Effectiveness of multidisciplinary care teams in reducing major amputation rate in adults with diabetes: A systematic review & meta-analysis

Above-ankle Reamputation and Mortality following Transmetatarsal Amputation in Diabetic and Non-diabetic Peripheral Artery Disease

The risk of above-ankle reamputation following a transmetatarsal amputation is around 30%. Patient selection may be crucial to achieve good outcomes, and to avoid futile operations and suffering. We are aware of no previous comparison between the two largest patient groups that undergo lower extremity amputations: patients with diabetes, and patients with non-diabetic peripheral artery disease. Patients with diabetes or non-diabetic peripheral artery disease who had undergone a transmetatarsal amputation from 2004 through 2018 at our institution were included. Patient characteristics and peri-operative details were analyzed retrospectively. Subjects with diabetes were compared with subjects with non-diabetic peripheral artery disease regarding above-ankle reamputation, reamputation level, and mortality. Five-hundred-and-sixty transmetatarsal amputations in 513 subjects were included. The majority of transmetatarsal amputations (86%) occurred in diabetic subjects. Subjects with non-diabetic PAD had a higher risk of above-ankle reamputation (p = .008), and death (p < .001). At the time of data collection, only multiple-ray amputation (vs. single-ray) was an independent risk factor for above-ankle reamputation. Only age, medical comorbidity in general, and chronic heart failure were independent risk factors of death. To our knowledge, this study is the first to report marked differences in above-ankle reamputation rates and mortality following transmetatarsal amputation, comparing diabetics with non-diabetic patients with peripheral artery disease. However, the differences may be attributed to non-diabetics being older, having more medical comorbidities, and having more advanced foot ulcers at the time of transmetatarsal amputation. In patients exhibiting several of these risk factors, transmetatarsal amputation may be futile. LEVEL OF CLINICAL EVIDENCE: Prognostic Level 2: Retrospective study.

Using Multidisciplinary Teams to Improve Outcomes for Treating Chronic-Limb Threatening Ischemia

Multidisciplinary teams are necessary to treat complex patients with chronic limb-threatening ischemia (CLTI). The need for adequate wound care and control of comorbid conditions cannot be accomplished by the vascular specialist alone. Numerous specialties have a role in this group to include surgical podiatrists, orthopedic surgery, plastic and reconstructive surgery endocrinology, and wound care. However, the vascular specialist must drive this team as the patients are usually referred to them and numerous studies have shown a direct correlation between major amputations and the lack of vascular involvement. Creating these teams is unique in each community and must consider practice patterns that are relevant in the local region. CLTI is a challenging disease to manage, and multidisciplinary teams have demonstrated an ability to improve outcomes and deliver superior care to this patient population.

Effectiveness of a Multidisciplinary Limb Preservation Program in Reducing Regional Hospitalization Rates for Patients With Diabetes-Related Foot Complications

OBJECTIVE

This study evaluated the toe and flow model (TFM), a limb preservation program led by podiatric surgeons in Alberta, Canada, for its impact on hospitalization rates and length of stay (LOS) in patients with diabetic foot complication (DFC). Diabetes, a leading cause of non-traumatic lower extremity amputations (LEAs) in Canada, often results in diabetic foot ulcers (DFUs), a major cause of infection, amputation, and hospitalization. TFM has reportedly reduced amputation rates by 39% to 56%.

METHODS

The study analyzed Alberta's health database from 2007 to 2017, focusing on diabetes patients aged 20 and above. It included patients with various DFCs and compared outcomes in regions using TFM and standard of care (SOC). The study also examined data from two major cities, one with TFM and the other without, including rural referrals to Calgary and Edmonton. The data were normalized for the diabetic population and analyzed using a standard Student's t-test.

RESULTS

TFM regions showed significantly lower hospitalization rates (p = 1.22E-12) than SOC regions. Over 11 years, TFM maintained lower average and median LOS by 0.13 and 0.26 days, respectively. TFM access reduced hospitalization risk by up to 30%, and patients in TFM regions had a 21% shorter LOS compared to SOC regions.

CONCLUSION

Despite similar demographics and healthcare systems, the TFM region benefited from a dedicated multidisciplinary program and comprehensive limb preservation services. The study shows that TFM effectively reduces hospitalizations and LOS for DFCs, with significantly better outcomes in the TFM region than in SOC regions.

