Malik A Humayun, Darryl Meeking
Department of Diabetes & Endocrinology, Queen Alexandra Hospital Portsmouth, UK
Address for correspondence: Dr Malik A Humayun
Specialist Registrar, Department of Diabetes & Endocrinology,
Queen Alexandra Hospital Portsmouth, Southwick Hill Rd,
Portsmouth, Hampshire PO6 3LY, UK
Tel: +44 (0)7588 565966
E-mail: docmalik@me.com
Br J Diabetes Vasc Dis 2015;15:180-183
http://dx.doi.org/10.15277/bjdvd.2015.038
Diabetes-related amputations have a dramatic effect on quality of life and life expectancy and are also a huge financial burden to the National Health Service (NHS). The city of Portsmouth had the second-highest amputation rate in the country from 2007–2010, according to data published in early 2011, leading to a restructuring of the foot care pathway in the area. Over a three year period, the rate of major amputations in people with diabetes in Portsmouth has fallen from 2.3/1,000 to 1.4/1,000, compared with the national average of 1.1/1,000. Repeat hospital admissions for diabetic foot disease are comparable to the national average for the first time. We continue to identify areas of improvement needed for our patients with diabetes and hope to continue to improve foot outcomes for our patients.
Key words: diabetic foot, ulceration, amputation
Diabetes increases the risk of developing a wide range of foot complications, including foot ulceration. Major leg amputation is almost universally preceded by foot ulceration. Every 30 seconds a lower leg is lost to diabetes somewhere in the world.1
Diabetes-related amputations have a dramatic effect on quality of life and life expectancy and are a huge financial burden to the NHS. The NHS spends £636–639 million per annum on diabetes-related ulceration and amputation, accounting for 0.6–0.7% of all NHS spending.2 The number of amputations in England has risen, from 5,700 in 2009/10 to more than 6,000 in 2010/11 and was expected to increase to more than 7,000 by 2014/15 if urgent action was not taken.3
The city of Portsmouth had the second-highest amputation rate in the country from 2007–2010, according to the data published in early 2011.4 The local diabetes service has identified many of the problems leading to amputation and attempted to correct them, with the aim of reducing the amputation rates in our area. This has led to a restructuring of the foot care pathway, which we describe in this article.
A series of local problems were identified that were likely to have accounted for the high rate of diabetes-related amputations in Portsmouth (Box 1). These problems have been compounded by the fact that foot care is delivered by healthcare professionals working for three different healthcare providers in our locality.
We commenced the “super six” model of diabetes care supported by a unique specialist-supported community model.5 The formation of the community diabetes team in 2010 led the way to improving diabetes management skills and education in primary care by supporting GP practices directly in their work place, as well as community nursing teams and patients within their own homes or local environment. The team provides direct day-to-day nursing support, twice-yearly community visits and telephone and email contact directly to nurse specialists and consultants, with the ownership of the patient remaining within the primary care setting.
We have pioneered four half-day education modules on foot disease each year since 2011 as part of a comprehensive diabetes education portfolio. These incorporate an explanation of the foot care pathway as it applies to a range of at-risk and diseased feet, a practical assessment of the foot, plus education on the management of diabetic foot disease and neuropathic pain. The courses are provided at no cost to all healthcare practitioners in our locality. They are currently supported by the pharmaceutical industry, although the education programme also receives financial support from Portsmouth Hospitals NHS Trust. We are exploring the option of these courses being commissioned and are planning to incorporate attendance towards the development of a Diabetes Practice Passport that endorses practices that deliver excellent diabetes care.
In 2011, we developed a diabetes care document for hospital inpatients to incorporate foot examination and a risk assessment for all patients with diabetes. Inpatient foot care was highlighted as a problem in the National Diabetes Audit and the use of this form is to be audited shortly.
The development of a new pathway of care (Box 2) was established to direct every patient with a diabetic foot ulcer or suspected acute Charcot disease to a specialist medical clinic comprising an advanced diabetes podiatrist and a diabetologist. The charts designed to guide foot management for people with diabetes are available online.6
There has also been a service commissioned to increase the frequency of physician-led clinics from one to three each week. Also, relocation of clinics to the acute hospital site has enabled rapid and easy access to the range of specialists required to deliver high-quality foot care. These changes have been accompanied by the introduction of a community diabetes team to support the delivery of routine diabetes care. This new model was introduced in Portsmouth in 2012 and provides healthcare practitioners working with diabetes with:
• Immediate telephone advice from Monday to Friday from diabetes nurse specialists until 17.00 and from hospital consultants from 17.30–19.00;
• Advice from both diabetes nurse specialists and hospital consultants available by email within 24 h;
• Twice-yearly 2 h visits to every GP surgery from the community team (a diabetes specialist nurse and a consultant) to be used according to the needs of each practice. Typically these sessions are used to update on service developments, to provide diabetes education, to provide advice on the management of specific patients, and to review complex patients.
