Patient and professional delay in the referral trajectory of patients with diabetic foot ulcers

AIMS

A cohort study investigated referral and treatment trajectories of patients with diabetic foot ulceration consulting podiatrists. The study aims were to quantify patient, professional and treatment (=total) delay and to identify relationships between patient- or professional-related characteristics, delays or ulcer healing time.

METHODS

Ten podiatrists specialising in diabetes care included 54 consecutive adults with diabetic foot ulceration. Assessments were performed retrospectively (e.g. delays) and prospectively (12 weeks).

RESULTS

Median (SD; range) patient delay was 3.0 days (50.6; 0-243), professional delay 7.0 days (63.4; 0-279) and treatment delay 20.5 days (97.3; 0-522). 57% of patients took >2 weeks before visiting a podiatrist. Ulcers healed in 67% of patients in 49.0 days (90.2; 4-408). The number of health care professionals in the referral trajectory was positively related to treatment delay (p<0.01) and to ulcer healing time (p<0.01). Professional delay and treatment delay was positively correlated with the duration of the podiatric treatment (p<0.05). Patient awareness of ulceration risk tended to decrease the healing time.

CONCLUSIONS

Patients with diabetic foot ulcers presented small median delays in the referral trajectory to podiatrists specialising in diabetes. The study results suggest that reducing the number of health care professionals in the referral trajectory might decrease treatment delay and ulcer healing time. Also improving patient awareness of ulceration risk might be beneficial for the healing time.

The behavior and psychological functioning of people at high risk of diabetes-related foot complications

PURPOSE

The purpose of this review was to propose a model that describes the influences on the behavior and psychological functioning of people at risk for diabetes-related foot complications.

METHODS

A literature search was conducted in Medline (1950-2005), CINAHL (1982-2005), and PsycInfo (1967-2005) databases and in reference lists of journal articles and relevant books. The search focused on published literature in the English language that was related to concepts such as diabetes-related foot complications, behavior, and psychology.

RESULTS

The literature reviewed was arranged to reflect the reciprocal relationship between the personal, environmental, and behavioral factors of people at risk of diabetes-related foot complications. The model proposed uses the concept of reciprocal determinism to illustrate how these factors interact and influence the development of diabetes-related foot complications.

CONCLUSION

The concept of reciprocal determinism may be useful when developing further investigation into educational and behavioral interventions in this clinical population.

New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow-up

OBJECTIVE

To evaluate 1) the new ulceration, the new major amputation, and the survival rates of 115 diabetic subjects hospitalized for foot ulceration from 1990 to 1993, with an average follow-up of 6.5 years, and 2) the demographic and clinical characteristics associated with these events.

RESEARCH DESIGN AND METHODS

A total of 115 subjects, 31 women and 84 men, were monitored until 31 December 1998. All subjects were provided with therapeutic shoes and received intense education. Data concerning new ulceration, new major amputation, and reamputation events and the date and cause of death were recorded for each patient. The prognostic factors for these events were then evaluated.

RESULTS

The average follow-up was 78.3 +/- 15.3 months (range 60-106). During this time, 13 homolateral and 12 contralateral episodes of new ulceration occurred. At univariate analysis, none of the variables considered were significantly associated with the new ulceration. There were three major amputations: two of the limb previously healed and one of the contralateral limb. Of the 115 subjects, 51 (44.3%) died: 24 of the 31 women (77.4%) and 27 of the 84 men (32.1%). Ischemic cardiopathy was the most frequent cause of death (60.8%). Mortality concerned 20 of the 27 subjects (74.1%) undergoing major amputation from 1990 to 1993 and 31 of the 88 healed subjects (35.2%), with a significant difference (P < 0.0001). Multivariate analysis showed the independent role of the ankle-brachial index < or =0.5 (P = 0.005), age (P = 0.003), and female sex (P = 0.027).

CONCLUSIONS

We believe that the use of therapeutic shoes and intense educational training, including the education of the family, have contributed to the low incidence of new ulceration and major amputation in our study population. The high frequency of ischemic cardiopathy as a cause of death should, perhaps, lead to a more aggressive diagnostic and therapeutic attitude toward this pathology in diabetic subjects admitted to hospitals for foot ulceration.