Associations between specialty care and improved outcomes among patients with diabetic foot ulcers

OBJECTIVE

Specialty care may improve diabetic foot ulcer outcomes. Medically underserved populations receive less specialty care. We aimed to determine the association between specialty care and ulcer progression, major amputation, or death. If a beneficial association is found, increasing access to specialty care might help advance health equity.

RESEARCH DESIGN AND METHODS

We retrospectively analyzed a cohort of Wisconsin and Illinois Medicare patients with diabetic foot ulcers (n = 55,409), stratified by ulcer severity (i.e., early stage, osteomyelitis, or gangrene). Within each stratum, we constructed Kaplan-Meier curves for event-free survival, defining events as: ulcer progression, major amputation, or death. Patients were grouped based on whether they received specialty care from at least one of six disciplines: endocrinology, infectious disease, orthopedic surgery, plastic surgery, podiatry, and vascular surgery. Multivariate Cox proportional hazard models estimated the association between specialty care and event-free survival, adjusting for sociodemographic factors and comorbidities, and stratifying on ulcer severity.

RESULTS

Patients who received specialty care had longer event-free survival compared to those who did not (log-rank p<0.001 for all ulcer severity strata). After adjusting, receipt of specialty care, compared to never, remained associated with improved outcomes for all ulcer severities (early stage adjusted hazard ratio 0.34, 95% CI 0.33-0.35, p<0.001; osteomyelitis aHR 0.22, 95% CI 0.20-0.23, p<0.001; gangrene aHR 0.22, 95% CI 0.20-0.24, p<0.001).

CONCLUSIONS

Specialty care was associated with longer event-free survivals for patients with diabetic foot ulcers. Increased, equitable access to specialty care might improve diabetic foot ulcer outcomes and disparities.

"I know what I'm supposed to do, but I don't do it": patient-perceived risk factors that lead to their lower extremity amputations

BACKGROUND

The purpose of this study is to extend on our previous research by exploring patient-perceived factors that lead to their Lower Extremity Amputations (LEA). LEA are a serious complication of Type 2 Diabetes Mellitus (T2DM), LEA are thought to be preventable with early detection and management of risk factors. Our previous study identified that these factors extend beyond the typical biological and modifiable risk factors and may also extend to patient awareness and competing priorities. Therefore, this research explored these issues in further detail, identifying patient-perceived factors that lead to their LEA.

METHODS

A qualitative descriptive methodology involving non-probability purposive sampling was used to recruit inpatients at a tertiary metropolitan hospital in South Australia. Semi-structured interviews were conducted, and data were transcribed verbatim. Data from the interviews were analysed using thematic analysis and the constant comparison approach.

RESULTS

A total of 15 participants shared their perspectives of risk factors for LEA. Two main themes emerged: intrinsic and extrinsic factors. Intrinsic factors identified in this study included identity, ambivalence, denial, inevitability, and helplessness. Extrinsic factors related to resources, rapport with healthcare professionals, and management of care.

CONCLUSIONS

Through identifying that a combination of perceived personal attributes (intrinsic) and system-level (extrinsic) factors likely contribute to LEA, this study highlights the complexity of factors that contribute to patients' perceptions of what led to their diabetes related LEA. These findings support the importance of a nuanced approach in managing patients with diabetes who are at risk of LEA as it's likely patients' personal circumstances, day-to-day life's requirements and responsibilities, their interaction with healthcare professionals all seemingly contribute to how risks are viewed and managed. Tackling this challenge will require reimagining diabetes care, acknowledgement of risk factors beyond the obvious and addressing persistent access and workforce issues.

Impact of multidisciplinary care of diabetic foot infections for inpatients at Campbelltown Hospital

BACKGROUND

Diabetic foot infection (DFI), including diabetic foot ulcer, is a serious complication of diabetes, particularly in the South Western Sydney (SWS) region where it is a leading cause of diabetes-related hospitalisations. Multidisciplinary team (MDT) involvement is effective at improving the health outcomes of DFI patients. This study investigated the impact of MDT (High Risk Foot Service, HRFS) on the length of stay and surgical outcomes of inpatients with DFI in a Sydney tertiary hospital.

METHOD

A retrospective audit of electronic medical records of inpatient admissions for DFI at Campbelltown Hospital between January 2019 - December 2021, was performed. The main outcome of the study was MDT involvement, defined as having two or more specialities involved in the patient's treatment. The other measured variables included length of stay (defined as the total duration from admission to discharge), and surgical outcomes including debridement, minor amputation, and major amputation.

