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Manji A, Basiri R, Harton F, Rommens K, Manji K. Effectiveness of a Multidisciplinary Limb Preservation Program in Reducing Regional Hospitalization Rates for Patients With Diabetes-Related Foot Complications. INT J LOW EXTR WOUND 2024:15347346241238458. [PMID: 38504634 DOI: 10.1177/15347346241238458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
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.
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Affiliation(s)
- Ali Manji
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Reza Basiri
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Institute of Biomedical Engineering, University of Toronto, Ontario, Canada
| | - Francois Harton
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kenton Rommens
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karim Manji
- Zivot Limb Preservation Centre, Alberta Health Services, Calgary, Alberta, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Basiri R, Manji K, LeLievre PM, Toole J, Kim F, Khan SS, Popovic MR. Protocol for metadata and image collection at diabetic foot ulcer clinics: enabling research in wound analytics and deep learning. Biomed Eng Online 2024; 23:12. [PMID: 38287324 PMCID: PMC10826077 DOI: 10.1186/s12938-024-01210-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 01/22/2024] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND The escalating impact of diabetes and its complications, including diabetic foot ulcers (DFUs), presents global challenges in quality of life, economics, and resources, affecting around half a billion people. DFU healing is hindered by hyperglycemia-related issues and diverse diabetes-related physiological changes, necessitating ongoing personalized care. Artificial intelligence and clinical research strive to address these challenges by facilitating early detection and efficient treatments despite resource constraints. This study establishes a standardized framework for DFU data collection, introducing a dedicated case report form, a comprehensive dataset named Zivot with patient population clinical feature breakdowns and a baseline for DFU detection using this dataset and a UNet architecture. RESULTS Following this protocol, we created the Zivot dataset consisting of 269 patients with active DFUs, and about 3700 RGB images and corresponding thermal and depth maps for the DFUs. The effectiveness of collecting a consistent and clean dataset was demonstrated using a bounding box prediction deep learning network that was constructed with EfficientNet as the feature extractor and UNet architecture. The network was trained on the Zivot dataset, and the evaluation metrics showed promising values of 0.79 and 0.86 for F1-score and mAP segmentation metrics. CONCLUSIONS This work and the Zivot database offer a foundation for further exploration of holistic and multimodal approaches to DFU research.
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Affiliation(s)
- Reza Basiri
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada.
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada.
| | - Karim Manji
- Zivot Limb Preservation Centre, Peter Lougheed Centre, Calgary, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Philip M LeLievre
- Zivot Limb Preservation Centre, Peter Lougheed Centre, Calgary, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - John Toole
- Zivot Limb Preservation Centre, Peter Lougheed Centre, Calgary, Canada
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Faith Kim
- Faculty of Kinesiology, University of Calgary, Calgary, Canada
| | - Shehroz S Khan
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
| | - Milos R Popovic
- Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
- KITE Research Institute, Toronto Rehabilitation Institute - University Health Network, Toronto, Canada
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Lew E, Collins NP, Marek J, Schenck RC, Richter D, Gallegos R, Dunlap L, Murdock R. The Impact of Implementing a Diabetic Limb-Preservation Program on Amputation Outcomes at an Academic Institution in a Majority-Minority State. INT J LOW EXTR WOUND 2023:15347346231169879. [PMID: 37157806 DOI: 10.1177/15347346231169879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background. Diabetic foot osteomyelitis may precede major limb amputations and lengthy hospital admission. These complications impact patients' morbidity and mortality. Healthcare institutions with dedicated limb-preservation teams realize reduced amputation rates and improved quality of care. This study evaluates the outcomes following the implementation of a rigorous diabetic limb-preservation program at an academic institution. Methods. Patients with diabetes admitted for osteomyelitis occurring below the knee were identified by ICD-10 codes and included for retrospective review. The number and type of amputations, bone biopsies, revascularizations, and hospital length of stay (LOS) were evaluated. Outcomes were compared using the high-low (Hi-Lo) amputation ratio for the 24 months preceding and the 24 months after the integration of a diabetic limb-preservation service. Results. The authors identified and included 337 patients admitted for diabetic foot osteomyelitis. In the 24-month period prior to program implementation, 140 patients were evaluated. In the 24-month period after program implementation, 197 patients were evaluated. The overall amputation rate decreased from 67.1% (n = 94) to 59.9% (n = 118) (P = .214). Major limb amputation rates significantly decreased from 32.9% (n = 46) to 12.7% (n = 25) (P = .001). Minor amputation rates significantly increased from 34.2% (n = 48) to 47.2% (n = 93) (P = .024). The Hi-Lo amputation ratio decreased from 0.96 to 0.27 (P < .001). The rate of obtaining bone biopsies increased from 32.1% (n = 45) to 72.1% (P < .001). The rate of revascularization increased from 10.7% (n = 15) to 15.2% (n = 30) (P = .299). Average hospital LOS decreased significantly from 11.6 days to 9.8 days (P = .044). Conclusion. After the implementation of a limb-preservation team, there was a precipitous drop in major limb amputations in favor of minor amputations. The average hospital LOS decreased. These findings demonstrated improved clinical care and outcomes in patients with lower extremity osteomyelitis and reinforce the importance of a diabetic foot-preservation service within healthcare institutions.
