The first Irish model of care for the diabetic foot was set up in November 2011. Building on international experience and knowledge around the diabetic foot, the theme of the programme was to direct targeted foot care towards those most at risk based on proper screening of cases.

Dr Ronan Canavan, consultant endocrinologist and clinical lead on the National Diabetes Programme, presented the model of footcare for Ireland to date, how implementation of the programme has turned out and what the outcomes are so far, at the recent Inaugural Conference of the National Clinical Programme for Diabetes in Farmleigh, Dublin.

Dr Canavan mentioned an Irish endocrinologist’s expression about diabetic footcare and how ‘it’s not rocket science, it’s much more complicated’.

“What he means is that despite that the management of the diabetic foot is based on a lot of simple principles, well working models and lots of understanding about how patients get the worst outcome in terms of amputations and diabetic foot ulcer, the outcome still proves resolutely difficult to get in terms of reducing amputations and diabetic foot ulcers.”

Dr Canavan outlined the background to the current Irish model of footcare by focusing on two studies^1,2 from the US and Germany. He also emphasised how history has shown that ‘one shot’ at improving diabetes foot care won’t do it.

“You have to go back, refocus and revisit. You have to keep up with the data and if you’re not making any real change [in improving diabetic foot outcome] you have to go back and see if there is any fresh evidence and see if there’s anything else that can be done,” explained Dr Canavan.

This was the case with the diabetic foot care programme set up in Germany in the mid-90s, which showed that after years of foot care programme implementation, there was no real impact on outcome, and so the programme was analysed and changed. Subsequent reviews of outcomes showed that they improved compared to before intervention.

“A simple fact is that 80% of diabetic foot amputations are preceded by a foot ulcer,” highlighted Dr Canavan.

He used the Pecoraro model³ to illustrate how amputations are preceded by a line of events starting at diabetic neuropathy; the build-up of hard callus; leading to a foot ulcer, which may get infected; and if this infection fails to heal, that’s when the amputation may occur.

“With this simple fact on board, we can build up a model of where to direct specific intervention to try and cut off the pathway to amputation,” he added.

The Irish model of foot care

Basically, the idea of the 2011 model of care for the diabetic foot was to target foot care towards those most at risk based on proper risk stratification and triage. 

“The model of care was introduced in 2010 at a time when things were getting bad, resources were being squeezed and any resources available had to be used for very cost-effective intervention. 

“So limited resources, around a million euros, was directed towards employing 16 podiatry posts within hospitals to set up a foot protection team to feed into the diabetes multidisciplinary foot care teams,” said Dr Canavan.

But by mid-2013, less than half of these HSE podiatry posts had been filled, Dr Canavan added. However, by the time he presented at the Farmleigh conference, he was able to give slightly more positive news in that all 16 positions have now been filled.

Outcomes to date

“The real change that the model has brought on in Ireland for the standard approach to the diabetic foot, is where it lies in terms of risk stratification,” said Dr Canavan.

“Basically what this means is that people at the lowest risk rarely go on to amputation,” he added.

Dr Canavan further explained that this allows for resources to be put in where they are most needed, so that patients in the low risk category get screened annually to make sure they stay in that category, while the patients in the high risk category get intensive treatment by a multidisciplinary foot care team.

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Another outcome since the implementation of the model of foot care is that education of practice and community nurses has taken place so that they can identify low-risk feet and those that may have complications. Leaflets with information about at-risk feet have also been produced to support patients.

Assessment to date

The model of care lists two major key performance indicators (KPIs) to be monitored in terms of diabetic foot outcome and these relate to diabetes-related amputations and hospital discharges for diabetic foot ulcer. 

While Dr Canavan pointed out that it’s a bit premature to be presenting any data since the model of care has only really been up and running for a year, he pointed out some baseline data from 2009 that outcomes can be compared with. Comparing 2013 data with baseline shows that amputations rates haven’t really changed.

“Bed days used due to amputations have remained relatively flat as well, but when we move on to diabetic foot ulceration, we see a significant jump in the number of admissions to hospital, and this probably reflects more activity on the ground; recognising the problem and patients being admitted to hospital for aggressive treatment,” explained Dr Canavan.

“We also see a drop in average length of stay both for amputations and diabetic foot ulcers, so this is something we need to bring back to our managers and say that the cost of diabetes [foot complications] is starting to reduce, and this saving needs to be reinvested into care of the diabetic foot, or indeed any element of diabetes care” he added.

And while Dr Canavan admitted that this reduction in bed days (see Table 2) may not be only due to the implementation of the foot care model, the ‘silver lining’ is still that now patients are being discharged to services where they have a foot protection team and specialist podiatrists ready to see the patients.

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“So even if a patient is discharged too early, at least they will now be routed back into the service and back into the multidisciplinary team, so I think it’s a much better situation than back in 2009.”

A simple audit that was sent out to the 16 HSE podiatrists in 2014 shows that 70% of the podiatrists’ time is taken up by seeing those patients with active foot disease and high-risk foot, with very little time spent on seeing patients with moderate or low-risk foot (see Table 3).

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“Also, the number of cancelled appointments and non-attendances is very low, so this service is probably seen as very worthwhile [by the patients],” added Dr Canavan.

Vision for the future

“The model of care of 2011 is a model of its time, so I don’t think there’s any need to change it,” Dr Canavan said.

“But I do think we need to look at specific parts of it and develop our multidisciplinary team involvement with our colleagues in vascular surgery and orthopaedics, and maybe learn from our German example that if we want to get where they are and confirm a 40% reduction in  amputations in the next four years, we probably need to get our skates on and initiate fresh initiatives and changes,” he added.

He pointed out that maybe what is measured also needs to be looked at and that there needs to be a national audit of the model of care. 

“Any patient who has gone on to have an amputation, the least that they can expect is that they have access and are seen by a multidisciplinary team where the best options were considered for them and discussed in detail, so I think one outcome that we will be measuring going forward is whether patients who do go on to have an amputation have had access to a diabetic foot care multidisciplinary team.”

“The future is better than it was five years ago. We do have clinical proofs that are actively being used for diabetic foot disease, we do have small research groups that are trying to improve the terms for diabetic foot disease and hopefully these networks will actually feed into research not just for the sake of better research, but for the sake of better outcomes for our patients,” he concluded.

References

1. Gregg EG, LI Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990-2010. NEJM 2014; 370: 1514-23
2. Trautner C, Haastert Bm Mauckner P, Gatcke L-M, Giani G. Reduced incidence of lower-limb amputations in the diabetic population of a German city, 1990-2005. Results of the Leverkusen amputation Reduction study (LARS). Diabetes Care 2007; 30:2633-2637
3. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 1990; 13(5): 513-521
4. Model of care for the diabetic foot. National diabetes programme clinical strategy and programmes directorate, HSE 2011