Diabetic foot in primary and tertiary (DEFINITE) Care: A health services innovation in coordination of diabetic foot ulcer (DFU) Care within a healthcare cluster - 18-month results from an observational population health cohort study

Cost-effectiveness of ON101 with general wound care for diabetic foot ulcers among patients with type 2 diabetes in Singapore: Analysis of a multi-ethnic country in Asia

AIMS

Diabetic foot ulcers (DFUs) impose a vast health and economic burden on individuals and healthcare systems globally. We assessed the cost-effectiveness of adding ON101, a novel treatment for accelerating wound healing, to general wound care (GWC) versus GWC alone for DFUs in Singapore, a multi-ethnic country with increasing DFU prevalence in a growing type 2 diabetes population.

MATERIALS AND METHODS

A Markov model was utilized to estimate the healthcare costs and quality-adjusted life years (QALYs) over 5 years from a healthcare sector perspective. Model inputs were mainly derived from the Singapore Wound Registry and published literature. The primary outcome was the incremental cost-effectiveness ratio (ICER). Subgroup analyses stratified by clinically important DFU conditions and scenario analyses were conducted to confirm the study's robustness.

RESULTS

Compared to GWC alone, adding ON101 yielded greater QALY gained (i.e., 0.15) and lower healthcare costs (i.e., -US$16237) for patients with DFUs. Remarkable cost-savings from the use of ON101 with GWC were observed for patients with complex DFUs, namely ICERs of -US$161 963, -US$181 726 and -US$199 130 per QALY gained for cases with HbA1c ≥ 9%, ulcer duration >6 months and ulcer size >5 cm2, respectively. Scenario analysis comparing ON101 with GWC to negative pressure wound therapy with GWC yielded an ICER of -US$677 243 per QALY gained.

CONCLUSIONS

Combining ON101 with GWC versus GWC alone was highly cost-effective for DFUs in Singapore. Also, the economic results for complex DFU cases underscore the value of ON101 in addressing DFU treatment challenges for managing complex cases, offering cost-savings alongside clinical benefits.

Diabetic foot in primary and tertiary (DEFINITE) care: An efficacious, synergistic and cost-effective multidisciplinary team model for diabetic foot care in Singapore

Diabetic foot ulcers (DFUs) and lower extremity amputations (LEAs) threaten survival and quality of life (QoL) of patients, contributing to healthcare and economic burden. Guidelines advocate for a multidisciplinary team (MDT) approach, but limited literature exists on cost-effectiveness and collaboration with primary care. We present the outcomes of the Diabetic Foot in Primary and Tertiary (DEFINITE) Care program, an MDT initiative in Singapore across primary and tertiary care. Patients with DFU from June 2020 to 2022 were enrolled. Clinical outcomes encompassed one-year minor and major LEAs, mortality and LEA-free survival rates. Healthcare utilization outcomes included number of admissions, length of stay, and primary care and hospital visits. QoL and Patient Reported Outcome Measures (PROMs) were respectively assessed using the EuroQol Five-Dimensional Questionnaire and Diabetic Foot Ulcer Scale-Short Form. Results from DEFINITE were propensity-score matched against a retrospective cohort. Cost-effectiveness analysis was performed using Markov simulation. Subgroup analyses focused on at-risk populations, including patients without access to MDT clinics or podiatry, appointment defaulters, octogenarians, patients with end-stage renal failure and different primary care locations. Total of 2,798 patients, with a mean age of 65.7 years and majority males (61.4%), were included for analysis. DEFINITE Care patients had higher minor LEA and improved LEA-free survival rates, fewer and shorter hospital admissions, and enhanced QoL and PROMs. DEFINITE Care demonstrated greater cost-effectiveness when compared to traditional care. Outcomes varied among subgroups. DEFINITE Care is an efficacious and cost-effective MDT model which fosters collaboration between primary and tertiary care for diabetic limb salvage.