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Affiliation(s)
- Eric Lew
- Department of Orthopaedics and Rehabilitation, Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Nathaniel Perryman Collins
- Department of Internal Medicine, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - John Marek
- Department of Surgery, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Robert C Schenck
- Department of Orthopaedics and Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Dustin Richter
- Department of Orthopaedics and Rehabilitation, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Regina Gallegos
- Rehabilitation Services Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Leslie Dunlap
- Department of Orthopaedics and Rehabilitation, Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Richard Murdock
- Rehabilitation Services Center for Healing in the Lower Extremity, The University of New Mexico Health Sciences Center, Albuquerque, NM, USA
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Ezzatvar Y, García-Hermoso A. Global estimates of diabetes-related amputations incidence in 2010-2020: A systematic review and meta-analysis. Diabetes Res Clin Pract 2023; 195:110194. [PMID: 36464091 DOI: 10.1016/j.diabres.2022.110194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/31/2022] [Accepted: 11/28/2022] [Indexed: 12/02/2022]
Abstract
AIMS/HYPOTHESIS This study sought to provide up-to-date pooled global estimates of diabetes-related amputation incidence from 2010 to 2020. METHODS Embase and Medline databases were searched for studies reporting the incidence rate (IR) of diabetes-related amputations from 2010 to 2020. IR estimates of diabetes-related amputations with associated 95% confidence interval (CI) per 100,000 individuals with diabetes were calculated. RESULTS 23 studies were included, reporting 505,390 diabetes-related lower extremity amputations. IR of minor amputations was 139.97 (95% CI 88.18-222.16) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 148.59 (95% CI 65.00-339.68) and in type 2 diabetes was 75.53 (95% CI 29.94-190.54). IR of major amputations was 94.82 (95% CI 56.62-158.80) per 100,000 individuals with diabetes, among patients with type 1 diabetes was 100.76 (95% CI 53.71-189.01) and among type 2 diabetes was 40.58 (95% CI 11.03-149.28). There were 83.84 annual amputations (95% CI 41.67-168.65) per 100,000 women with diabetes and 178.04 (95% CI 81.16-390.55) per 100,000 men. CONCLUSIONS Globally, annual incidence of diabetes-related amputations from 2010 to 2020 has shown to disproportionately affect men and individuals with type 1 diabetes mellitus, although its incidence is not uniform across countries.
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Affiliation(s)
- Yasmin Ezzatvar
- Department of Nursing, Universitat de València, Valencia, Spain.
