Improving the provision of foot care services available to diabetes patients is “key” to cutting amputations, and potentially ulcers as well, according to UK researchers.
They found the gradual introduction of 10 foot care services for diabetes patients was accompanied by a “sustained” regional reduction in major diabetes-related amputation incidence.
“We have shown a powerful negative correlation between major amputation incidence and service provision”
The study authors looked at patient data and service provision in the South West of England between 2005 and 2015, finding that as certain foot care services were set up, the number of amputations also fell.
They identified 10 foot services as particularly important, including standardised general practice screening, improved community podiatry staffing, and hospital multi-disciplinary foot clinics.
Commissioning recommendations key for effective diabetic foot care services:
- Patient education at annual review
- Regular community healthcare professional education
- Adequate podiatry community staffing with rotation in to multi-disciplinary diabetic foot team
- Job planned multi-disciplinary diabetic foot team weekly
- Administrative support
- Pathways and communication of plan of care to patient
- Identification of diabetic in-patients and their foot checks
- Orthotist an integral part of multi-disciplinary diabetic foot team
- Urgent vascular opinion available to foot clinic staff
- Ulcer database and root cause analysis of all amputations
For example, between 2005 and 2007, only between two and five of the recommended services were funded by South Devon Clinical Commissioning Group, increasing to nine or 10 between 2009 and 2015.
Over the whole period, major amputations per 10,000 diabetes patients fell from around 35 in 2005 to less than five in 2015 across the CCG, with the number beginning to fall soon after services were added.
The study authors, from the South-West Cardiovascular Strategic Clinical Network peer diabetic foot service review team, stated that introduction of the 10 key services was “accompanied by a sustained reduction in major diabetes-related amputation incidence”.
“A reduction in major amputation incidence has occurred within two years of improvement in diabetic foot care service provision in seven provider services,” they noted.
“The introduction of 10 key elements of foot care service provision in one area of the South-West resulted in stabilisation of foot ulcer incidence and sustained reduction in amputation incidence from 2007,” they said in the journal Diabetic Medicine.
“We strongly recommend robust commissioning to provide and co-ordinate 10 key service provisions”
Meanwhile, they found failure to improve unsatisfactory service provision resulted in continued high amputation incidence. There had been a “continued high incidence of major amputation” in two areas where only two or three of the diabetes foot services had been sustained.
In addition, they said they found a “trend towards a reduction in diabetic foot ulcer incidence”, following the introduction of the various foot care services.
For example, in South Devon the number of new ulcers per 1,000 patients with diabetes fells from around 15 in 2005 to around seven in 2015.
“Future reductions in diabetes-related foot ulcer incidence in successful service provider areas would indicate that the service provisions recommended were effective in ulcer prevention as well as in reduction in major amputation incidence,” they noted.
The researchers said overall their study had shown a “powerful negative correlation between major amputation incidence and service provision”.
“Based on these findings we strongly recommend robust commissioning to provide and co-ordinate 10 key service provisions for diabetic foot care in all clinical commissioning groups,” they added.