We Can’t Manage What We Can’t Measure: Australia’s Diabetic Foot Registry Shows the Way #ActAgainstAmputation #WoundHealing

A foot ulcer heals in a clinic. A health system learns when that experience becomes part of a larger, honest picture: who received care, how quickly they received it, what happened to the wound, and what happened to the person. We can’t manage what we can’t measure. In diabetic foot care, our friends in Australia are showing us how to make that principle practical.

A generous round of applause for our Aussie Colleagues

Huge congratulations to Stephen Twigg and Peter “Pete” Lazzarini, together with lead author Joel Lasschuit, Georgina Frank, Sofianos Andrikopoulos, Natalie Wischer, and the teams contributing to the Australian Diabetes Foot Registry (ADFR). Their new International Wound Journal paper describes the difficult, valuable work of turning a shared idea into a national collaboration. [1]

Established in 2020 under the Australian Diabetes Society and National Association of Diabetes Centres, with St Vincent’s Hospital Sydney as sponsor and data custodian, the ADFR follows people with active foot ulcers and/or active Charcot neuro-osteoarthropathy attending interdisciplinary high-risk foot services.

By the end of June 2025, the registry had enrolled 10,919 people, representing 13,150 care episodes and 22,383 ulcerations. Forty-nine sites across 37 services had completed implementation; 42 sites remained actively collecting data at that time. Mean service-level capture of eligible patients reached 80% in 2024–2025. Those are different denominators, and keeping them straight is part of the point.

The achievement is a working system for shared measurement: a common data dictionary, support for participating teams, annual benchmarking reports, and tools that let a service examine its own performance. The registry already stratifies key metrics by baseline ulcer severity using SINBAD, a standardized ulcer-severity score; fuller risk-adjusted benchmarking is a stated priority for future development.

Caroline Fife’s question: are we really as good as we think we are?

Our friend Caroline Fife has spent years asking a question that every wound service should welcome: are we really as good as we think we are? Her work with the U.S. Wound Registry makes the case for honest denominators and fair comparisons.

In their 2018 paper, Publicly Reported Wound Healing Rates: The Fantasy and the Reality, Fife, Kristen Eckert, and Marissa Carter reported that 30.5% of diabetic foot ulcers in the registry analysis healed by 12 weeks. That analysis included 62,964 DFUs after excluding one-visit wounds and those still in service. We highlighted this work on DiabeticFootOnline in May 2018. [2]

The same paper reported 12-week healing of 29.6% for pressure ulcers and 44.1% for venous leg ulcers. These are wound-specific findings from a historical dataset, rather than a universal healing rate for all wounds or a direct comparison of today’s clinics.

The message remains urgent. In the newer Diabetic Foot Consortium Open Wound Master Protocol cohort, 26% of DFUs healed by week 12. We covered those results in July 2026. Different cohorts and methods, but another strong reason to examine our assumptions about healing. [3]

Before comparing services, we need to know which patients were included, how severe their disease was, when the clock started, and how amputation, death, transfers, and missing follow-up were handled. A reassuring percentage means very little without those answers.

There are already foundations around the world

Australia’s work joins several important efforts. This is a selection of complementary registries and audits, each with its own population and purpose; their results cannot simply be pooled or ranked.

• Australia — ADFR: a prospective clinical quality registry for active ulceration and active Charcot disease in interdisciplinary high-risk foot services, linking local audit to national benchmarking. [1]
• England and Wales — National Diabetes Foot Care Audit (NDFA): monitors specialist foot care against NICE guidance and benchmarks structures, processes, and patient outcomes across services. A national clinical audit offers lessons alongside a registry. [4]
• United States — U.S. Wound Registry: Caroline Fife and colleagues have built a longstanding platform for wound-care quality measurement, including diabetic foot care. Its work on offloading and arterial assessment, alongside the Wound Healing Index, underlines the need to compare patients with similar healing risk. It covers multiple wound types. [5,6]
• United States — STEADY: Jared Adams and colleagues describe a prospective multicenter DFU registry designed to follow treatment patterns, healing, recurrence, resource use, and patient-reported outcomes. The published design aims to enroll 5,000 adults over a 10-year study; that is a target, not a completed enrollment count. [7]
• Sweden — RiksSår: the national quality registry for ulcer treatment includes diabetic foot ulcers among several types of hard-to-heal wounds and works across disciplines and levels of care. [8]
• Belgium — IQED-Foot: Sciensano’s recurring quality-improvement audit collects data from recognized multidisciplinary diabetic foot clinics and provides individualized feedback to help services improve. [9]

The U.S. opportunity: make measurement part of care

The U.S. has important building blocks. Caroline’s registry, STEADY, and the Diabetic Foot Consortium deserve recognition and support. The next opportunity is broader participation and enough consistency to learn across services, settings, and communities.