RESULTS

Over the three years, 78 participants presented to the hospital for 89 unique DFI admissions. There were 24 admissions in 2019, 28 admissions in 2020, and 37 admissions in 2021, with MDT attendance showing a steady increase at 62.5%, 75.0% and 83.8% respectively. Patients with serious comorbidities such as chronic kidney disease were more likely to have MDT involvement (84.8% vs. 15.2%, P = 0.048). Imaging was more likely to be performed with MDT involvement (78.8% vs. 21.3%, p < 0.05). Comparing patients who received and did not receive MDT care, the mean HbA1c (%) (8.4 ± 2.0 vs. 8.2 ± 2.7, P = 0.701), median length of stay (LOS: 7.8, IQR 15.0 days vs. 4.8 IQR 7.9 days, P = 0.243) and rate of surgical outcomes (74.6% vs. 72.7%, P = 0.262) were similar. Patients who required major amputation had significantly longer LOS (24 days, IQR 21.5 vs. 5.2 days, IQR 13.0, P = 0.004) but similar HbA1c (P = 0.552) compared to those who had conservative intervention.

CONCLUSION

Adopting an MDT approach was associated with more thorough investigation of DFI, with similar rates of surgical outcomes. Further research on the impacts of MDT on length of stay and surgical outcomes of DFI patients in other SWS hospitals is needed.

The experiences of health workers using telehealth services for diabetes-related foot complications: a qualitative exploration

BACKGROUND

Diabetes-related foot disease (DFD) accounts for up to 75% of lower-extremity amputations globally. Rural and remote communities are disproportionately affected by DFD. Telehealth has been advocated as a strategy to improve equity of access to health care in rural and remote communities. Current literature suggests that successful implementation of telehealth requires access to adequate reliable equipment, staff training, and support. A real-time video-based telehealth foot service (TFS) for delivering DFD management has recently been established in a Vascular Surgery and Podiatry clinic within a large South Australian metropolitan hospital. The purpose of this study was to gain insights into the experiences of rural and remote health professionals utilising the TFS, as this could be invaluable in optimising the uptake of telehealth use in DFD.

METHODS

This exploratory, descriptive qualitative study employed one-on-one, semi-structured interviews with health professionals who utilised the service. Thematic analysis using an essentialist inductive approach was employed.

RESULTS

Participants included 14 rural and remote health professionals; 2 general practitioners, 2 nurses, 1 Aboriginal Health Practitioner, and 9 podiatrists. In addition, 2 metropolitan-based TFS staff were interviewed. Five key themes were identified. 'Patients have reduced travel burden' included that telehealth enabled Indigenous patients to stay on country. 'Patients had increased psychosocial support' covered the benefits of having health professionals who knew the patient present in consults. 'Improved access' incorporated how telehealth improved interprofessional relationship building and communication. 'Technological and equipment challenges' highlighted that poor network connectivity and poor access to equipment to conduct telehealth consults in rural areas were barriers. The last theme,'Lack of service communication to rural health professionals', highlighted the need for communication around service details.

CONCLUSION

Telehealth is a valuable tool that can improve access to treatment for rural and remote Indigenous DFD patients. While this has the potential to improve DFD outcomes, empirical data is required to confirm outcomes. Considering the advantages of telehealth and rural staff shortages, there is an urgent need for investment in improved equipment and processes and an understanding of the training needs of the health care workforce to support the use of telehealth in DFD management.

The multidisciplinary team in diagnosing and treatment of patients with diabetes and comorbidities: A scoping review

Background

Multidisciplinary Teams (MDTs) has been suggested as an intervention to overcome some of the complexities experienced by people with diabetes and comorbidities in terms of diagnosis and treatment. However, evidence concerning MDTs within the diabetes field remains sparse.

Objective

This review aims to identify and map available evidence on key characteristics of MDTs in the context of diagnosis and treatment in people with diabetes and comorbidities.

Methods

This review followed the PRISMA-ScR guidelines. Databases PubMed, EMBASE, and CINAHL were systematically searched for studies assessing any type of MDT within the context of diagnosis and treatment in adult people (≥ 18 years) with diabetes and comorbidities/complications. Data extraction included details on study characteristics, MDT interventions, digital health solutions, and key findings.