Rapid Access From Primary Care to a Multidisciplinary Clinic at Tertiary Care Improves Clinical Outcomes for Patients With Diabetic Foot Ulcers: Results From Diabetic Foot in Primary and Tertiary (DEFINITE) Care's Lower Extremity Amputation Prevention Program (LEAPP) Clinic

Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional, multidisciplinary team (MDT) program for patients with diabetic foot ulcers (DFU) within a healthcare cluster in Singapore. This is one of our subgroup analyses within DEFINITE Care, assessing clinical outcomes of lower extremity amputation prevention program (LEAPP), a multidisciplinary diabetic foot clinic, and non-LEAPP patients within the program. From June 2020 to June 2022, 2798 patients within the DEFINITE cohort completed a minimum of 12-month follow up. Of these patients, 20.6% were managed by LEAPP, whereas 79.4% were non-LEAPP patients. Patients in the LEAPP cohort were older with co-existing metabolic conditions and complications of diabetes. Using non-LEAPP cohort as the reference group and after adjusting for age, gender, ethnicity, comorbidities, and medications, there was a significantly lower risk of death (odds ratio [OR] 0.60, P = .001) and composite major lower extremity amputation (LEA) or death (OR 0.66, P = .002) among LEAPP patients at 1 year with longer mean days from enrollment to minor LEA, major LEA, and death. The adjusted 1-year healthcare utilization outcomes for LEAPP patients demonstrated an increase in inpatient admissions, primary care polyclinic visits, hospital specialist outpatient clinic (SOC) visits and elective day surgery procedures. Despite the increased in inpatients admissions, cumulative hospital length of stay in LEAPP patients were lower. This subgroup analysis has demonstrated that the MDT approach to caring for patients with DFU in tertiary centers not only improves mortality by 40%, but also delayed the incidence of minor LEA, major LEA, and death.

Clinical Characteristics of Inpatients with Diabetic Foot Ulcer Admitted with Non-Ulcer Complaints: A Retrospective Study

Background

Diabetic foot ulcer (DFU) inpatients admitted with non-ulcer complaints constitute a neglected group that might suffer from more non-standard treatments. This study intends to describe their clinical characteristics, and clarify the problems existing in the DFU management process.

Methods

In this retrospective study, admission complaints were determined by combining the final diagnosis and clinical documentation, and were categorized as: ulcer-related or non-ulcer complaints.

Results

A total of 264 DFU inpatients were included in the final analysis, of which, 80 (30.3%) were admitted with non-ulcer complaints. A total of 82.5% of the DFU inpatients with non-ulcer complaints were admitted to departments without DF specialists. IWGDF/IDSA grade, cerebrovascular diseases, chronic kidney disease, infection in other parts, glycosylated hemoglobin A1c and the source of hospitalization expenses were the independent influencing factors for admission with non-ulcer complaints (all P < 0.05). Before admission, only 11.3% of the patients with non-ulcer complaints had ever been treated by a DF specialist and/or in a clinical setting with DF specialists. After admission, 25.0% of the DFU inpatients with non-ulcer complaints did not receive any local wound care, and only 7.6% of the patients admitted to the departments without DF specialists obtained a referral.

Conclusion

Approximately one-third of inpatients with DFU are admitted with non-ulcer complaints and most of them are admitted to departments without DF specialists. Inpatients with non-ulcer complaints have milder wounds but more severe and greater comorbidities and worse organ function. These patients do not receive standardized management for DFU either before or after admission. Targeted measures are needed to improve this situation.

Outcome evaluation and cost-effectiveness analysis for an integrated multidisciplinary diabetic limb salvage program: a combined observational and simulation study

INTRODUCTION

To compare the clinical outcomes and healthcare utilization of patients enrolled in the multidisciplinary Diabetic Foot in Primary and Tertiary (DEFINITE) Care program with a matched historical cohort and estimate the program's long-term cost-effectiveness using simulation.

