A clinic that provides multidisciplinary foot care for diabetic patients may significantly reduce the need for diabetes-related lower-extremity amputations, UK researchers reported here at the 46th European Association for the Study of Diabetes (EASD) meeting.
In 2005, the Whittington Hospital NHS Trust in London, established the “Combined Foot Clinic,” which focuses on limb salvage in diabetic patients who present with disease-related foot ulcers. Individuals are referred to the clinic by their primary care physician where they are managed by a team which includes a full-time, senior level diabetologist, podiatrist, and a so-called “tissue viability” nurse. A radiologist, vascular surgeon, orthopedic surgeon, microbiologist, and other specialists with expert knowledge of diabetes-related foot problems are also available for consultation, as needed. By three years after the clinic was launched, the incidence of major amputations had been halved. “Before we set up the clinic, the care of patients with diabetes-related foot problems was delivered on an ad-hoc basis because we had no specific protocols or guidelines,” Dr. Ploutarchos Tzoulis, specialist registrar in diabetes, commented. “As a result, there was a huge variation in the type of assessment and treatment a patient might receive along with patient outcomes.”
A comparison of outcomes for the five-year period before the introduction of the multidisciplinary foot team versus the three years afterwards found that the yearly incidence of major amputations had decreased from 6.3 to 3.0, or by 52.4%. “This finding is extremely important because major amputations are associated with significant morbidity and mortality,” Dr. Tzoulis said. “Patients who undergo a major amputation have reduced mobility and have a 30 to 35% risk of dying within first 12 months after amputation.” The study also showed a 15% decrease in the incidence of total amputations per year (from 17.3 to 14.7) and a 30.3% decrease in peri-operative mortality (from 6.6% to 4.6%). Dr. Tzoulis emphasized that the foot team offers regular community-wide educational programs to teach primary care physicians when to refer patients. Referral is indicated in a patient with a new ulcer or an ulcer that appears infected or if there are signs of necrosis or inadequate vascular supply, he said.