This study reports what, to our knowledge, is the first survey of Australian podiatrists’ practice in relation to diabetic foot best practice guideline recommendations. The survey had good internal consistency and high face and content validity for measuring the diabetic foot management construct. Furthermore, the results are based on what appears to be the largest sample of any Australian survey of podiatrists. Overall, the findings suggest Australian podiatrists treat a significant number of people with diabetes and generally adhere to best practice guidelines with some key exceptions. The most notable exception is a very low rate of irremovable offloading device use, which aligns with the results reported in similar international studies [14,15].
In terms of clinical practice, the suggestion is that Australian podiatrists “very often” adhere to the vast majority of best practice guideline recommendations in relation to assessment, examination, risk classification and review periods when managing patients with diabetes. Performing a comprehensive examination of the foot, including neurovascular and musculoskeletal assessments, is core general podiatry practice recommended by the Australian and New Zealand Podiatry Accreditation Council [28], thus, a high adherence rate to the diabetes guidelines for these items that relate is understandable. Performing an ABI or toe pressure was the only item to score below “very often” and aligned with a similar finding in a recent study of Western Australian podiatrists that reported 63% of podiatrists use the ABI [29]. These findings may also be expected as guideline recommendations typically suggest using an ABI or other non-invasive vascular assessment when pedal pulses are not readily palpable [4]. With peripheral arterial disease rates reported in approximately 15 – 25% of Australians with diabetes [2,30] it is not unexpected that podiatrists only “sometimes” use non-invasive vascular assessments to detect peripheral arterial disease.
Furthermore, guideline recommendations were “very often” adhered to for most diabetic foot ulcer assessment and management items However, notable exceptions were the “never” and “very rare” use of total contact casts and irremovable cast walkers respectively and the “sometimes” use of the validated University of Texas Wound Classification System [31] and topical hydrogels. The recommendation of irremovable offloading (including total contact casting and irremovable cast walkers) device use has the highest level of evidence of all Australian diabetic foot guideline recommendations to optimise foot ulcer healing [4,32]. In contrast, evidence to support the use of removable offloading to heal foot ulcers has amongst the lowest level of evidence reported in diabetic foot management guidelines [4,32]. Our findings suggest that this evidence is not reflected in clinical practice. Contrary to recommendations, podiatrists report using removable offloading devices (including orthoses and felt padding) “very often” when treating their patients with diabetic foot ulcers but use irremovable cast walkers “very rarely” and total contact casts “never”. This finding has also been reported in other international studies indicating that further work is urgently required to encourage the routine use of irremovable offloading devices in clinical practice for the management of patients with diabetic foot ulceration [14,15].
To the best of the authors’ knowledge there is little or no research on clinician compliance with the use of topical hydrogels or the University of Texas Wound Classification System in clinical practice. Although topical hydrogels have a relatively high level of evidence it is primarily for autolytic debridement of wounds rather than as a wound dressing [4]. Thus, again it is understandable that podiatrists who regularly use what has been reported to be a much more efficient debridement modality with sharps debridement [4] do not routinely use topical hydrogels. Furthermore, whilst the University of Texas Wound Classification System was only “sometimes” used by podiatrists to classify the complexity of foot ulcers, they did report “very often” using some form of foot ulcer classification system that still included the necessary best practice assessment components of depth, infection and peripheral arterial disease to categorise foot ulcer severity [4]. This suggests the vast majority of patients seeing a podiatrist for foot ulcer management are receiving best practice guideline recommendations on foot ulcer assessment. Reassuringly, public podiatrists who report treating a much higher volume of patients with foot ulcers report using the validated research quality University of Texas system [31] “very often” in their clinical practice.
The majority of podiatrists indicated they had referral access to expert multidisciplinary diabetic foot teams consistent with guideline recommendations [4]. However, it must be noted that more than one third of private podiatrists did not have access to these teams when the acuity of their patients need it. Whilst this access appears to be increasing compared to other Australian reports [16,33] there still appears to be a significant number of podiatrists, and their patients, that do not have the necessary access to these limb-saving services. Multi-disciplinary teams are vital for best practice diabetic foot ulcer treatment and amputation prevention [4,6-9]. This is an important finding as the exact number and location of expert multidisciplinary foot care teams in Australia is currently not clear [33]. However, some studies indicate that there are grossly insufficient numbers of multidisciplinary diabetic foot care teams in Australia and that they are generally located at metropolitan tertiary hospitals [10,33]. Interestingly, in a country as vast as Australia, the podiatrists in this survey reported very low access to these multidisciplinary experts via telehealth. Access to wound care experts via telehealth has high level evidence in Australia to improve access for rural and remote clinicians’ in particular and studies have demonstrated significantly reductions in amputation rates [4,32,34]. It is strongly recommended that strategies to increase access to multi-disciplinary diabetic foot teams, including via in person and telehealth avenues, are optimised to ensure people with diabetes foot ulcers in Australia are receiving best practice guideline recommendations to significantly reduce their chance of amputation [4].