RESEARCH DESIGN AND METHODS

This study consisted of two components: a 1-year observational outcome evaluation and a long-term simulation-based cost-effectiveness analysis (CEA). We conducted an observational study to analyze 2798 patients with diabetic foot ulcers (DFUs) enrolled in the program between June 2020 and June 2021 (DEFINITE Care group) and 5462 patients with DFUs from June 2016 to December 2017 as historical controls. One-to-one propensity score matching (PSM) with replacement was conducted to estimate the treatment effect of the program on clinical outcomes and healthcare utilization over 1 year. For the simulation component, a long-term CEA was performed using a Markov state transition model on a simulated cohort of 10 000 patients with DFUs over a 20-year period, assessing transitions between health states, including minor and major amputations and death. The incremental cost-effectiveness ratio (ICER) was calculated for the DEFINITE Care program relative to routine care.

RESULTS

The estimation of average treatment effects based on propensity scores showed that the DEFINITE Care group exhibited a 9% lower mortality, 5% higher lower extremity amputation (LEA)-free survival, yet a 5% higher minor LEA rate compared with the matched historical controls. Additionally, they experienced fewer inpatient admissions (0.98 fewer episodes) and shorter hospital stays (5.5 fewer days) within 1 year (p-value <0.001). The ICER was US$22 707 (SE: 430) per quality-adjusted life year gained, indicating long-term cost-effectiveness. Probabilistic sensitivity analysis supported these findings.

CONCLUSIONS

The integrated multidisciplinary DEFINITE Care program improved LEA-free survival, reduced inpatient admissions and length of stay within 1 year and demonstrated long-term cost-effectiveness managing DFUs.

Investigating Nonadherence in an Integrated Diabetic Limb Salvage Programme: Reasons, Associated Factors, and Impacts on Care Outcomes

Adherence to treatment plans is crucial for patients with diabetic foot ulcers (DFUs) to achieve positive outcomes. With limited understanding of nonadherence and its impacts on care outcomes, this study aimed to explore the reasons and factors associated with nonadherence in an integrated diabetic limb salvage (DLS) programme and evaluate its effects on care outcomes. This study included 2798 DFU patients who were enrolled in an integrated DLS programme across multiple institutions in central and northern Singapore from 2020 to 2021. Reasons for nonadherence were obtained via telephone interviews. Factors associated with nonadherence were identified using multiple logistic regression. Differences in one-year outcomes, including minor and major lower extremity amputation (LEA), mortality, LEA-free survival, and healthcare utilisation between adherent and nonadherent patients, were examined based on a significance level of P < .05. Nonadherence was observed in 40.2% of patients, with higher rates among younger patients, Malays and Indians, and those with higher HbA1c levels. Patient-related factors were the most commonly reported reasons for missed appointments (50.4%). Compared to adherent patients, nonadherent patients exhibited a relatively higher minor LEA rate (13.0% vs 10.2%, OR = 1.18, 95% CI: 0.93, 1.51), lower mortality rate (8.6% vs18.1%, OR = 0.50, 95% CI: 0.39, 0.65), higher overall LEA-free survival (76.4% vs 71.1%, OR = 1.27, 95% CI: 1.06, 1.53), and more hospitalisations (IRR = 1.22, 95% CI: 1.11, 1.33) and emergency visits (IRR = 1.27, 95% CI: 1.16, 1.39). While nonadherent patients showed relatively higher minor LEA rates and more healthcare utilisation, they also exhibited lower mortality and higher LEA-free survival. This suggests that nonadherence in this population may be associated with complex patient characteristics and behaviours that warrant further investigation to tailor interventions effectively.

Cost-effectiveness and clinical outcomes of artificial intelligence-enhanced screening for diabetic foot ulcers: A simulation study

Diabetic foot ulcers (DFUs) are a serious complication of diabetes mellitus, with a lifetime risk estimated to be between 19% and 34%.1 Without timely prevention and management, DFUs can lead to lower extremity amputations (LEAs) and premature death.2,3 DFUs also impose significant healthcare and societal costs, especially in Southeast Asia.4,5 Regular foot screenings are essential for preventing these complications.

