive intervention and how best to achieve outcomes such as reduced re-ulceration rates and improved mobility for our patients. Clearly we believe that prescription shoes are needed for most patients in order to prevent re-ulceration, but is this actually the case? This quarter sees the publication of two papers from Amsterdam which take a critical look at the efficacy of footwear provision for diabetes patients (Arts et al, 2012 and Waaijman et al, 2013, summarised alongside). This group has an excellent track record and reputation for quality studies on shoes and insoles for diabetes patients.
The Arts study looked at custom made shoes, which often in the UK will cost over £500 per pair with insoles, and measured in shoe pressures at known sites of ulceration and forefoot deformity in 171 patients with 336 feet. It compared the regional maximum pressures with non-deformed feet or a peak pressure level of 200 kPa.
The conclusions were that pressures were adequately reduced in less than two-thirds of previous ulcer locations and less than a half of forefoot high-pressure areas caused by forefoot deformity. The authors emphasised the need for more evidence-based interventions to enhance footwear efficacy. Certainly these findings, coupled with the fact that the shoes are worn less than 75% of the time when patients are walking, as published in the paper from the same group (summarised alongside), go a long way to explaining why shoes do not prevent re-ulceration in so many patients. Insoles need to be reviewed regularly and frequently replaced to ensure offloading is correct and maintained.
What else can we do about this? The Waaijman paper concludes that separate shoes for indoor wearing would help and also that more attractive shoes are more likely to be worn, and this is certainly my experience with my patients. Unfortunately, when feet are severely deformed this is not always possible but when custom shoes cost more than a pair of Prada or Louboutins then patients need better choice and more stylish footwear to encourage wearing, or else this is money we are spending which might not have any benefits for many patients and is an area that the NHS is looking at for possible cuts.
To read the article summaries, please download the PDF from the article options link at right.