Barriers to podiatric care among diabetic patients in the San Francisco Bay area

This study investigates the provision of general medical and foot care, the barriers to access for foot care, and the awareness of foot risks in an urban diabetic population. A survey composed of 26 questions was mailed to 2375 diabetic patients in the San Francisco Bay area who are members of the American Diabetes Association (ADA). Three hundred ninety-two surveys were returned for a response rate of 16%. Of the 392 respondents, 7 (1.8%) indicated that they were not receiving any medial care for their diabetes, with another 15 (3.8%) receiving general medical care from an alternative health care provider. Among the respondents, 87 (22%) did not have their feet examined by any health care provider. The remainder of the patients were receiving foot care from a health care provider with 191 (48.7%) under the care of a provider other than a podiatrist. Of those not receiving any foot care, 53 (61%) reported that they did not seek any pedal care because they do not have any apparent foot or leg problems. Another 12 (13.8%) indicated that they did not know whom to see for their lower extremity problems. Lack of insurance or inability to afford medical care was the main reason that prevented 7 (8%) of the patients from receiving routine foot care. With respect to the patient's knowledge of diabetes-associated foot disorders, the majority (72%-79%) knew that poor circulation, neuropathy, ulcers, painful leg and foot conditions, infection, and amputation were associated with diabetes. From all the surveyors, 106 (27%) reported that they were not advised or educated on the potential lower extremity complications of diabetes by their health care provider. The results of this study indicate that in an urban population of diabetic patients, all of whom were members of ADA, a significant number are not adequately educated on the importance of routine foot care.

A systematic review of foot ulcer in patients with Type 2 diabetes mellitus. I: prevention

AIM

To evaluate the role of preventative strategies in reducing foot ulcers in patients with Type 2 diabetes mellitus, both in the general population and those identified to be at a raised risk.

METHOD

A systematic review of interventions to prevent diabetic foot ulcers.

RESULTS

Available studies are generally unsatisfactory in their ability to answer the important questions relating to prevention. However, where people with diabetes receive well-organized and regular care with rapid referral to appropriate specialist multidisciplinary teams when problems (or their precursors) occur, ulcer morbidity can be substantially reduced.

CONCLUSION

Foot ulcers are common in people with diabetes and are costly in terms of both patient morbidity and the use of healthcare resources. Although it is nearly a decade since the St Vincent Declaration called for a marked reduction in morbidity to be achieved through better patient management, available evidence suggests that the process of care in Britain is still very variable in quality. Foot care for people with diabetes must be organized to provide monitoring, education and referral in a manner acceptable to patients and realistic for local healthcare providers.

Diabetic neuropathy: pathophysiology and prevention of foot ulcers

Diabetic neuropathy, which affects 60% to 70% of those with diabetes mellitus, is one of the most troubling complications for persons with diabetes, often leading to foot ulcers and potentially to lower limb amputations, both of which are preventable. The physiologic, structural, and functional changes associated with diabetic neuropathy and foot ulcers are discussed. Advanced practice nurses are in a unique position to implement strategies for the prevention of serious and debilitating complications from diabetic neuropathy, including foot assessment, education, and specialist referrals. Research evidence is given to support the use of the Semmes-Weinstein monofilaments to evaluate decreased plantar sensation, a common precursor to ulceration. Ongoing patient and family education can emphasize the importance of preventive self-care measures. Referrals for specialist care and therapeutic footwear can be made by advanced practice nurses. If begun early, these interventions can prevent foot ulcers from diabetic neuropathy, thereby improving the quality of life and reducing healthcare costs for this chronic disease.

Psychological status of diabetic people with or without lower limb disability

The aim of this study was to compare the quality of life between diabetic people with chronic foot ulceration or lower limb amputation and diabetic controls. Each participant was interviewed using the Psychosocial Adjustment to Illness Scale, the Hospital Anxiety and Depression (HAD) scale, a specifically designed foot questionnaire and a quality of life ladder. Thirteen diabetic unilateral lower limb amputees (DA) were matched for age and sex with 13 unilateral diabetic patients with chronic foot ulceration (DU). Twenty six age- and sex-matched diabetic people with no history of foot ulceration were the controls (DC). Significantly poorer psychosocial adjustments to illness were found in DU and DA compared to diabetic controls (both P < 0.05). DU were also significantly more depressed than the DC (P < 0.05) using the HAD scale. The quality of life ladder revealed that DU were significantly more dissatisfied with their personal lives than DC (P < 0.05). Finally, the foot questionnaire showed that DU had a significantly more negative attitude towards their feet than DC and DA (P < 0.05). This study showed that the psychological status of mobile amputees was better than that of the diabetic foot ulcer patients but not as good as diabetic controls.

