Improving identification and management of the at-risk foot in diabetes
Background: Diabetes-related foot ulcers (DFUs) are one of the most common lower extremity complications of diabetes. The lifetime risk of a person developing a DFU is estimated to be as high as 34%. They are associated with increased risk of limb loss, increased hospitalisations and poorer quality of life. However, they are preventable through timely identification of risk factors, and referral to appropriate prevention services. It is internationally recommended that people with diabetes be offered annual diabetic foot screening to identify risk factors and allow for timely implementation of prevention strategies. However, evidence suggests diabetic foot screening is one of the least complied with elements of diabetes care internationally. This means many people who have risk factors are not being identified, not receiving appropriate care for risk factors and experiencing preventable DFUs and subsequent limb loss. Aim: To enhance understanding of how recommendations for identifying and managing individuals at-risk for DFUs are being implemented and how best to identify and manage those at risk. Methods: This thesis followed a convergent mixed methods study design, comprising five studies to answer four interrelated research objectives. Firstly, to achieve consensus on what terms should be used within clinical practice guidelines to describe identification of the at-risk foot, guidelines were assessed and people with lived experience of diabetes were consulted. Secondly, to examine what care people with diabetes are receiving and where and by whom their care is being delivered, using Ireland as a case study, two separate studies examined healthcare professionals’ and people with diabetes’ experiences of preventative diabetic foot care in Ireland. An online cross-sectional survey of podiatrists examined podiatrists experiences of providing integrated diabetic foot care. A qualitative study involving semi-structured interviews with general practitioners, practice nurses and people with diabetes explored their experiences of providing and accessing diabetic foot screening and factors influencing this. This qualitative study also explored perspectives on moving diabetic foot screening into a systematic screening programme. Third, to evaluate potential risks and benefits of a systematic diabetic foot screening programme, a scoping review study conducted in line with Arksey and O'Malley and the Joanna Briggs Institute methodologies, evaluated and mapped the evidence on diabetes-related foot screening using the World Health Organisation screening principles. Fourth, to improve identification of those at-risk for DFUs, a prospective cohort study including people with Type 1 diabetes and Type 2 diabetes assessed the association of cardiac autonomic neuropathy with incident DFUs and amputation. Results from these individual studies were brought together using a narrative approach. Results: Following a review of seven clinical practice guidelines, and consultation with people with diabetes, consensus on the appropriate terminology to describe identification of the at-risk foot was achieved. Findings from the national survey of podiatrists (n = 50) and qualitative study (n = 26) suggested that national policies outlining referral pathways are insufficient to ensure at-risk individuals are managed appropriately. Adequate staffing, and information technology infrastructure to enable improved information flow between healthcare settings are needed to support the transition of patients between settings. In addition, increased efforts are needed to educate patients on the importance of foot screening. The scoping review of 46 articles found introduction of foot screening into a systematic screening programme could lead to more harm than benefit. Finally, those with cardiac autonomic neuropathy have a threefold (IRR: 2.99; 1.5 – 5.5; p<0.01) increased risk of ulceration. Conclusion: Findings from this thesis enhance our understanding of factors enabling identification and management of the at-risk foot in diabetes. Collectively, the results indicate that while current national policies and clinical guidelines provide a foundation, they are insufficient on their own to ensure people at risk for DFUs are being identified and managed in line with international recommendations. A more integrated systematic approach involving information technology infrastructure that supports communication between healthcare settings is needed. Health systems also need to ensure adequate staffing and enhanced patient education to ensure at-risk individuals receive timely and appropriate care. Based on current evidence, findings suggest addressing these factors may be more effective than implementing a systematic diabetic foot screening programme. Finally, the identification of cardiac autonomic neuropathy as an independent risk factor for DFUs improves our understanding of risk factors for disease onset. The findings from this thesis have the potential to inform future policy, improve clinical practice, and ultimately reduce the burden of diabetes-related foot complications on both patients and healthcare systems.
Diabetes, Diabetic foot, Screening, Prevention
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