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guest editorial 782 Improving referral of patients with diabetic foot ulcer to specialised diabetes foot care units The prevalence of diabetes is increasing and by 2030 it is expected that 578 million people worldwide will have a diagnosis of diabetes.1 During their lifetime, 15–25% of patients with diabetes can develop a diabetic foot ulcer (DFU), resulting in breakdown of the normal integrity of the skin. This can be associated with infection, leading to destruction of deep tissue, and is associated with neuropathy or arterial disease in diabetes.2 DFU is a major complication of diabetes, and associated with a high risk of mortality3 and lower limb amputation.4,5 The latter is known to increase a person’s mortality by 50–68% at five years, comparable with or worse than rates for some cancers.6 Thus, even if there have been improvements in treatment in the past few years, the management of DFU remains a major health challenge. The effect of a policy of prioritisation A major element of DFU management is to ensure a prompt and appropriate referral to specialised diabetes foot care units, because it is associated with a better prognosis. A study conducted in 105 patients in Norway found that patients referred at ≥52 days to a specialised unit had a decreased healing rate compared with those referred < 52 days.7 A national audit of 5212 patients in England and Wales, showed healing rates at 12 weeks were influenced by delays in referral: by as much as 50% if the delay was < 2 weeks, 43% at between two weeks and two months, and 34% if >2 months.8 Faglia et al. reported that delayed surgical debridement of patients with ischaemic and infected DFUs results in a higher rate of amputation in comparison with early surgical debridement.9 A retrospective study of diabetes foot infection, showed the proportion of patients with major lower limb amputation or mortality was significantly higher in those with a referral time of >59 days than those with a referral time < 9 days (21.2% versus 10.5%, respectively).10 Moreover, several studies found that using a multidisciplinary approach was associated with better outcomes for DFU, mainly by decreasing the rate of lower limb amputation.11–15 Despite the evidence and guidelines recommending a prompt referral to a specialised unit,16 late referral remains an important problem. Indeed, we showed in an article on this issue that the proportion of patients referred to a specialised unit >3 months after the onset of a DFU was unchanged between 200417 and 2015 across Europe (27% versus 25%, respectively). The same observations were made by Manu et al. in a study involving four European countries. They found that 48% of patients were referred after an unknown duration or >1 month from the onset of a DFU.18 Lin et al. in Taiwan showed a referral delay of >59 days in 24.7% of patients managed in a specialised foot care centre.10 Benjamin Bouillet Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France; INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France Marco Meloni University of Roma Tor Vergata, Roma, Italy How do we explain why a proportion of patients with DFU still have a delayed referral to specialist limb and tissuepreserving treatment? Prompt, early referral requires: • The patient to have the ability to Raju Ahluwalia Department of Orthopaedics and King’s Diabetes Foot Clinic, King’s College Hospital, Denmark Hill, London, UK examine his/her foot daily and to contact a first-line health professional if they observe any signs of a DFU • The ability of first-line health professionals to properly assess the DFU and to refer to a specialised unit • The existence of multidisciplinary foot care teams. It is common for patients to recognise a new foot problem. A study from England of 669 patients with a DFU reviewed by a multidisciplinary foot clinic, confirmed 61.3% of all lesions were first detected by the patient or a relative, and the median time between onset and first professional review was four days (range: 0–247 days.) In this study, 96% of patients were seen within four weeks of primary recognition.19 However, recognition may not necessarily be associated with insight into severity. A study of five European countries, presented in 2016,20 found in 370 patients managed in specialised units that: 1. 60.1% of patients perceived their problem to be mild even though 22.2% had an ulcer classified as IIID according to University of Texas Classification 2. 43.3% of patients took >1 month to seek a primary care opinion 3. The mean time between the discovery of the new foot problem and seeking professional help was 40.3 days. A more recent study20 showed in 202 patients with a DFU referred to a UK multidisciplinary foot team, that only 4% knew their current foot risk and 52% did not know why they were being managed in a specialised Ltd lthcare Hea MA 2021 © JOURNAL OF WOUND CARE VOL 30, NO 10, OCTOBER 2021
