Establishing a multidisciplinary partnership integrating podiatric care into the Quebec public health-care system to improve diabetic foot outcomes: A retrospective cohort

Highlights

• There is no podiatrist integrated in MDT for DFUs in the public health system in Quebec, Canada and this situation prevails in several countries.

• The effect of podiatric interventions needs to be more defined for the management of DFUs in MDT.

• Patients with DFU who were managed in MDT which includes a podiatrist can improve both their healing rate and time.

• Implementation of integrated MDT with podiatrists is expected to reduce DFUs complications as the literature highly suggest.

Abstract

Diabetic foot ulcers (DFUs) are one of the main complications of diabetes affecting many Canadians that need to be effectively managed. There is limited data concerning outcomes of Canadian patients with DFUs treated with a team approach in the public health system. Podiatrists are known to be key members of a multidisciplinary team approach to DFUs management, but in Quebec, Canada, they are only available in private practice. The aim of this study is to evaluate diabetic foot outcomes after integrating podiatric care into in-hospital wound care clinic settings. A 12-month retrospective cohort study was conducted into a new organization named the Pododiabetology University Center (PUC), which is described in this article. Healing rate and healing time were the outcomes measured. The analysis was performed by comparing data collected before and after the integration of the podiatrists. Preliminary results indicate that 73.2% of DFUs (n = 52) healed in an average of 19.8 weeks (time to wound closure). Previous data collected on 15 individuals before the integration of podiatric care showed a 27.3% of DFUs resolved in 44.6 weeks. The findings suggest that a patient with DFUs who receives wound care from a multidisciplinary team that includes a podiatrist can improve both their healing rate and time. An integrated multidisciplinary approach including podiatrists for patients affected by acute DFU is highly suggested in the literature in order to reduce the number of hospitalizations, amputations and financial burden, which are variables that could be evaluated in further studies.

Introduction

Diabetes is a worldwide disease with an increasing incidence. It afflicts 2.7 million Canadians, from which 345,000 will develop a diabetic foot ulcer (DFU). This is based on the lifetime incidence of DFUs, which is estimated at 15%–25% for people with diabetes [1], [2]. The annual cost of DFU and related care is estimated at Can$21,371 per incident case [3]. The 5-year mortality rate following a DFU episode is between 43% and 55%, and up to 74% with a lower-extremity amputation [4]. The risk of death at 5 and 10 years is respectively 2.5 and 2 times higher for patients with DFUs than patients with diabetes but without a DFU. DFUs should be seen as a major warning sign for mortality in people with diabetes, and as such, they require closer monitoring and medical follow-up [5], [6]. However, diabetic foot complications can be partially avoided by early detection and appropriate management strategies (wound care, offloading, education [7], [8]). Proper preventive foot care is also a key management strategy for DFUs [9]. Although well documented in the guidelines, many patients with diabetes still do not receive preventive foot care prior to ulceration. Two reports from the Canadian Institute for Health Information (CIHI) highlight the priority for the management of DFUs and report several disparities in diabetic foot healthcare. Wounds are a heavy burden for the healthcare system and need more support in Canadian hospitals [10], [11]. One strategy for the integrated foot care is the multidisciplinary team (MDT) approach. It has been shown to reduce DFUs, recurrences and amputations. Multidisciplinary healthcare centers in Europe and in the United States reported that this approach helped reducing amputation rates by 49%–85% [7], [12], [13], [14]. As part of a MDT approach, podiatrists have been suggested to serve as “gatekeepers” for the prevention and management of diabetes-related foot complications. Integrated foot care programs also highlight their role in MDT approach [7], [15]. Studies have demonstrated that the management of people with diabetes by a specialty multidisciplinary podiatric medical team and podiatrists is associated with lower rates of ulcerations and amputations, thereby reducing healthcare costs [16], [17], [18]. Podiatric cares in those with a history of DFUs can reduce high level amputation rates by 65–80% [19].

In other countries, the role of podiatrists becomes increasingly important with the implementation of guidelines and DFU cares algorithms [8], [20]. Canadian best practice recommendations from Wounds Canada suggest that patients identify appropriate healthcare professionals and services, and consult a podiatrist according to their level of risk of having an acute DFU. They also suggest that all members of the team should be in one location. Patients with disabilities, which include many patients with diabetes, need further support [21]. There is thereby a problem of accessibility to a podiatrist in Quebec’s public health system. To the authors’ knowledge, podiatrists are mainly available through private practice, and there is no podiatrist working as part of an in-hospital primary care team for diabetic foot complications in Quebec. The present study hypothesized that the accessibility problem is linked to the lack of recognition of the profession by the public health system, the fact that the profession is not well known by the population, and the fact that diabetic foot care can be expensive in the private sector. Therefore, a podiatrist working in a hospital is more easily accessible and improves the outcomes on the DFUs, as stipulated in the literature [7], [12], [16], [17], [18], [22]. The main objective of this study was to discuss the podiatrists work within a MDT approach for debilitating outcomes of DFUs. This study also aimed at evaluating diabetic foot outcomes after integrating podiatric care into an in-hospital wound care clinic settings. Healing rates and healing time were the outcomes measured. Then, the analysis was performed by comparing data collected before and after the integration of the podiatrist into the team. Also, an objective was to describe the establishment of a diabetic foot care team within in-hospital wound care clinic (WCC). This team, called the Pododiabetology University Center (PUC) includes a podiatrist at the Centre de santé et de services sociaux du Nord de Lanaudière (CSSSNL). This study involves the first data about the inclusion of a podiatrist into an in-hospital WCC setting of Quebec’s public health system for DFUs outcomes in people with diabetes.