Results

Overall, 19 studies were included. Generally, the MDTs were characterized by high heterogeneity. Four overall components characterized the MDTs: Both medical specialists and healthcare professionals (HCPs) of different team sizes were represented; interventions spanned elements of medication, assessment, nutrition, education, self-monitoring, and treatment adjustment; digital health solutions were integrated in 58% of the studies; MDTs were carried out in both primary and secondary healthcare settings with varying frequencies. Generally, the effectiveness of the MDTs was positive across different outcomes.

Conclusions

MDTs are characterized by high diversity in their outline yet seem to be effective and cost-effective in the context of diagnosis and treatment of people with diabetes and comorbidities. Future research should investigate the cross-sectorial collaboration to reduce care fragmentation and enhance care coordination.

Considerable gaps and differences in rehabilitation after major lower extremity amputations across regions and municipalities in Denmark - A national survey

INTRODUCTION

Equal access to healthcare is a fundamental principle in the fully tax-financed Danish healthcare system. This study reveals whether this system lives up to the principle of equal access when it comes to the rehabilitation of patients who have major lower extremity amputations.

METHODS

With the aim of exploring possible inequality in rehabilitation for patients having major lower extremity amputation in Denmark, a nationwide electronic survey was conducted in the autumn of 2020, which included all hospitals and municipalities in Denmark.

RESULTS

Eighty six percent of hospitals (n = 19) and 97% (n = 95) of municipalities responded. Of the 32% (n = 6) of hospitals and 78% (n = 74) of municipalities that provided prosthesis rehabilitation, the majority (hospitals 50% /municipalities 91%) provided prostheses for <10 patients in 2019, and 36% reported having competencies at only a general level among physiotherapists performing prosthetic training. Psychosocial rehabilitation modalities were lacking overall.

CONCLUSIONS

This national study documents pronounced geographic inequality in access to qualified rehabilitation services for the relatively few patients undergoing lower extremity amputations in Denmark. The decentralised organisation of amputation rehabilitation makes it difficult to build and maintain specialist competencies among healthcare professionals. Inconsistent availability of psychosocial rehabilitation modalities of all kinds found in this study points to a need for action particularly among patients not in prosthetic rehabilitation where palliative needs should also be considered.

Cost-effectiveness of guideline-based care provision for patients with diabetes-related foot ulcers: A modelled analysis using discrete event simulation

AIMS

The provision of guideline-based care for patients with diabetes-related foot ulcers (DFU) in clinical practice is suboptimal. We estimated the cost-effectiveness of higher rates of guideline-based care, compared with current practice.

METHODS

The costs and quality-adjusted life-years (QALYs) associated with current practice (30% of patients receiving guideline-based care) were compared with seven hypothetical scenarios with increasing proportion of guideline-based care (40%, 50%, 60%, 70%, 80%, 90% and 100%). Comparisons were made using discrete event simulations reflecting the natural history of DFU over a 3-year time horizon from the Australian healthcare perspective. Incremental cost-effectiveness ratios were calculated for each scenario and compared to a willingness-to-pay of AUD 28,000 per QALY. Probabilistic sensitivity analyses were conducted to incorporate joint parameter uncertainty.

RESULTS

All seven scenarios with higher rates of guideline-based care were likely cheaper and more effective than current practice. Increased proportions compared with current practice resulted in between AUD 0.28 and 1.84 million in cost savings and 11-56 additional QALYs per 1000 patients. Probabilistic sensitivity analyses indicated that the finding is robust to parameter uncertainty.

CONCLUSIONS

Higher proportions of patients receiving guideline-based care are less costly and improve patient outcomes. Strategies to increase the proportion of patients receiving guideline-based care are warranted.

Trends in diabetes-related foot disease hospitalizations and amputations in Australia, 2010 to 2019

AIM

To determine trends in the incidence of hospitalizations and amputations for diabetes-related foot disease (DFD) in Australia.

METHODS

We included 70,766 people with type 1, and 1,087,706 with type 2 diabetes from the Australian diabetes registry from 2010 to 2019, linked to hospital admissions databases. Trends in age-adjusted incidence were summarized as annual percent changes (APC).