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guest editorial foot unit. Therefore, the knowledge and awareness of patients with diabetes regarding their feet could be improved. These findings reinforce the need for patient education in diabetic foot problems to improve recognition and interpretation. A lack of appreciation of DFU presentation by first‑line health professionals and interpretation of severity may also be added into the mix and provide a further reason for late referral to specialised centres. In a study conducted of 600 general practitioners (GPs) in four European countries (England, Germany, France and Spain), 29–40% of GPs in all countries did not feel they were sufficiently trained in DFU management (the proportion reached 50% for lack of training on offloading). Up to 30% of GPs in France and Germany thought that there was no clinical guidelines about DFU management, and 15–27% of GPs did not have identified DFU clinical practitioners working in a hospital facility.21 Among 425 health professionals in the UK providing care in people with diabetes and foot problems, 44% reported a lack of access to multidisciplinary care, 24% a lack in the education of health professionals, and 21% a lack of awareness of the need for referral.22 These observations can at least in part explain a gap between guideline recommendations and the management of DFUs in primary care. Further evidence from the EURODIALE study, showed an offloading device was prescribed in only 35% (range: 0–68%) of patients with a DFU, and a vascular assessment was performed in only 54% (range: 14–86%) of patients with critical limb ischaemia.17 In the EDUCARE study,22 30–35% of GPs did not perform vascular assessment in patients with a DFU, and in France, neurologic testing was not performed by 70% of GPs. In a large audit conducted in primary care in the UK, only 22% of patients with a DFU were referred to a specialised unit, 31% of patients received an antibiotic treatment without bacteriological documentation, an offloading device was prescribed in only 5% of patients, and a vascular assessment was performed in only 13% of patients.23 All of these studies highlight the need to improve the training of health professionals in DFU management, the knowledge of referral pathways, and awareness of existing specialised foot care teams. Developing solutions In order to improve both early and appropriate referral to specialised units, and management by first-line health professionals of patients with DFU, the 'fasttrack pathway' was developed by the International Diabetic Foot Care Group (IDFCG) and D‐Foot International.24 This easy tool, designed for primary care health professionals, allows patients to be characterised into three levels of care, according to the severity of their DFU and comorbidities: 1. Uncomplicated DFUs (superficial, not infected and not ischaemic ulcers) can be monitored by health professionals and should be referred to specialised centres in the case of absence of clinical improvement 2. Complicated DFUs (suspected ischaemic ulcers or infected or deep ulcers) should be referred to specialised units within 2-4 days 3. Severely complicated DFUs (wet gangrene, abscess, phlegmons, fever or signs of sepsis) need urgent hospitalisation in specialised unit within 24 hours of diagnosis. An adapted version of the original fast-track pathway to local healthcare organisations has been developed in England, Germany, France, Italy and Spain. The implementation of this fast-track pathway was evaluated in 204 patients in Italy.25 Following two years of implementation, the number of patients with late referral was reduced (20.5% versus 60%). Early referral, according to classification of the fast-track pathway, was independently associated with healing rate, healing time, limb salvage, hospitalisation, and survival, showing a clear improvement in referral patterns and benefits for DFU outcome. Conclusion Late referral of patients with DFU to specialised diabetes foot care units is associated with impaired wound healing and increased risk of lower limb amputation. Functional outcomes and improved quality of life metrics are still required to understand the long‑term impact of appropriate early referral and foot care.26 For the last few decades, lower limb amputation rates have been declining; however, a recent study highlighted that amputation rates may no longer be decreasing.28 Even if the reasons for this are currently unclear, we cannot exclude that delayed referral to specialised centres may play a role in this. We have shown that a delay in referring patients with DFU to specialised units can be shortened with a significant improvement on DFU outcome, with structured and targeted vigilance. Therefore, prompt referral to specialised units should be considered a primary objective of first-line professionals involved in DFU patient care.  JWC Ltd lthcare Hea MA 2021 © References 1 International Diabetes Federation. Diabetes atlas (9th edn). https:// diabetesatlas.org/en/resources/ (accessed 20 September 2021) 2 Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293(2):217–228. https://doi.org/10.1001/ jama.293.2.217 3 Morbach S, Furchert H, Gröblinghoff U et al. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care 2012;35(10):2021–2027. https://doi. org/10.2337/dc12-0200 4 Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366(9498):1719–1724. https://doi.org/10.1016/s0140-6736(05)67698-2 JOURNAL OF WOUND CARE VOL 30, NO 10, OCTOBER 2021 783

