Article

Prevention of diabetic foot ulcers:

The bottlenecks in the pathway
Citation: Zoe Lysy (2014)
Prevention of diabetic foot ulcers:
The bottlenecks in the pathway.
Diabetic Foot Canada 2: 38–40
Article points
1. Prevention of diabetic foot
ulcers is more cost effective
than their treatment. While
guidelines advocate screening,
systemic barriers make
this difficult to execute.
2. There are many barriers to
establishing appropriate
preventative pathways for
diabetic foot ulceration,
Zoe Lysy
The management of diabetes involves multifaceted preventative care, targeting
management of macro- and microvascular complications and glycemic control. The
case has been made for diabetes foot screening as an integral part of diabetes care.
While amputation is a rare outcome compared to the other vascular complications
of diabetes, the consequence is costly, both on a personal and health systems’
perspective. Partly because of the multifactorial etiology of the foot ulcer and
amputation, it has been difficult to establish impact of a single-handed intervention
to reduction of outcomes, but it is well known that the best outcomes come from
the combined effort of multidisciplinary efforts. This commentary outlines why this
is the knowledge we must give to frontline physicians, in addition to access to these
resources.

including lack of funding for
chiropody services and referral
pathways for patients at risk.
3. While it is difficult to determine
a cause effect relationship for
single intervention in wound
care prevention, the work of
multidisciplinary clinics has
been proven to be effective in
preventing diabetic wounds.
Key words
- Barrier
- Diabetes
- Foot ulcer
- Prevention
Author
Zoe Lysy, Endocrinologist,
Ambulatory Care Fellow,
Department of Medicine,
Women’s College Hospital,
University of Toronto
I
t is estimated that as of 2008/9, 2.4 million
Canadians aged one year or older are living
with type 2 diabetes, with a projected
prevalence of 3.7 million in 2018/19 (Public
Health Agency of Canada, 2011). While foot ulcers
and amputations are neither the most prevalent
nor incident complications of diabetes, they are
certainly among the most costly. In fact, they
rank just behind the cost of stroke (a much more
common complication) according to Canadian
estimates (Discharge Abstract Database, 2011).
Canadian data provided by Canadian Institute
for Health Information in 2011 highlights diabetes
as the leading risk factor for wounds in all patient
settings (inpatient, home care, continuing complex
care and long term care) (Discharge Abstract
Database, 2011). It is estimated that in Ontario,
patients with diabetes account for about 80% of
amputations and that patients with diabetes have
a 20 times higher risk of being hospitalized for an
amputation than those without (Hux et al, 2003).
Furthermore, it is estimated that about 15–25%
of patients with diabetes will develop an ulcer at
some point in their lives (Lavery et al, 2003) . An
ulcer precedes up to 84% of most diabetic non-
traumatic lower limb amputations (Pecoraro et al
1990; Singh et al, 2005) .
The case for wound care prevention has been
made from many fronts. Preventative measures
are cost effective compared to their complications
(Ragnarson, 2001; Cavanagh 2012). Furthermore,
foot screening and multidisciplinary foot clinics
have been shown to reduce complications such as
ulceration and amputation (Gottrup et al, 2001;
Calle-Pascual et al, 2002), which is particularly
pertinent for the subset of high risk patients most
prone to develop them (Monteiro-Soares et al,
2011).
The prospective factors for development of
leg ulcer have been studied and help identify
patients who should be screened more frequently
or be referred to a high risk foot clinic or a
multidisciplinary team (Boyko et al, 1999; Mason
et al, 1999). This is assuming that such care is
readily accessible. Current clinical guidelines
advocate yearly foot screening in all patients
with diabetes, with heightened screening in
patients deemed at high risk for complications
and appropriate education and fitted footwear
(Bowering, 2013). These are patients with foot
abnormalities (callus, deformity, structural
deformity, limited joint motility), documented
loss of monofilament sensation and patients with
history of ulceration, amputation or peripheral
vascular disease (Fernando et al, 1991; Boyko
et al, 2006; Lavery et al, 2008).