| | - Antonio García-Hermoso
- Navarrabiomed, Hospital Universitario de Navarra (HUN), Universidad Pública de Navarra (UPNA), IdiSNA, Pamplona, Spain
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Ponkilainen VT, Vuorlaakso M, Kaartinen I, Kiiski J, Saarinen E, Huttunen TT, Paloneva J, Mattila VM. The Development of Lower Limb Amputations in Finland from 1997 to 2018: A Nationwide Retrospective Registry Study. Eur J Vasc Endovasc Surg 2021; 63:138-146. [PMID: 34774371 DOI: 10.1016/j.ejvs.2021.09.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/25/2021] [Accepted: 09/19/2021] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To investigate the rates of transfemoral, transtibial foot and toe amputations, and lower limb revascularisations in Finland between 1997 and 2018. METHODS Retrospective observational cohort study. Data from the Finnish National Hospital Discharge Register for the period 1997 - 2018 were used. The study population covered all patients 20 years and older who underwent lower limb revascularisations or amputations in private and public hospitals during the study period. All (outpatient and inpatient) amputations and revascularisations were included. The age adjusted incidence rates were based on the annual mid populations, which were obtained from the Official Statistics of Finland. Continuous variables were presented as median with interquartile range (IQR) or as mean with standard deviation. The 95% confidence intervals (CI) for the incidence rates were calculated using the Poisson exact method. All changes in incidence were calculated as relative change (%). RESULTS A total of 75 230 patients underwent 149 492 lower limb revascularisations and amputations between 1997 and 2018 in Finland. The median (IQR) age of the patients was 73 (65, 80) and 60% of the patients were men. The incidence of all endovascular lower limb revascularisations increased by 159% while the incidence of lower limb amputations increased by 25%. The most notable increase occurred in toe (84%) and foot (107%) amputations, while the incidence of transfemoral amputations remained steady and transtibial amputations decreased by 53%. The first minor-major amputation ratio (CI) increased from 1.13 (1.03 - 1.24) to 1.49 (1.36 to 1.62) during the study period. CONCLUSION The findings of this nationwide cohort study suggest that the incidence of both lower limb revascularisations and amputations is increasing. More specifically, revascularisations are more often performed endovascularly, and the incidence of transtibial amputations is declining, whereas the incidence of toe and foot amputations is increasing.
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Affiliation(s)
| | - Miska Vuorlaakso
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Surgery, Kanta-Häme Central Hospital, Hämeenlinna, Finland
| | - Ilkka Kaartinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Juha Kiiski
- Department of Plastic Surgery, Tampere University Hospital, Tampere, Finland
| | - Eva Saarinen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Centre for Vascular Surgery and Interventional Radiology, Tampere University Hospital, Tampere, Finland
| | - Tuomas T Huttunen
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Tampere Heart Hospital, Tampere University Hospital, Tampere, Finland; The Division of Orthopaedics and Biotechnology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Juha Paloneva
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Faculty of Health Sciences, University of Eastern Finland, Kuopio, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Orthopaedics and Traumatology, Tampere University Hospital, Tampere, Finland; COXA Hospital for Joint Replacement, Tampere, Finland
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Essien SK, Linassi AG, Farnan C, Collins K, Zucker-Levin A. The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006-2019: a population-based study. BMC Surg 2021; 21:385. [PMID: 34717614 PMCID: PMC8557533 DOI: 10.1186/s12893-021-01381-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 10/19/2021] [Indexed: 11/10/2022] Open
Abstract
Background Understanding trends in limb amputation (LA) can provide insight into the prevention and optimization of health care delivery. We examine the influence of primary (first report) and subsequent (multiple reports) limb amputation on the overall (all reports) rate of limb amputation in Saskatchewan considering amputation level. Methods Hospital discharged data associated with LA from 2006 to 2019 and population estimates in Saskatchewan were used. LA cases were grouped based on overall, primary, and subsequent LA and further divided by level into major (through/above the ankle/wrist) and minor (below the ankle/wrist). Incidence rates were calculated using LA cases as the numerator and resident population as the denominator. Joinpoint and negative binomial were used to analyze the trends. In addition, the top three amputation predisposing factors (APF) were described by LA groups. Results The rate of overall LA and primary LA remained stable (AAPC − 0.9 [95% CI − 3.9 to 2.3]) and (AAPC −1.9 [95% CI −4.2 to 0.4]) respectively, while the rate of subsequent LA increased 3.2% (AAPC 3.2 [95% CI 3.1 to 9.9]) over the 14-year study period. The rate of overall major LA declined 4.6% (AAPC − 4.6 [95% CI −7.3 to −1.7]) and was largely driven by the 5.9% decline in the rate of primary major LA (AAPC − 5.9 [95% CI − 11.3 to –0.2]). Subsequent major LA remained stable over the study period (AAPC −0.4 [95% CI − 6.8 to 6.5]). In contrast, the overall rate of minor LA increased 2.0% (AAPC 2.0 [95% CI 1.0 to 2.9]) over the study period which was largely driven by a 9.6% increase in the rate of subsequent minor LA (AAPC 9.6 [95% CI 4.9 to 14.4]). Primary minor LA rates remained stable over the study period (AAPC 0.6 [95% CI − 0.2 to 1.5]). The study cohorts were 1.3-fold greater risk of minor LA than major LA. Diabetes mellitus (DM) was the leading APF representing 72.8% of the cohort followed by peripheral vascular disease (PVD) and trauma with 17.1 and 10.1% respectively. Most (86.7%) of subsequent LA were performed on people with DM. Conclusions Overall LA rates remained stable over the study period with declining rates of major LA countered by rising rates of minor LA. Minor LA exceeded major LA with the largest rate increase identified in subsequent minor LA. Diabetes was the greatest APF for all LA groups. This rising rate of more frequent and repeated minor LA may reflect changing intervention strategies implemented to maintain limb function. The importance of long-term surveillance to understand rates of major and minor LA considering primary and subsequent intervention is an important step to evaluate and initiate prevention and limb loss management programs.
