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36 The Organisation of Diabetic Foot Care: Evidence-Based Recommendations Robert J. Young
WHY IS A STRUCTURE OR SYSTEM OF CARE NECESSARY?
Wherever there is good evidence about the beneficial nature of a particular sequence of health care interventions, it is necessary to put in place organisational arrangements that will maximise the chance that the interventions will be performed and that the arrangements are effective.
Thus, it is not sufficient simply to train health care professionals to perform their technical and professional roles adequately.
Nor can one reasonably expect that patients will inevitably turn up for a due intervention in the right place at the right time.
Rather, there need to be structures or pathways of care capable of supporting professionals in ways that enable them to apply their knowledge and training consistently and efficiently.
And there need to be signposts or self- enabling information for patients.
This is just as true for the unpredictable and extended course of interventions that comprise care for long-term conditions as it is for the more predictable and short-term interventions associated with elective medicine.
In respect of the diabetic foot, there is appreciable evidence for the effectiveness of inter- ventions that can minimise the onset of neuropathy and peripheral vascular disease (primary preventive care), that can detect and minimise the consequences of early peripheral neuropathy, peripheral vascular disease and other susceptibility factors (secondary preventive care) and that will minimise limb loss and maintain mobility if serious problems arise (tertiary preventive care or salvage therapy).
It is the systems that underpin this approach to primary, secondary and tertiary prevention of diabetic foot disease that form the content of this chapter.
The approach is consistent with presently accepted models of long-term condition management such as are advocated in the English National Service Framework for Diabetes: Standards,1 and with the detailed evidence that led to the recommendations assembled in the formulation of the National Institute for Clinical Excellence (NICE) guidelines2 (http://www.nice.org.uk/page.aspx?o=dg .endocrine).
The Foot in Diabetes, 4th Edition. Edited by Andrew J.M. Boulton, Peter R. Cavanagh and Gerry Rayman. C 2006 John Wiley & Sons, Ltd. ISBN: 0-470-01504-7
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CARE NEEDED BY EVERYONE WITH DIABETES 399
5% active ulcers, infection, revascularisation, amputation Multidisciplinary foot care team management 15% high risk Intensive ‘foot protection’
20% increased risk Regular ‘foot protection’
60% no current abnormality Routine annual screening
Figure 36.1 The ‘Pyramid of Foot Care’ for a population of people with diabetes
THE SCALE OF THE TASK Foot complications are common in diabetes.
Everyone with diabetes is potentially susceptible.
Overall, about 30% of people with diabetes have neuropathy and 30% have peripheral vascular disease.
These conditions and other vulnerabilities of the foot increase with advancing age.
Around 5% of people with diabetes may develop a foot ulcer in any one year, and major amputation rates are currently around 0.5% per year.
Given that the prevalence of diabetes is presently of the order of 3, 4%, and likely to increase by 50, 100% over the next 10 years, care structures need to be organised on a communitywide basis and resourced to a level commensurate with the volumes of patients that will require screening or intervention at each level (Figure 36.1).
CARE NEEDED BY EVERYONE WITH DIABETES Registration, recall and regular review are at the heart of continuing care for people with diabetes.
Continuing care encompasses reviews of glucose control and vascular risk factors.
Optimisation of these factors is the means whereby the onset and progression of the cardinal risk factors for diabetic lower limb disease (peripheral neuropathy and peripheral vascular disease) can be attenuated.
There is therefore a set of tasks that relates to reviewing the current management plan and agreeing on a future plan.
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400 THE ORGANISATION OF DIABETIC FOOT CARE
In addition, the review process offers a systematic opportunity to identify early evidence of emerging complications.
For the eyes the process is retinal screening, for the kidneys it is test- ing the urine for microalbuminuria, but in the feet it requires examination for early evidence of peripheral neuropathy or peripheral vascular disease plus the evaluation of any supplementary risk factors that might intensify their effect (e.g. foot deformity, poor vision or balance prob- lems).
Pragmatically and for administrative convenience (this is a formidable administrative task for primary care providers) these routine reviews are usually organised annually.
CARE THAT SOME DIABETIC PATIENTS NEED If, during the continuing care review process, significant risk factors for diabetic foot disease are discovered, then preventive care needs to be enhanced.
The person who has intact sensation, palpable pulses and warm feet is at low current risk of a diabetic foot problem and can simply be rescheduled for repeat examination, usually in a year.
However, a person with diabetes who has impaired sensation and/or absent pulses is at increased risk of diabetic foot ulceration.
This risk can be contained (secondary preventive care).
Accordingly, there needs to be a sys- tem whereby the people with increased risk receive enhanced foot care education, particularly with regard to choice of footwear (minimally traumatic, maximally protective), more regu- lar foot review (3, 6 monthly) and, ideally, intensified efforts to optimise glucose control and cardiovascular risk factors.
Sometimes, the identification of an early abnormality and an expla- nation of its attendant implications may facilitate greater ongoing engagement in the relevant as- pects of preventive care, i.e. it creates a state of ‘readiness to change’.
Such explanation, discus- sion and shared decision making require significant amounts of time if they have to be effective.
Whereas in many models of care the primary care provider will carry out the routine foot ex- amination, these enhanced services are usually organised by podiatrists as a service to primary care providers and constitute what is sometimes known as a ‘foot care protection programme’.
In respect of realising the opportunities to intensify glucose control and cardiovascular risk factor reduction, it is clearly essential that podiatric and primary care services communicate effectively.
CARE THAT A FEW DIABETIC PATIENTS NEED Some people with diabetes are not just at increased risk but at high risk of foot ulceration.
They not only have reduced sensation and/or absent pulses but also have a history of previous ulceration and/or foot deformity.
More intensive ‘foot care protection’ reduces the risk that such people will progress to (re-)ulceration.
Such patients require all the interventions offered to people with increased risk but in addition require more frequent (1, 3 monthly) podiatric reviews that include foot care education, reassessment of the need for revascularisation, skin and nail care and, where necessary, the provision of specialist orthotics and footwear to offload vulnerable areas of intense pressure.
CARE FOR DIABETIC PATIENTS WITH ACTIVE FOOT PROBLEMS People with new ulcers, swelling or skin discolouration should be referred to a multidisciplinary foot care team within 24 h. A multidisciplinary high-risk foot care team should comprise highly