Orthotic provision has been a problematic area and we have struggled to get timely access to appropriate offloading, including both the acute elements of this service (e.g. within 24 h provision of air-cast walkers) and the chronic elements (e.g. the fashioning of customised footwear). A private provider was introduced while orthotic services were tendered, resulting in significant improvements in service delivery.
Self-care is enormously important in both the identification of foot problems and to facilitate early treatment. Foot education is provided directly to patients at Diabetes Education and Self Management for Ongoing and Newly Diagnosed (DESMOND) educational courses, which are available for all new patients with type 2 diabetes in our area. Foot care issues will also be highlighted at refresher courses being set up to educate patients with pre-existing diabetes who may not have attended DESMOND or may require updates. A highly motivated group of patients in Portsmouth have set up an annual patient conference, which also provides an opportunity for an update on foot care issues.
The rate of major amputations in Portsmouth has fallen from 2.3/1,000 to 1.4/1,000 adults with diabetes over a three year period, compared with the national average of 1.1/1,000 (Figure 1, Table 1).4,7 The frequency of repeat hospital admissions for diabetic foot disease is comparable to the national average for the first time.8
The majority of diabetes-related amputations are preceded by foot ulceration and amputations may be prevented by the early discovery and appropriate intervention during the at-risk stage. Comprehensive education of all patients about diabetic foot problems to improve self-care is important. Regular appropriate assessment in primary care will identify a person’s foot risk and facilitate onward referral to a foot ulcer prevention team. Once a foot ulcer has occurred, early and appropriate intervention by a broad range of healthcare professionals (podiatrist, orthotist, tissue viability nurse, diabetologist, vascular surgeon, ortho-paedic surgeon, radiologist, microbiologist, community nurse and general practitioner) contribute to the reduction in amputation rates.
Improvements in some of these areas may have contributed to this dramatic reduction in amputation, but much work remains to be done to provide an optimised service for our local diabetes population. Box 3 summarises areas in which we would like to see further improvements.
Our diabetic foot service is improving and a range of healthcare providers in Portsmouth are working together to provide appropriate resources that are targeted it in a way that maximises improvement in foot outcomes for patients with diabetes. Major amputation rates remain above, but close to, the national average. Almost all (about 95%) of amputations are preceded by the development of diabetic foot ulceration, which itself may not develop in many patients until decades after diagnosis. Accordingly, it would not be reasonable to expect an immediate reduction of amputation rates to the national average. Other recognised risk factors for foot ulceration are prevalent in Portsmouth, including socioeconomic deprivation and Caucasian heritage. We continue to identify areas of improvement and, by addressing these, we can continue to improve foot outcomes for our patients with diabetes.
Conflict of interest None
Funding None
1. International Diabetes Federation/International Working Group on the Diabetic Foot. Diabetes and foot care. Time to Act. A joint publication of the International Diabetes Federation and the International Working Group on the Diabetic Foot. www.idf.org/webdata/docs/T2A_Introduction.pdf (accessed May 2015).
2. Diabetes UK. Putting feet first: Fast track for a foot attack: Reducing amputations February 2013. http://www.diabetes.org.uk/upload/News/Factsheet Footcare for people with diabetes.pdf/(accessed May 2015).
3. The Information Centre for Health and Social Care. Hospital Episode Statistics 2007/08–2010/11. http://www.hscic.gov.uk/searchcatalogue? q=title%3A%22Hospital+Episode+Statistics%2C+Admitted+patient+care+-+England%22&size=10
4. National Cardiovascular Intelligence Network. Diabetes footcare activity profile. August 2011. http://www. yhpho.org.uk/diabetesprofilesfoot/default.aspx (accessed May 2015).
5. Goulder T, Kar P. Facillitating diabetes care - a community approach. BMJ Qual Improv Report 2013;2. http://dx.doi.org/10.1136/bmjquality.u201112.w708
6. Portsmouth Diabetes. May 2015. Guidance charts for diabetic foot care: Diabetes Foot Referral Pathway, Diabetic Foot Management Guideline, Charcot Alert. Available at http://www.portsmouthdiabetes.co.uk/images/portsmouth/diabetesfootreferralpathwayjan2010webversion.pdf (accessed May 2015).
7. National Cardiovascular Intelligence Network (NCVIN). http://www.yhpho.org.uk/default.aspx?RID=182342 (accessed May 2015).
8. Diabetes footcare activity profile; March 2014. http://www.yhpho.org.uk/diabetesprofilesfoot/default.aspx (accessed May 2015).