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Affiliation(s)
- Samuel Kwaku Essien
- School of Rehabilitation Science, University of Saskatchewan, Health Science Building, E-Wing, Suite 3400, 3rd Floor, 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada.
| | - A Gary Linassi
- Department of Physical Medicine and Rehabilitation, University of Saskatchewan, Saskatoon, SK, S7K 0M7, Canada
| | - Colin Farnan
- Patient-Oriented Team (PORT), 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada
| | - Kassondra Collins
- School of Rehabilitation Science, University of Saskatchewan, Health Science Building, E-Wing, Suite 3400, 3rd Floor, 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada
| | - Audrey Zucker-Levin
- School of Rehabilitation Science, University of Saskatchewan, Health Science Building, E-Wing, Suite 3400, 3rd Floor, 104 Clinic Place, Saskatoon, SK, S7N 2Z4, Canada
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Brousseau-Foley M, Blanchette V. Multidisciplinary Management of Diabetic Foot Ulcers in Primary Cares in Quebec: Can We Do Better? J Multidiscip Healthc 2020; 13:381-385. [PMID: 32368075 PMCID: PMC7173947 DOI: 10.2147/jmdh.s251236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/27/2020] [Indexed: 11/23/2022] Open
Abstract
A growing body of evidence supports the presence of integrated foot care based on multidisciplinary and interdisciplinary teams in the management and prevention of diabetic foot ulcer (DFU) worldwide. This model of care is however rare in the clinical setting in Quebec, Canada. Many best practice gaps are identified as well as probable causal hypothesis are listed in this commentary. We support our opinions with a pilot audit conducted as part of a continuous quality improvement process in managing patients with DFU in our area and on Canadian facts and data. Our pilot study (n = 27 hospitalized patients) included a typical DFU population with neuropathy, peripheral arterial disease and previous amputation. It highlights underachievement of best practice recommendations implementation such as multidisciplinary DFU management and offloading interventions in our establishment. Due the high morbidity and mortality associated with DFU patients, four died during the studied hospitalization episode. Several barriers were encountered in the pilot audit justifying that no robust conclusion can be raised. However, our observations are concerning. Even though data accessibility was limited, our observations are sadly coherent with what is found in the literature. Economic data of what this means for our health system is put forward in the overall discussion. We are preoccupied by the trends outlined by some facts and observations, and this commentary was written with this in mind. In the face of the diabetes crisis that is arising, a plea is made to reassess care pathway for this vulnerable population as we emphasize the importance of teamwork in managing DFU.
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Affiliation(s)
- Magali Brousseau-Foley
- University Family Medicine Group, Faculty of Medicine Affiliated to Université De Montréal, Centre intégré universitaire de santé et de services sociaux de la Mauricie-et-du-Centre-du-Québec (CIUSSS-MCQ), Trois-Rivières, Québec, Canada
- Department of Sciences of Physical Activity and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
| | - Virginie Blanchette
- Department of Sciences of Physical Activity and Podiatric Medicine, Université du Québec à Trois-Rivières, Trois-Rivières, Québec, Canada
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Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis. J Foot Ankle Res 2020; 13:15. [PMID: 32192509 PMCID: PMC7083052 DOI: 10.1186/s13047-020-0380-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 02/27/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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