RESULTS

In people with type 1 diabetes, total DFD hospitalizations increased from 20.8 to 30.5 per 1,000 person-years between 2010 and 2019 (APC: 5.1% (95% CI: 3.5, 6.8)), including increases for ulceration (13.3% (2.9, 24.7)), osteomyelitis (5.6% (2.7, 8.7)), peripheral arterial disease (7.7% (3.7, 11.9)), and neuropathy (8.7% (5.5, 12.0)). In people with type 2 diabetes, DFD hospitalizations changed from 18.6 to 24.8 per 1,000 person-years between 2010 and 2019 (APC: 4.5% (3.6, 5.4); 2012-2019), including increases for ulceration (8.7% (4.0, 13.7)), cellulitis (5.4% (3.7, 7.0)), osteomyelitis (6.7% (5.7, 7.7)), and neuropathy (6.9% (5.2, 8.5)). Amputations were stable in type 1, whereas in type 2, above knee amputations decreased (-6.0% (-9.1, -2.7). Adjustment for diabetes duration attenuated the magnitude of most increases, but many remained significant.

CONCLUSIONS

DFD hospitalizations increased markedly in Australia, mainly driven by ulceration and neuropathy, highlighting the importance of managing DFD to prevent hospitalizations.

Multidisciplinary extremity preservation program improves quality of life for patients with advanced limb threat

INTRODUCTION

The need for multidisciplinary care of patients with advanced limb threat is well established. We examined patient reported outcomes and health-related quality of life (HR-QoL) for those who completed a multidisciplinary extremity preservation program (EPP) at our institution.

METHODS

Patients with advanced limb threat, who had previously failed standard management at a tertiary-care center, were referred to EPP for evaluation by a multidisciplinary panel of vascular, plastic, orthopedic and podiatric surgeons, along with infectious disease, prosthetics, orthotics, imaging, palliative care, social work and wound nursing specialists. HR-QoL was quantified before and after EPP participation with the RAND-36 questionnaire. The validated RAND-36 assesses physical function, role limitations caused by physical and emotional health problems, social functioning, emotional well-being, energy, pain and general health perceptions.

RESULTS

From 2018 to 2020, 185 patients were referred to EPP. After review by the multidisciplinary panel, 120 were accepted into the program, 63 of whom completed their course of care; 9 were one-time consultations. The median number of EPP in-person care visits was 23 (13-54) per participant; 87.3% of patients received one or more surgical procedure, including operative debridement (73%), revascularization (44%), soft tissue reconstruction or transplantation (46%), as well as hyperbaric oxygen therapy (11%) during their course of treatment. 85.7% of patients achieved complete wound healing, 41.5% occurring within 6 months. Ultimately, 14.3% required a major amputation. Graduates noted improvement in all categories of the HR-QoL upon completion, including those undergoing major amputation. On adjusted multivariate regression analysis, patients with immunocompromised status were more likely to show greater improvement in their social function (OR: 10.1; P<0.044) and emotional role limitation (OR:8.1; P=0.042), while patients with larger wound volume at presentation were more likely to have greater improvement in their general health (OR: 1.1; P<0.049). Conversely, patients with a smoking history had less improvement in energy level (OR:0.4; P=0.044) and patients with dialysis-dependence had less improvement in social function (OR:0.2; P=0.034).

CONCLUSION

Coordinated, multidisciplinary extremity preservation program improves HR-QoL of patients with complex limb threat, including those who are immunocompromised with impaired social function and emotional role limitations. Further study is warranted to better characterize the generalizability of this approach, including considerations of cost-effectiveness, wound recidivism, and limiting the number of in-person visits required to achieve complete healing.

Trends in the Incidence of Hospitalization for Major Diabetes-Related Complications in People With Type 1 and Type 2 Diabetes in Australia, 2010-2019

OBJECTIVE

To determine trends in the incidence of major diabetes-related complications in Australia.

RESEARCH DESIGN AND METHODS

This study included 70,885 people with type 1 and 1,089,270 people with type 2 diabetes registered on the Australian diabetes registry followed from July 2010 to June 2019. Outcomes (hospitalization for myocardial infarction [MI], stroke, heart failure [HF], lower-extremity amputation [LEA], hypoglycemia, and hyperglycemia) were obtained via linkage to hospital admissions databases. Trends over time in the age-adjusted incidence of hospitalizations were analyzed using joinpoint regression and summarized as annual percent changes (APCs).