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guest editorial

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Improving referral of patients with diabetic foot ulcer to specialised diabetes foot care units

The prevalence of diabetes is increasing and by 2030 it is expected that 578 million people worldwide will have a diagnosis of diabetes.1 During their lifetime, 15–25% of patients with diabetes can develop a diabetic foot ulcer (DFU), resulting in breakdown of the normal integrity of the skin. This can be associated with infection, leading to destruction of deep tissue, and is associated with neuropathy or arterial disease in diabetes.2 DFU is a major complication of diabetes, and associated with a high risk of mortality3 and lower limb amputation.4,5 The latter is known to increase a person’s mortality by 50–68% at five years, comparable with or worse than rates for some cancers.6 Thus, even if there have been improvements in treatment in the past few years, the management of DFU remains a major health challenge.

The effect of a policy of prioritisation A major element of DFU management is to ensure a prompt and appropriate referral to specialised diabetes foot care units, because it is associated with a better prognosis. A study conducted in 105 patients in Norway found that patients referred at ≥52 days to a specialised unit had a decreased healing rate compared with those referred < 52 days.7 A national audit of 5212 patients in England and Wales, showed healing rates at 12 weeks were influenced by delays in referral: by as much as 50% if the delay was < 2 weeks, 43% at between two weeks and two months, and 34% if >2 months.8 Faglia et al. reported that delayed surgical debridement of patients with ischaemic and infected DFUs results in a higher rate of amputation in comparison with early surgical debridement.9 A retrospective study of diabetes foot infection, showed the proportion of patients with major lower limb amputation or mortality was significantly higher in those with a referral time of >59 days than those with a referral time < 9 days (21.2% versus 10.5%, respectively).10 Moreover, several studies found that using a multidisciplinary approach was associated with better outcomes for DFU, mainly by decreasing the rate of lower limb amputation.11–15

Despite the evidence and guidelines recommending a prompt referral to a specialised unit,16 late referral remains an important problem. Indeed, we showed in an article on this issue that the proportion of patients referred to a specialised unit >3 months after the onset of a DFU was unchanged between 200417 and 2015 across Europe (27% versus 25%, respectively). The same observations were made by Manu et al. in a study involving four European countries. They found that 48% of patients were referred after an unknown duration or >1 month from the onset of a DFU.18 Lin et al. in Taiwan showed a referral delay of >59 days in 24.7% of patients managed in a specialised foot care centre.10

Benjamin Bouillet Department of Endocrinology, Diabetes and Metabolic Disorders, Dijon University Hospital, France; INSERM Unit, LNC-UMR 1231, University of Burgundy, Dijon, France

Marco Meloni University of Roma Tor Vergata, Roma, Italy

How do we explain why a proportion of patients with DFU still have a delayed referral to specialist limb and tissuepreserving treatment? Prompt, early referral requires: • The patient to have the ability to

Raju Ahluwalia Department of Orthopaedics and King’s Diabetes Foot Clinic, King’s College Hospital, Denmark Hill, London, UK

examine his/her foot daily and to contact a first-line health professional if they observe any signs of a DFU • The ability of first-line health professionals to properly assess the DFU and to refer to a specialised unit • The existence of multidisciplinary foot care teams.

It is common for patients to recognise a new foot problem. A study from England of 669 patients with a DFU reviewed by a multidisciplinary foot clinic, confirmed 61.3% of all lesions were first detected by the patient or a relative, and the median time between onset and first professional review was four days (range: 0–247 days.) In this study, 96% of patients were seen within four weeks of primary recognition.19 However, recognition may not necessarily be associated with insight into severity. A study of five European countries, presented in 2016,20 found in 370 patients managed in specialised units that: 1. 60.1% of patients perceived their problem to be mild even though 22.2% had an ulcer classified as IIID according to University of Texas Classification 2. 43.3% of patients took >1 month to seek a primary care opinion 3. The mean time between the discovery of the new foot problem and seeking professional help was 40.3 days. A more recent study20 showed in 202 patients with a DFU referred to a UK multidisciplinary foot team, that only 4% knew their current foot risk and 52% did not know why they were being managed in a specialised

Ltd lthcare

Hea

MA

2021

©

JOURNAL OF WOUND CARE VOL 30, NO 10, OCTOBER 2021

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