Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada

Abstract

Background Neuropathy and vasculopathy can lead to costly and debilitating complications in people with diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate risk in Alberta, Canada between 2014 to 2019. Methods Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes. Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and 2019 using two-tailed Fisher’s exact test or Chi-square test. Results Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly (p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway recommendation was also improved. Conclusion Provision of a clinical pathway for diabetic foot care along with education and resources led to increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare providers with an important option for referral and also provided increased expertise for procedures such as vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.

Variation in treatment and outcomes for patients with chronic limb‐threatening ischaemia in New South Wales, Australia

“…Early access to outpatient care like high‐risk foot clinics 20 may reduce late, complex presentations of CLTI and facilitate integrated care. Multidisciplinary team (MDT) management reduces amputation rates and improves CLTI outcomes 21,22 through better management of comorbidities and vascular disease 17,23 . Our study highlights that patients aged 75 years or older have poor AFS, increased reoperations and more adverse perioperative outcomes than younger patients.…”

What are the current diabetic foot assessment methods in private podiatry practices in Flanders, Belgium: an exploratory mixed method study

“…Moreover, the guidelines must be as specific as possible to reduce ambiguity and confusion among clinicians managing patients with DFUs [40]. Several studies have shown that developing a national diabetic foot assessment guideline, based on the international recommendations, not only increases the frequency of diabetic foot assessments [42, 43] but also reduces the incidence of diabetes‐related LEA [19, 44]. However, in Belgium, the international recommendations have not yet been implemented into a national diabetic foot assessment guideline.…”

Promoting Foot Care and Footwear in the Community: A Case Study

“…From an organizational perspective, policy that supports prevention can be developed and led at the provincial level [in Canada]. For example, health leaders in Alberta 12,13 emphasized the need for organizational changes to be led through the implementation of a comprehensive foot care program. 10,11 In the province of Nova Scotia it was reported that, upon implementation of a diabetes-related foot pathway, screening increased significantly and follow up intervals improved.…”