Sector of employment appears to have an effect on adherence to best practice guidelines. For all items reporting a low adherence rate, public-employed podiatrists reported higher adherence rates than private-employed podiatrists and also had greater access to multidisciplinary teams. Chen et al. also found that rates of ABI use were also higher in public sector than private podiatry [29]. There are a variety of hypotheses why this may be the case including that public podiatrists see a larger volume of patients with diabetic foot ulcers in particular, and thus, more inclined to be aware of and use best practice management recommendations. However, a number of papers have reported concern that the current Australian health system’s Medicare funding model for chronic disease in Australia may be inadequate to deal with patients affected by complex chronic disease [24,35-37]. The Medicare model appears to provide some access for patients with non-complex chronic disease, yet is inadequate in providing best practice care for those with more complex chronic conditions such diabetic foot ulcers [24,35-37]. Alternatively, public podiatrists are supported by government funding at a state level to implement best practice care and this has been shown to improve clinical practice adherence to best practice guidelines [10] and in turn significantly reduces diabetic foot hospitalisation and amputation [38,39].
Interestingly, the findings from this study suggest that Australian podiatrists manage significant caseloads of patients with diabetes each week (median 21 – 30 patients per week). This median range extrapolated to all registered Australian podiatrists equates to approximately 75,000 – 110,000 diabetes-related podiatry consultations occurring weekly in Australia. Similarly, podiatrists report managing 1 – 5 diabetes patients with foot ulcers on average each week, equating to approximately 3,700 – 18,000 podiatry consultations each week. Whilst these figures are encouraging in terms of capacity to treat Australia’s burgeoning diabetes foot ulcer population, it still appears significant further capacity is required to manage the minimum estimated 20,000 Australians (2% of Australia’s diabetes population) requiring multi-disciplinary management of their diabetic foot ulcer each week [24] to meet best practice guideline recommendations [4].
Limitations
Whilst this study reports some interesting findings they should be read cognisant of a number of limitations. Firstly, the sampling technique used by this study is likely to have caused sampling bias. As the study was voluntary, entitled ‘diabetic foot management’ and promoted at conference sessions discussing diabetic foot complications it could be suggested that the majority of podiatrists more likely to complete such a survey are those interested in diabetic foot management, and thus, more likely to adhere to guideline recommendations. An example of this is the over representation of public sector podiatrists completing this survey; 50% of respondents for this survey indicated they were publicly employed, whilst only 20% of registered Australian podiatrists are publicly employed [25,40]. Secondly, using a non-validated survey tool decreases the reliability and external validity of our results. However, the survey was based on a similar US survey [15] and with direct questions and phrasing from specific Australian diabetic foot guideline recommendations [4], the questionnaire appears to have suitable content and face validity as indicated by a small sample of expert and general podiatrists and had good internal. Thirdly, the method of survey distribution did not allow for the determination of an exact denominator population of podiatrists invited, and thus, a response rate could not be calculated. The authors anticipate the survey invitation reached a minimum of 2,000 podiatrists who were members of the Australian Podiatry Associations but would not have reached all registered podiatrists (n = 3746) [25]. Thus, the estimated response rate would range between 8 – 16% and acknowledged as a low response rate. However, the high female proportions (70%) and median years of experience (11–15 years) are representative of the Australian registered podiatry workforce [40]. Furthermore, 311 respondent podiatrists appear to make this the largest survey of Australian podiatrists published to date. Lastly, the authors are cognisant of potential response bias by participants completing the survey as they believe the investigators would like it to be completed. The authors attempted to address this in the participant information prior to survey completion which advised participants that the survey results were anonymous and “this survey is not a test of your knowledge. Answers that reflect the way you actually practice will give the most meaningful results.”
Our survey did not gather information on why guideline recommendations were or were not followed. Fife et al. found that there are a number of specific barriers to the utilisation of best practice in diabetic foot ulcer care. For example, the TCC is time consuming, difficult to apply, and there are risks involved with its use. [14]. Further research examining these and other barriers and enablers at both the individual and system level are strongly recommended if we are to ensure people with diabetes foot complications have access to best practice care in Australia. This study suggests that public sector podiatrists may be implementing best practice recommendations in diabetic foot care significantly more often than private sector podiatrists. Considering the increasing prevalence of diabetes and the limited public health budget it is important the reasons for these differences are identified and addressed where possible [41].