RESULTS

In type 1 diabetes, the incidence of all complications remained stable, except for stroke, which increased from 2010-2011 to 2018-2019 (financial years; APC: +2.5% [95% CI 0.1, 4.8]), and hyperglycemia, which increased from 2010-2011 to 2016-2017 (APC: +2.7% [1.0, 4.5]). In type 2 diabetes, the incidence of stroke remained stable, while the incidence of MI decreased from 2012-2013 to 2018-2019 (APC: -1.7% [95% CI -2.8, -0.5]), as did the incidence of HF and hypoglycemia from 2010-2011 to 2018-2019 (APCs: -0.8% [-1.5, 0.0] and -5.3% [-6.7, -3.9], respectively); the incidence of LEA and hyperglycemia increased (APCs: +3.1% [1.9, 4.4], and +7.4% [5.9, 9.0]). Most trends were consistent by sex, but differed by age; in type 2 diabetes most improvements were confined to individuals aged ≥60 years.

CONCLUSIONS

Trends in admissions for diabetes-related complications were largely stable in type 1 diabetes. In type 2 diabetes, hospitalization rates for MI, HF, and hypoglycemia fell over time, while increasing for LEA and hyperglycemia.

Podiatric care from diabetologists point of view

Scoring for the risk of Diabetic foot syndrome (DFS) should be performed regularly in each patient with diabetes mellitus (DM). Patients at risk for DFS should be followed by diabetologists, those with moderate and severe risk for the development of DFS or those with DFS in remission should be already followed by podiatrists. The aim of our study was to determine the extent of DFS risk screening procedures, dispensary care of patients at risk for DFS and treatment of patients with newly developed DFS in diabetes clinics in the Czech Republic.

METHODS

To find out the study data, we prepared in cooperation with the &#268;DS &#268;LS JEP Committee a questionnaire survey for outpatient diabetology specialists.

RESULTS

The questionnaire was completed by 57% (76/135) of diabetologists. Most of them dispensary approximately 1000- 2000 patients with DM. Their feet are checked by 98.7% of diabetologists (1.6 ± 0.8 times a year on average). Screening for the risk of DFS (13024) is performing in less than 100 patients by 74.3% of diabetologists, in 100-200 patients by 14.9% and in more than 200 patients by 10.8% of diabetologists. 77% of respondents are able to examine neuropathy, the rest send their patients to neurologists, peripheral arterial disease is evaluated by only 47.3% of diabetologists (35.3% of them use some form of instrumental examination), others (48.6%) send patients to angiologists, 4.1% of diabetologists do not examine PAD at all). Based on the assessed findings, more than half of the respondents (50.7%) perform scoring for the risk of DFS, but 1/5 of outpatient diabetologists do not know how the scoring is performed. If colleagues find a patient at a risk for DFS, they usually follow him/her by themselves (64.4%), in 24.6% of cases they send the patient immediately to podiatry or surgery (11%). If a patient with a new DFS comes at diabetology clinic, 72.6% of diabetologists are able to prescribe off-loading, 60.3% antibiotics, 47.9% local therapy. Only 52.1% of diabetologists send a patient with a new DFS to outpatient foot clinic, 39.7% to surgery, the rest of them elsewhere.

CONCLUSION

Based on the questionnaire survey results, the screening of DFS is currently severely undersized in outpatient diabetology clinics, it is sufficiently performed only by 11% of diabetologists. Only 16% of diabetologists perform some form of non-invasive diagnostic procedures detecting peripheral arterial disease, neuropathy examinations are more common. If a diabetologist meet a patient with newly developed DFS, he/she is able to prescribe off-loading or antibiotics, but only half of the diabetologists send the patient to outpatient foot clinic, probably due to a lack of them or their overload.

Establishing the national top 10 priority research questions to improve diabetes-related foot health and disease: a Delphi study of Australian stakeholders

INTRODUCTION

Diabetes-related foot disease is a large cause of the global disease burden yet receives very little research funding to address this large burden. To help address this gap, it is recommended to first identify the consensus priority research questions of relevant stakeholders, yet this has not been performed for diabetes-related foot disease. The aim of this study was to determine the national top 10 priority research questions for diabetes-related foot health and disease from relevant Australian stakeholders.

RESEARCH DESIGN AND METHODS

A modified three-round Delphi online survey design was used to seek opinions from relevant Australian stakeholders including those with diabetes or diabetes-related foot disease or their carers (consumers), health professionals, researchers and industry. Participants were recruited via multiple public invitations and invited to propose three research questions of most importance to them (Round 1), prioritize their 10 most important questions from all proposed questions (Round 2), and then rank questions in order of importance (Round 3).

