The foot has often been called the “Cinderella” of diabetes. I would suggest that peripheral arterial disease (PAD) is the Cinderella aspect of both the foot in diabetes and cardiovascular disease. PAD and its role in diabetic foot disease always seems to lag behind the more glamorous ugly sisters, namely wound care, infection and offloading.
Yet PAD is arguably the most important causative factor in the most devastating outcome of diabetic foot disease – amputation (Adler et al, 1999). Perhaps the relative difficulty of achieving significant improvement of PAD, compared with the areas mentioned above, is why it is often not well dealt with in the clinic. With a few vascular surgeons as notable exceptions, PAD does not have many champions, and fewer still are involved in diabetic foot care.
But PAD’s time has now come! Earlier this year, NICE announced it was going to produce guidance on PAD.
NICE stakeholders and the Guideline Development Groups
Foot In Diabetes UK (FDUK) – among others – registered as a stakeholder and was invited to attend the NICE PAD Stakeholder Workshop in May 2010. As an FDUK Executive Committee member, and an NHS-based podiatrist now working entirely in PAD, I represented FDUK at the workshop. It was an opportunity to review the draft scope and to ensure that the content was healthily debated. Following the workshop, revisions were made to reflect stakeholder comments.
Next, applications were opened for membership of the PAD Guideline Development Group (GDG). GDGs are made up of healthcare professionals, patients, carers and a technical team (health economist, information specialist, project manager and systematic reviewer).
I was concerned when reading the initial GDG membership list, which included vascular surgeons, specialist vascular nurses and physiotherapists, but did not include a podiatrist. I lobbied on this issue; NICE took note and consequently advertised a podiatrist position for the PAD GDG. Having been hooked by the vitality of the workshop, I decided to apply for the GDG podiatrist post and was successful. Here I am now, a footman accompanying Cinderella PAD to the NICE ball!
The PAD GDG meets monthly with a remit to: (i) set the evidence review priorities; (ii) review and debate the evidence; (iii) develop the recommendations. NICE recommendations are based on systematic review of the best available evidence. When minimal evidence is available, a range of consensus techniques are used to develop recommendations. In the often poorly evidenced realms of diabetic foot disease – PAD included – guidance is frequently based on the limited evidence, or consensus expert opinion. Thus, it was one of the roles of the PAD GDG to advise on how to identify best practice in clinical areas where research is absent, weak or equivocal. This places a great responsibility on the members to help produce meaningful and robust NICE guidance, which will subsequently direct large NHS resource investments.
Getting involved: Influencing the guideline development process
As a reader of this journal you are, by implication, a stakeholder in PAD. So, what can you do to get involved and influence the NICE PAD guidance?
First, have a look online at the key documents related to the project, including the final scope and the list of registered stakeholders (guidance.nice.org.uk/CG/Wave23/5). It is very likely that, through your clinical practice, you have a natural link to one or more of the registered stakeholders and can engage with them, requesting that they submit specific suggestions or comments to NICE during the guideline consultation process. The next key opportunity for engagement will be when the draft guideline goes out to the stakeholders for consultation in March 2012.
Conclusion
If you have read this far, I urge you to become involved in the consultation on this important document. This is a unique opportunity to change the status quo for the management of PAD in the UK and really invest in lessening the burden of this condition. This guidance, with the support of all stakeholders, will help us move away from the current situation, where gold standard PAD management is represented by (as put so well by an unnamed source) “islands of excellence in a sea of mediocrity”.
The work described here was undertaken by the National Clinical Guidelines Centre which received funding from the National Institute for Health and Clinical Excellence. The views expressed in this publication are those of the author and not necessarily those of the Institute.
