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