Our goal should be to make measurement an ordinary part of limb-preservation care. Record the essentials during routine care, give teams useful feedback, and fund the people and infrastructure needed to sustain the effort.

The Australian paper makes that last point tangible. Two sites stopped collecting data and five suspended collection because of staffing or technical challenges. A registry depends on protected staff time, responsive support, and resources that survive the departure of a local champion.

We should also follow people beyond wound closure. Healing begins remission. Recurrence, hospitalization, survival, mobility, and the patient’s own experience belong in the next chapter of measurement. Ulcer-free, hospital-free, activity-rich days should be an ambition we work toward measuring consistently.

A worldwide effort can start with a shared minimum

My proposal is a practical international collaboration built around a small, agreed core dataset. Countries and services could retain local governance while agreeing on definitions and reporting methods. Any sharing would need patient protections, appropriate permissions, and participation from the communities represented.

We should agree on how to describe the wound and the threatened limb; how to record time to specialist assessment, offloading, and vascular care; and how to follow healing, recurrence, amputation, and survival. We should report who is missing as carefully as who is included.

Fair comparisons require case-mix adjustment. Equitable measurement also requires resources for services that have the least capacity to contribute. A global effort should include rural communities, Indigenous peoples, underserved populations, and settings with limited resources from its beginning.

The ADFR paper establishes feasibility and early implementation. It does not yet demonstrate that registry participation reduces amputations or improves healing, and voluntary enrollment in specialist services does not capture everyone with diabetic foot disease. Those boundaries help define what the next studies and investments should address.

Stephen, Pete, Joel, and colleagues have given us something worth celebrating—and something worth building on. Caroline and other registry pioneers have shown why honest measurement matters. The invitation now is to connect that learning, strengthen it in the U.S., and make it accessible around the world.

Related reading

• Our 2018 coverage of Caroline Fife: Wound Healing Rates—The Fantasy and the Reality
• One in Four by Twelve Weeks: our Diabetic Foot Consortium coverage
• The Census and the Core Sample: STEADY, DARE-DiaFoot, and measuring what we manage
• Australian Diabetes Foot Registry: public resources, reports, and participation information

References

1. Lasschuit JWJ, Lazzarini PA, Frank G, Andrikopoulos S, Wischer N, Twigg SM. The Australian Diabetes Foot Registry: From Conceptualisation to National Collaboration. International Wound Journal. 2026;23:e71060.
2. Fife CE, Eckert KA, Carter MJ. Publicly Reported Wound Healing Rates: The Fantasy and the Reality. Advances in Wound Care. 2018;7(3):77–94.
3. Xu C, Schmidt BM, Krambrink A, et al. Longitudinal Healing and Amputation Trajectories in Diabetic Foot Ulcers: Predictive Power of Wound Area and Duration and Sample-Size Implications From the Diabetic Foot Consortium. Wound Repair and Regeneration. 2026;34(4):e70189.
4. NHS England. National Diabetes Foot Care Audit 2018 to 2023; audit overview and dashboard links.
5. U.S. Wound & Podiatry Registries. Do the Right Thing.
6. Fife CE, Horn SD, Smout RJ, Barrett RS, Thomson B. A Predictive Model for Diabetic Foot Ulcer Outcome: The Wound Healing Index.
7. Adams JR, Lannon JN, Driver VR, et al. The STEADY diabetic foot ulcer registry: methods, insights, and future directions. Wounds. 2026;38(4):97–106.
8. RiksSår. Swedish national quality registry for ulcer treatment: English overview.
9. Sciensano. IQED-Foot: quality improvement and epidemiology in multidisciplinary diabetic foot clinics.

Every wound belongs to a person. Every person deserves to count!!!