Foot self-care behaviour in primary care patients with diabetic foot ulcers: Structural equation modelling of psychological predictors

Diabetic foot ulcers (DFUs) are one of the most prevalent and costly diabetes complications, associated with diminished quality of life and poor prognosis. Management of DFUs relies heavily on patients' foot self-care behaviour. This study aims to explore psychological determinants of this important behaviour among primary care patients. A total of 186 patients with active DFUs self-reported their illness perception, diabetes distress, self-efficacy, and foot self-care behaviour. Structural equation modelling was performed to examine interrelationships among measured variables. The final model demonstrated satisfactory fit, CFI = 0.933, TLI = 0.913, RMSEA = 0.050, SRMR = 0.073, χ2(95) = 132.256 (p = 0.004), and explained 51.1% of the variance of foot self-care. Illness threat perceptions (i.e., consequence, timeline, identity, concern, and emotion) had a direct positive effect on foot self-care behaviours, but also indirectly decreased foot self-care through increasing diabetes distress. Control perceptions (i.e., personal control, treatment control, and coherence) were not directly associated with foot self-care behaviours, but indirectly improved foot self-care by reducing diabetes distress and increasing foot care confidence. These findings suggest illness perceptions, diabetes distress, and self-care confidence as modifiable predictors to be targeted in self-management interventions for patients with DFUs.

Can acupuncture increase microcirculation in peripheral artery disease and diabetic foot syndrome? - a pilot study

Background

Globally, diabetes mellitus (DM) and peripheral artery disease (PAD) have an increasing incidence and a high prevalence and are both associated with high morbidity and complication rates, e.g., as chronic non-healing peripheral ulcers. Impaired macro- and microcirculation and peripheral neuropathy lead to an increased risk of foot ulcers and infections. These complications are difficult to treat, have a high risk of becoming chronic and often lead to lower limb amputation. The aim of this planned study was to investigate the potential effects of acupuncture on improving microcirculation in patients with Diabetic Foot Syndrome (DFS) and PAD.

Materials and methods

In 18 patients with chronic non-healing peripheral ulcers and diagnosed DM or PAD, data on 8 microcirculatory parameters were collected simultaneously on intact skin close to the wound margin. Microcirculation was assessed using an O2C device combining laser Doppler shift and white light spectroscopy (LEA Medizintechnik GmbH, Giessen, Germany). Unilateral and bilateral acupuncture was performed on the connecting line between acupuncture points Stomach 14 and Stomach 15.

Results

After unilateral acupuncture (ipsilateral to the wound side), a statistically significant improvement in 7 out of 8 microcirculatory parameters was demonstrated compared to baseline measurements before acupuncture. After bilateral acupuncture, there was an additional improvement and statistical significance in all parameters in both DFS and PAD patients.

Discussion

These results show an improvement in the microcirculation and peripheral blood flow at the edges of the wound. As impaired micro- and macrocirculation is considered to be a critical prognostic factor for the healing of a peripheral lesion, the intervention could have a positive impact on the healing of (chronic) peripheral wounds.

Empowering Foot Care Literacy Among People Living With Diabetes and Their Carers With an mHealth App: Protocol for a Feasibility Study

BACKGROUND

Diabetic foot ulcers (DFUs) cause significant morbidity affecting 19% to 34% of people living with diabetes mellitus. DFUs not only impair quality of life but may also result in limb loss and mortality. Patient education has been advocated to raise awareness of proper foot self-care and the necessity of seeking assistance when a foot wound occurs. Modern technologies, including mobile health (mHealth) interventions such as health apps, bring the potential for more cost-effective and scalable interventions.

OBJECTIVE

This study aims to examine the feasibility and usability of a newly developed mHealth app called Well Feet, which is a diabetes and foot care education app for individuals at risk of developing DFU.

METHODS

Well Feet was developed using an evidence-based and expert panel cocreation approach to deliver educational content available in 3 languages (ie, English, Chinese, and Malay) via animation videos and a range of additional features, including adaptive learning. A nonrandomized, single-arm feasibility study using a mixed methods approach with a series of validated questionnaires and focus group discussions will be conducted. In total, 40 patients and carers will be recruited from a tertiary hospital diabetes clinic to receive a 1-month mHealth intervention. The primary outcomes are the usability of the app and a qualitative perspective on user experience. Secondary outcomes include changes in foot care knowledge, self-management behaviors, and quality of life.

