Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada

Basiri, Reza; Haverstock, Brent D.; Petrasek, Paul; Manji, Karim

doi:10.7547/19-137

Cited by 12 publications

(14 citation statements)

References 35 publications

(6 reference statements)

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“…We chose to study all causes and levels of LA to identify the true scope of the social and economic burden placed on the health care system, family, and caregivers [ 24 ]. This was important as other Canadian researchers limited their studies based on diagnosis (e.g., diabetes, trauma) level (major, minor), or extremity (upper, lower) [ 19 , 20 , 35 – 38 ]. To add some understanding of the cohort demographics, we included the three most common amputation predisposing factors (APF) and identified DM as the leading cause of limb loss followed by PVD and trauma among all groups.…”

Section: Discussionmentioning

confidence: 99%

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

Essien

Linassi

Farnan³

et al. 2021

BMC Surg

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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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Section: Discussionmentioning

confidence: 99%

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

Essien

Linassi

Farnan³

et al. 2021

BMC Surg

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“…One included cohort study had 4 substudies [41] and another, 2 substudies [38]. Reasons for exclusion (consensus between authors) were: mixed data when reporting primary outcome [42], eminent difference of basic population [43][44][45], podiatric interventions pre and post cohort [46] and incomplete data for pooling the outcomes [40,[47][48][49][50][51].…”

Section: Literature Searchmentioning

confidence: 99%

“…All 23 studies included in the systematic review were in English. We identified 6 studies from the United States [40,45,47,48,54,55], 2 from Canada [44,55] and 10 from Europe, of which 5 were from the United Kingdom [41,43,50,56,57], 2 from Spain [36,38], 1 from Sweden [51], 1 from the Netherlands [58] and 1 from Italy [49]. There were also 3 articles from Asia, of which 2 were from China [42,59] and 1 from Singapore [60].…”

Section: Description Of Included Articlesmentioning

confidence: 99%

“…Concerning the role of the podiatrist, we decided a posteriori to distinguish their role according to their implication in the MDT. With this in mind, the podiatrist intervenes in a primary role in 8 articles (leading role or core of the team) [36,43,44,47,48,54,55,59]. Specifically, in these articles, the podiatrist formed the core of the team with endocrinologists [36,59], nurses [43,55], and vascular surgeons [44,47,54].…”

Section: Description Of Included Articlesmentioning

confidence: 99%

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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

Blanchette

Brousseau-Foley

Cloutier

2020

Journal of Foot and Ankle Research

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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, I 2 = 64%, P = 0.002)) and major LEAs (RR: 0.45, 95% CI 0.23-0.90, I 2 = 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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“…Even though few examples of established team approach DFU management teams can be found in Quebec, they should represent the norm not the exception. [7][8][9] With that in mind, we need to ask ourselves if we can strive for an improved continuum of care for patients with DFU in Quebec's and Canada's public health systems? We firmly believe that we can do better and we should unequivocally improve our methods.…”

Section: Introductionmentioning

confidence: 99%

<p>Multidisciplinary Management of Diabetic Foot Ulcers in Primary Cares in Quebec: Can We Do Better?</p>

Brousseau-Foley¹,

Blanchette²

2020

JMDH

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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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Reduction in Diabetes-Related Major Amputation Rates After Implementation of a Multidisciplinary Model: An Evaluation in Alberta, Canada

Cited by 12 publications

References 35 publications

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

The influence of primary and subsequent limb amputation on the overall rate of limb amputation in Saskatchewan, Canada, 2006–2019: a population-based study

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

<p>Multidisciplinary Management of Diabetic Foot Ulcers in Primary Cares in Quebec: Can We Do Better?</p>

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