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AUSTRALIA lags behind comparable high income countries when it comes to investment in and resources for the care of diabetes-related foot disease, and the result is 26 000 hospitalisations, 4500 amputations – the second highest of all OECD nations – and 1700 deaths a year.
“Around 300 000 Australians diagnosed with diabetes also have risk factors for diabetic foot disease (DFD),” said Dr Peter Lazzarini, Principal Research Fellow at Queensland University of Technology, and co-chair of Diabetic Foot Australia.
“Around 4% of people with diabetes – 50 000 Australians – are walking around today with a foot ulcer, infection or ischaemia,” he said in an exclusive podcast.
“We also know that about 1% – 12 500 – have had a previous amputation. Unfortunately, each year we see about 26 000 hospitalisations, 4500 amputations and 1700 deaths attributed to DFD.”
Dr Lazzarini is the lead author of a Perspective, published today by the MJA, which details a new Australian strategy that should finally reduce the significant national burden of DFD.
He described DFD as one of Australia’s “least known major health problems”.
“DFD is Australia’s leading cause of amputations, is within the top 20 causes of all hospitalisations, has mortality rates worse than many cancers, and costs Australia an estimated $1.6 billion each year,” Lazzarini and colleagues wrote.
“Patients who develop DFD also need more consultations, referrals and hospitalisations than patients with heart disease, kidney disease or cancer.”
Historically, the technical definition of DFD is infection, ulceration or destruction of tissues of the foot associated with the diabetes complications of peripheral neuropathy and/or peripheral arterial disease in people with diabetes, Dr Lazzarini told MJA InSight.
“A more contemporary definition is simply a foot ulcer, infection or ischaemia in someone with diabetes. Circulation is part of the problem; however, probably the most critical problem is the peripheral neuropathy, causing a lack of sensation, pain, pressure and temperature.
“Unfortunately, men … aren’t as good at getting off and getting care, and if there’s no pain involved as well, they tend to delay it even more so.”
According to Lazzarini and colleagues, nations such as the UK, Belgium and the Netherlands, which have the lowest amputation rates in the OECD, also have “coordinated nationwide systems that recognise and reimburse accredited interdisciplinary DFD services”.
“Additionally, these nations’ systems regularly monitor and report DFD outcomes for national clinical benchmarking and research network purposes.”
Speaking with MJA InSight, Dr Lazzarini said that the UK and Germany’s example was a stark contrast to the system in Australia.
“We’ve just launched an accreditation [for DFD services] system through the National Association of Diabetes Centres, but in countries such as Germany this has been going on for a number of years and they have 300-odd multidisciplinary services that are accredited for DFD services,” he said.
“In the UK, they complain that 20% of their hospitals don’t have DFD multidisciplinary care teams, and here we would struggle to have 20% that do.”
Diabetic Foot Australia, formed in 2016, has the goal of “ending avoidable amputations within a generation”. They have just launched the Australian Diabetes-related Foot Disease Strategy 2018–2022, which outlines nine key recommendations, split into three domains:
Access to care
- All people with diabetes should have access to annual DFD screening and understand their risk of developing diabetes-related foot disease.
- All people at risk of DFD should have access to preventive evidence-based health care from appropriately trained health professionals.
- All people with DFD should have access to evidence-based healthcare from specialised interdisciplinary foot disease services.
Safe quality care
- All health professionals and specialised interdisciplinary foot disease services caring for people with, or at-risk of DFD should demonstrate they meet minimum Australian evidence-based standards.
- All health service regions should report their DFD outcomes annually to monitor progress towards ending avoidable amputations.
- Australian national DFD guidelines should continually reflect the most up-to-date robust evidence to guide standards for health care provision and outcome reporting.
Research and development
- An Australian research agenda for DFD should be developed and endorsed to guide national research priorities.
- An Australian DFD clinical trials network should be established to provide national research support and leadership.
- Investments in research and development for DFD should be proportionate to the national health burden caused by the disease.
Lazzarini and colleagues called on “Australian health professionals, researchers and governments to finally act on one of our least known major health problems and invest in these detailed actions to achieve the recommendations in the Australian Diabetes-related Foot Disease Strategy 2018–2022”.
“Investments in this plan should ensure not only a significant financial return on investment to the health budget but, more importantly, save the limbs and lives of Australians.”
One of the major problems to this “elegant solution” is that appropriate footwear is so expensive that many patients can’t afford it and by the time the government has agreed to pay … the leg is lost!
Why are we certain that the number of amputations is the best indicator of success? One sees patients struggle for years with miserable DFD, only to die of stroke/heart attack/sepsis/pressure sores or some other complication of prolonged impaired mobility.
The most important thing in foot & ankle surgery is understanding the problem from the patient’s point of view. For some the problem is pain, for others it is the disfiguring deformities that DFD can cause. For others the problem is the impairment of social participation/workforce participation/intellectual stimulation caused by prolonged hospital admission and/or home IV antibiotic therapy and/or never-ending debridements.
In selected cases, preferred treatment is elective amputation followed by prompt prosthesis fitting and rehabilitation. Will this choice be available to patients in health service regions that are evaluated by the number of amputations?
Stop swabbing those wounds to “wrongly” direct antibiotic therapy! Swabs pick up all organisms (mostly non-pathogenic) from the surface – some grow faster than others and are misrepresented and misleading.
I suspect the most effective way of educating patients with diabetes regarding the importance of foot care is to have them take their shoes and socks off at each visit, inspecting their feet, and explaining why you are doing so.
Re your headline: That’s an elegant solution?
As a medical student over 50 years ago I was taught that diabetics should see a chiropodist regularly. Now the better educated specialists in the area are podiatrists. In the meantime I am a 75-year-old practising psychiatrist with type II diabetes of several years duration on insulin. The only significant complication is a peripheral neuropathy which of course makes feet vulnerable. I find my six weekly visit to the podiatrist very useful and possibly a lifesaver. With advancing stiffness of the joints even routine attention from one self to the feet becomes increasingly difficult. So I endorse the advice that I was given in the 1960s and in your article
A very common problem managed in General Practice but with poor funding and difficulty accessing specialist services especially in rural areas. It would be excellent to have multidisciplinary teams available to help our patients.