RESULTS

Patient recruitment began in July 2023, and the intervention and data collection will be completed by the end of September 2023. This study has been approved by National Healthcare Group Domain Specific Review Board (2022/00614) on February 10, 2023. The expected results will be published in spring 2024.

CONCLUSIONS

Through this feasibility study, the Well Feet DFU education app will undergo a comprehensive quantitative and qualitative evaluation of its usability and acceptance for future improvement in its design. With local contextualization, cultural adaptation, and its multilingual functionality, the app addresses a critical aspect of DFU health education and self-management in a multiethnic population. Findings from this study will refine and enhance the features of the app based on user feedback and shape the procedural framework for a subsequent randomized controlled trial to assess the effectiveness of Well Feet.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05564728; https://clinicaltrials.gov/study/NCT05564728.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52036.

Cerium oxide nanoparticles in diabetic foot ulcer management: Advances, limitations, and future directions

Diabetic foot ulcer (DFU) is one of the most serious complications of diabetes, potentially resulting in wound infection and amputation under severe circumstances. Oxidative stress and dysbiosis are the primary factors that delay wound healing, posing challenges to effective treatment. Unfortunately, conventional approaches in these aspects have proven satisfactory in achieving curative outcomes. Recent research has increasingly focused on using nanoparticles, leveraging their potential in wound dressing and medication delivery. Their unique physical properties further enhance their therapeutic effectiveness. Among these nanoparticles, cerium oxide nanoparticles (CONPs) have garnered attention due to their notable beneficial effects on oxidative stress and microbial abundance, thus representing a promising therapeutic avenue for DFU. This review comprehensively assesses recent studies on CONPs in treating DFU. Furthermore, we elaborate on the wound healing process, ceria synthesis, and incorporating CONPs with other materials. Crucially, a thorough evaluation of CONPs' toxicity as a novel metallic nanomaterial for therapeutic use must precede their formal clinical application. Additionally, we identify the current challenges CONPs encounter and propose future directions for their development.

The Metabolic Characteristics of Patients at the Risk for Diabetic Foot Ulcer: A Comparative Study of Diabetic Patients with and without Diabetic Foot

Backgrounds and Objective

Diabetic foot is a relatively severe complication in patients with type 2 diabetes (T2D), with peripheral neuropathy and angiopathy frequently serving as risk factors. However, it is unknown how the other major systemic metabolic factors impacted the profile of these patients, besides glucose management. Thus, we investigated the distinct characteristics of patients with diabetic foot ulcers and their relationships with angiopathy.

Materials and Methods

We obtained the laboratory data of 334 diabetic patients at Shanghai Pudong Hospital from 2020 to 2023. The comparisons were performed between the groups with or without diabetic foot, including glucose metabolism, lipids profile, liver and kidney function, thyroid function, and serum iron. The association between metabolic factors and lower extremity computed tomography angiography (CTA) was analyzed.

Results

We found significant disparities between groups in relation to age, serum protein content, liver transferase, serum creatinine, estimated glomerular filtration rate (eGFR), serum uric acid (UA), small dense low-density lipoprotein (sdLDL), lipoprotein A (LP(a)), apolipoprotein A1 (APOA1), thyroid function, serum iron, and hemoglobin (Hb) (p<0.05). The Spearman correlational analyses showed that the severity of CTA, categorized by the unilateral or bilateral plaque or occlusion, was positively significantly correlated with UA (r=0.499), triglyceride (TG) (r=0.751), whereas inversely correlated with serum albumin (r=-0.510), alanine aminotransferase (r=-0.523), direct bilirubin (DBil) (r=-0.494), total bilirubin (TBil) (r=-0.550), Hb (r=-0.646).

Conclusion

This cross-section investigation showed that compared to T2D only, the patients with diabetic foot ulcer (DFU) might display similar glucose metabolic control context but adverse metabolic profiles, and this profile is associated with macrovascular angiopathy characteristics and their severity.