RESULTS

After Round 1, a total of 226 unique questions were proposed by 210 participants (including 121 health professionals and 72 consumers). Of those participants, 95 completed Round 2 and 69 completed Round 3. The top 10 priority research questions covered a range of topics, including health economics, peripheral neuropathy, education, infection, technology, exercise, and nutrition. Consumers prioritized peripheral neuropathy and prevention-related questions. Health professionals prioritized management-related questions including Australia's First Peoples foot health, health economics and infection questions.

CONCLUSIONS

These priority research questions should guide future national research agendas, funding and projects to improve diabetes-related foot disease burdens in Australia and globally. Future research should focus on consumer priority research questions to improve the burden of diabetes-related foot disease on patients and nations. Further research should also investigate reasons for different priorities between consumers and health professionals.

The Cost Consequences of the Gold Coast Integrated Care Programme

Introduction

The Australian Gold Coast Integrated Care programme trialled a model of care targeting those with chronic and complex conditions at highest risk of hospitalisation with the goal of producing the best patient outcomes at no additional cost to the healthcare system. This paper reports the economic findings of the trial.

Methods

A pragmatic non-randomised controlled study assessed differences between patients enrolled in the programme (intervention group) and patients who received usual care (control group), in health service utilisation, including Medicare Benefits Schedule and Pharmaceutical Benefits Scheme claims, patient-reported outcome measures, including health-related quality of life, mortality risk, and cost.

Results

A total of 1,549 intervention participants were enrolled and matched on the basis of patient level data to 3,042 controls. We found no difference in quality of life between groups, but a greater decrease in capability, social support and satisfaction with care scores and higher hospital service use for the intervention group, leading to a greater cost to the healthcare system of AUD$6,400 per person per year. In addition, the per person per year cost of being in the GCIC programme was AUD$8,700 equating to total healthcare expenditures of AUD$15,100 more for the intervention group than the control group.

Conclusion

The GCIC programme did not show value for money, incurring additional costs to the health system and demonstrating no significant improvements in health-related quality of life. Because patient recruitment was gradual throughout the trial, we had only one year of complete data for analysis which may be too short a period to determine the true cost-consequences of the program.

Efficacy and safety of intramuscular administration of allogeneic adipose tissue derived and expanded mesenchymal stromal cells in diabetic patients with critical limb ischemia with no possibility of revascularization: study protocol for a randomized controlled double-blind phase II clinical trial (The NOMA Trial)

Background

Chronic lower limb ischemia develops earlier and more frequently in patients with type 2 diabetes mellitus. Diabetes remains the main cause of lower-extremity non-traumatic amputations. Current medical treatment, based on antiplatelet therapy and statins, has demonstrated deficient improvement of the disease. In recent years, research has shown that it is possible to improve tissue perfusion through therapeutic angiogenesis. Both in animal models and humans, it has been shown that cell therapy can induce therapeutic angiogenesis, making mesenchymal stromal cell-based therapy one of the most promising therapeutic alternatives. The aim of this study is to evaluate the feasibility, safety, and efficacy of cell therapy based on mesenchymal stromal cells derived from adipose tissue intramuscular administration to patients with type 2 diabetes mellitus with critical limb ischemia and without possibility of revascularization.

Methods

A multicenter, randomized double-blind, placebo-controlled trial has been designed. Ninety eligible patients will be randomly assigned at a ratio 1:1:1 to one of the following: control group (n = 30), low-cell dose treatment group (n = 30), and high-cell dose treatment group (n = 30). Treatment will be administered in a single-dose way and patients will be followed for 12 months. Primary outcome (safety) will be evaluated by measuring the rate of adverse events within the study period. Secondary outcomes (efficacy) will be measured by assessing clinical, analytical, and imaging-test parameters. Tertiary outcome (quality of life) will be evaluated with SF-12 and VascuQol-6 scales.

Discussion

Chronic lower limb ischemia has limited therapeutic options and constitutes a public health problem in both developed and underdeveloped countries. Given that the current treatment is not established in daily clinical practice, it is essential to provide evidence-based data that allow taking a step forward in its clinical development. Also, the multidisciplinary coordination exercise needed to develop this clinical trial protocol will undoubtfully be useful to conduct academic clinical trials in the field of cell therapy in the near future.

Trial registration

ClinicalTrials.govNCT04466007. Registered on January 07, 2020. All items from the World Health Organization Trial Registration Data Set are included within the body of the protocol.