38 Diabetic Foot Canada Volume 2 No 1 2014


Barriers to screening
Where then are the potential sites where breakdown
is occurring in our screening and action plan for
patients at highest risk? In spite of compelling
data, and even though foot screening is part of the
yearly diabetes flow sheet on the basis of which
remuneration for diabetes is provided in some
provinces like Ontario, foot screening is only done
in 50% of cases (data not specific to Ontario;
Commonwealth Fund, 2005). This certainly
constitutes a first breakdown in the assessment of
ulcer risk and subsequent action.
The potential professional barriers to screening
have been described, including competing clinical
priorities and time for assessment (Perkins, 2003).
Barriers to treatment and screening in diabetes, not
specific to foot care but potentially applicable also
include discrepancy between patient and provider
expectations, unclear diagnosis and treatment
protocols, inevitable deterioration in the ulcer or
wound regardless of intervention, time and expense
(Larme et al, 1998).
There may also be confusion around whose
responsibility it is in fact to screen the foot and
dispense either education, treatment or refer
onwards (Kuhnke et al, 2013). While this occurs
with other facets of diabetes management, it is
emphasized in foot care where there may not be a
designated member of the team dedicated to foot
care, unless a chiropodist is involved.
One can also hypothesize about a lack
of clinician self-efficacy surrounding their
intervention or lack of knowledge on how to
address and treat a finding. More research in these
areas at a primary care level would be help, to
assess the role that each of these barriers may play
and target them accordingly. Future work should
be focused on how to encourage primary screening
and how to encourage counseling and action
taking when an abnormal finding comes up on the
routine foot exam.
Barriers to referrals
If one follows the guidelines, patients who are
deemed high risk should be referred to chiropody or
appropriate foot specialist for management of their
foot, fitted for specialized footwear to prevent callus
and given education about adequate foot care. A
number of questions arise. Where are these services
Diabetic Foot Canada Volume 2 No 1 2014
Prevention of diabetic foot ulcers: The bottlenecks in the pathway
offered? Who is able to offer chiropody services and “There may also be
to whom? What is their cost? confusion around whose
While a single intervention has not yet
responsibility it is in fact
been shown to reduce ulceration, care by a
multidisciplinary team or intensive foot care setting to screen the foot.”
have achieved reductions (Mayfield et al, 2000;
Reiber et al, 2002; Caputo et al, 2004; Borssen et
al, 2006). It would seem that the combination of
preventative services seen in these settings have the
highest success from a prevention perspective. A lack
of successful outcomes from isolated interventions
(physician inspection of feet, visit to chiropody,
fitted footwear, patient education) may not show as
robust results as a multifaceted intervention specific
to the foot but this should not be interpreted as lack
of efficacy but rather that it may very well be that
these interventions function best in combination.
When proving endpoints to policymakers, this
lack of cause and effect from a single intervention
can be a challenge to advocate for funding.
This is unlike other micro- and macrovascular
complications of diabetes (nephropathy, retinopathy,
heart attack) where the impact of pharmacotherapy
and glycemic control has been well validated
in large randomized studies (Davis et al, 1998;
UKPDS, 1998; Gross et al, 2005; Mohamed et al,
2007). Furthermore, these usually fall within the
window of particular subspecialties or health care
professionals where consultation is accessible, or at
least funded.
Barriers to funding
Another dilemma of the diabetic foot is the lack
of funding for comprehensive screening and
assessment. There is a window between presentation
with a high risk foot (but no active ulcer) and
development of an ulcer where the importance
of screening and acting in this window cannot
be undermined. The beneficial cost effectiveness
and the health status of the patient in whom an
ulcer is prevented greatly outweighs the cost and
effort of screening and prevention (Apelqvist, et al
1995; Lavery et al, 2003). And yet, services such
as chiropody and orthotic footcare, which are
essential parts of the intervention shown to reduce
ulcer occurrence or recurrence and ultimately
amputation, are not funded by the government
healthcare plan.
We advocate for universal screening in patients
39
Prevention of diabetic foot ulcers: The bottlenecks in the pathway
“Would dissemination and referral for those at high risk but do not
of this consensus provide the financial support to offset the cost to
the patient. From a cost perspective, it would seem
and the associated
that preventing only a few amputations would well
tools to manage the offset the cost of the preventative care invested. To
high risk foot reduce compound this, it is well established that risk of
ulcer incidence and amputation is inversely proportional to income and
socio-economic status (Eslami et al, 1995; Selby
potentially improve
et al, 1995). While proving cause and effect is
screening rates?” difficult for diabetic foot care as stated above, the
low incidence of high risk feet and the high cost of
its ultimately complication may be amenable to a
budget impact that would reveal cost effectiveness
of funded intervention.
Barriers to action
What advice then can be given to physicians on
the frontline of diabetes care? As stated on multiple
occasions, the case for performing a screening exam
is compelling as the first step to triaging patients
with diabetes and stratifying their risk. What are
the barriers to action? Can we establish consensus
on how best to advise the clinicians who through
screening detects a foot at high risk of ulceration?
Would dissemination of this consensus and the
associated tools to manage the high risk foot reduce
ulcer incidence and potentially improve screening
rates? Is accessibility to multidisciplinary foot
clinics more helpful? Would universal referral of
all patients at high risk be the best strategy? Would
disseminated the knowledge and confidence in the
yield of a validating screening tool and subsequent
action make the test more enticing?
These are all barriers and questions that could be
explored at the front line among family physicians,
Reiber GE, Smith DG, Wallace C chiropodists and endocrinologists who manage
et al (2002) Effect of therapeutic
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Diabetic Foot Canada Volume 2 No 1 2014