Why bother educating the multi-disciplinary team and the patient--the example of prevention of lower extremity amputation in diabetes

Amongst all the long-term complications of diabetes it is believed that foot ulceration and amputation are the most preventable: small studies have suggested that more than 50% of amputations should be avoidable by screening and appropriate education. There is ample evidence that simple non-invasive screening tests are not being carried out in many diabetic clinics--one study confirmed that poor patient care was responsible for 50% of heel ulcers in a hospital setting. There is a similar lack of awareness of potential problems in many 'at risk' diabetic patients. Thus, simple screening of diabetic patients should be routine clinical practice: those identified as being at 'high risk' of foot, problems should receive appropriate education in protective foot care. The rewards are potentially great, and include the realization of the St. Vincent target, a 50% reduction in amputation.

Foot pathology in insulin dependent diabetes

OBJECTIVES

Foot pathology is a major source of morbidity in adults with diabetes. The aim of this study was to determine if children with insulin dependent diabetes have an increased incidence of foot pathology compared with non-diabetic children.

DESIGN

Questionnaire, clinical examination, and biomechanical assessment.

SUBJECTS

67 diabetic children and a comparison group matched for age, sex, and social class.

RESULTS

We found significantly more foot pathology in the children with diabetes (52 children) than the comparison group (28 children); with more biomechanical anomalies (58 children with diabetes, 34 comparison group); and a higher incidence of abnormal skin conditions (53 children with diabetes, 27 comparison group). Forty two children with diabetes had received foot health education compared with 27 in the comparison group, but the study revealed ignorance and misconceptions among the diabetic group, and previous contact with a podiatrist was minimal.

CONCLUSIONS

The survey suggests that children with diabetes have an increased incidence of foot pathology justifying greater input of podiatric care in the hope of preventing later problems.

The prevalence of foot ulceration and its correlates in type 2 diabetic patients: a population-based study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34-90) years, diabetes duration 7.4 (0-50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or > or = 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3-44.9%) and the prevalence of PVD, 11% (9.1-13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.

Clinical presentation and management of diabetic neuropathy and foot ulceration

A simple classification of the more common neuropathies is presented. The most frequent disorder in diabetes is a symmetrical sensory polyneuropathy in the lower limbs. Acute sensory polyneuropathies frequently follow sudden metabolic disturbance although there may be little evidence of neurological abnormalities on clinical examination. Similar symptoms occur with chronic sensory polyneuropathy but onset is gradual and this condition may persist for years with only minor symptoms. A significant proportion of patients with chronic polyneuropathies have few if any symptoms and are only diagnosed by careful clinical examination. An approach to the diagnosis and management of symptomatic sensory polyneuropathy is suggested. Sensory loss, and the possible complication of vascular dysfunction, greatly increases the risk of insensitive foot lesions in diabetic patients. Some may progress to the insensitive foot without prior evidence of neuropathy. Regular and thorough examination is therefore the only way to identify patients at risk who then require education in preventative foot care. The identification of such patients and the clinical presentation and management of foot ulcers is discussed.

How effective is cushioned therapeutic footwear in protecting diabetic feet? A clinical study

Therapeutic footwear with cushioned insoles was supplied to 50 diabetic patients with severe peripheral neuropathy and/or peripheral vascular disease (age 59(SD 12) years, known duration of diabetes 17(7) years), 36 of whom had a history of foot ulceration. A follow-up examination was carried out 25(14) months later, except in 8 patients who died from conditions unrelated to their foot lesions, and 1 patient who died from sepsis due to upper limb amputation. Among the surviving 41 patients, intercurrent foot lesions during follow-up occurred in significantly fewer (42%) of the 26 who had worn the shoes regularly than of the 15 who had worn the shoes irregularly (87%, p less than 0.01). At follow-up, only 15% of the 41 patients were being treated for foot-lesions, compared with 78% of these 41 patients before cushioned shoes were provided. It is concluded that the availability of therapeutic shoes with cushioned insoles for diabetic patients at risk of foot lesions decreases the morbidity due to the diabetic foot syndrome.