ECONOMIC VALUE OF PODIATRY SERVICE IN LIMB SALVAGE ALLIANCE

INTRODUCTION

Over the last decade, multidisciplinary "toe and flow" programs have gained great popularity with proven benefits in limb salvage. Many vascular surgeons have incorporated podiatrists into their practices. The viability of this practice model requires close partnership, hospital support, and financial sustainability. We intend to examine the economic values of podiatrists in a busy safety-net hospital in the Southwest United States.

METHODS

An administrative database that captured monthly OR cases, clinic encounters, in-patient volume, and total work relative value units (wRVU) in an established limb salvage program in a tertiary referral center were examined. The practice has a diverse patient population with >30% of minority patients. During a period of three years, there was a significant change in the number of podiatrists (n=1 to 4) within the program where the clinical full-time employees for vascular surgeons remained relatively stable.

RESULTS

The limb salvage program experienced >100% of growth in total OR volumes, clinic encounters, and total wRVUs over a period of four years. A total of 35,591 patients were evaluated in a multidisciplinary limb salvage clinic and 5535 procedures were performed. The initial growth of clinic volume and operative volume (P<0.01) were attributed by the addition of vascular surgeons in year one. However, recruitment of podiatrists to the program significantly increased clinic and OR volume by an additional 60% and >40% respectively (P<0.01) in the last three years. With equal number of surgeons, podiatry contributed 40% of total wRVUs generated by the entire program in 2019. Despite that most of the foot and ankle procedures that were regularly performed by vascular surgeons were shifted to the podiatrists, vascular surgeons continued to experience an incremental increase in operative volume and >10% of increase in wRVUs.

CONCLUSION

This study shows that the value of close collaboration between podiatry and vascular in a limb salvage program extends beyond a patient's clinical outcome. A financial advantage of including podiatrist in a vascular surgery practice is clearly demonstrated.

The effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer: A randomized, double-blind, placebo-controlled trial

This study was conducted to determine the effects of curcumin intake on wound healing and metabolic status in patients with diabetic foot ulcer (DFU). The current randomized, double-blind, placebo-controlled trial was conducted among 60 patients with grade 3 DFU. Participants were randomly allocated into two groups (30 participants each group), received either 80 mg nanocurcumin daily for 12 weeks or placebo. Primary endpoints in this study were serum insulin levels and insulin resistance. Curcumin intake significantly decreased fasting plasma glucose (p = .02), insulin (p = .01), insulin resistance (p = .02), and significantly increased insulin sensitivity (p = .008) compared with the placebo. Moreover, curcumin intake led to a significant reduction in total- (p < .001), LDL-cholesterol (p < .001), and a significant increase in total antioxidant capacity (TAC) (p < .001) and total glutathione (GSH) (p = .01) compared with the placebo. However, there was no significant improvement in wound healing parameters. Overall, our study demonstrated that nanocurcumin intake in patients with DFU resulted in a significant improvement of glycemic control, total- and LDL-cholesterol, TAC, and GSH but did not affect the indicators of ulcer size.

Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis

Multidisciplinary team (MDT) approach has been shown to reduce diabetic foot ulcerations (DFUs) and lower extremity amputations (LEAs), but there is heterogeneity between team members and interventions. Podiatrists have been suggested as “gatekeepers” for the prevention and management of DFUs. The purpose of our study is to review the effect of podiatric interventions in MDTs on DFUs and LEAs. We conducted a systematic review of available literature. Data’s heterogeneity about DFU outcomes made it impossible for us to include it in a meta-analysis, but we identified 12 studies fulfilling inclusion criteria that allowed for them to be included for LEA outcomes. With the exception of one study, all reported favourable outcomes for MDTs that include podiatry. We found statistical significance in favour of an MDT approach including podiatrists for our primary outcome (total LEAs (RR: 0.69, 95% CI 0.54–0.89, I² = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23–0.90, I² = 67%, P < 0.02). Our systematic review, with a standard search strategy, is the first to specifically address the relevant role of podiatrists and their interventions in an MDT approach for DFU management. Our observations support the literature that MDTs including podiatrists have a positive effect on patient outcomes but there is insufficient evidence that MDTs with podiatry management can reduce the risk of LEAs. Our study highlights the necessity for intervention descriptions and role definition in team approach in daily practice and in published literature.