Diabetic foot complications, as we all know, are devastating to those who suffer from them and lead to increased morbidity, reduced quality of life and increased mortality. Additionally, demands placed upon the health and social care systems are unacceptably high. It is recognised that well-structured and integrated diabetic foot care services between primary and secondary care are effective in reducing diabetic foot complications. Measuring success is generally conducted by looking at major amputation levels and comparing them locally and regionally.
The paper I want to bring to your attention to is focused on improving diabetic foot care services and outcomes. When major amputation rates were published fairly recently, the south west of England had one of the highest rates compared with other parts of the UK. A study undertaken by Paisey et al, published in Diabetic Medicine, has examined the impact of changes to service upon diabetes-related major amputations and ulceration rates within the south-west region of England.
Following the introduction of 10 key elements of foot care service provision in one south-western area in 2007, stabilisation of foot ulcer incidence and sustained reduction in amputations were achieved. The key elements included: administrative support, standardised general practice foot screening, improved community podiatry staffing, hospital multidisciplinary foot clinics, effective care pathways, as well as the availability of an orthotist and audit. These changes were encouraged to be undertaken throughout the south-west region. Peer reviews of services were carried out in 2013 were conducted by two diabetologists, two lead podiatrists and an NHS England quality improvement lead. This showed that the 3-year diabetes-related major amputation incidence correlated inversely with adequate delivery of diabetes foot care services (P=0.0024, adjusted R2=0.51). Further service recommendations were made and, in 2015, another peer review was conducted by a panel, including two diabetologists, two lead podiatrists, a vascular surgeon, an NHS quality improvement lead and an orthopaedic/podiatric surgeon. None of these reviewed their own services. These reviews found that two or more foot care service improvements were reported by six diabetes foot-care providers, with an improvement in outcomes. The negative relationship between major amputation incidence and service provision remained strong both in the period 2012–2015 and in 2015 only (P≤0.0012, adjusted R2=0.56, and P=0.0005, R2=0.62, respectively).
This commentary is not able to describe the methodology in full due to word constraints, but there are some very clear messages that commissioning groups should consider when looking at diabetic foot care services. Ultimately, as the authors conclude: the incidence of major lower-limb amputation is inversely correlated with foot-care services provision. By introducing more effective service provision, significant reductions in major amputation and ulceration can be achieved. Many of the improvements, according to the authors, are inexpensive and improve patient care.
To read the article summaries, please download the PDF.
