How do Australian podiatrists manage patients with diabetes? The Australian diabetic foot management survey

Diabetic foot complications are a major public health problem, causing significant morbidity, mortality and burden on the broader health system [1-4]. In Australia diabetic foot complications are a leading cause of hospital admission for people with diabetes [1,4] and the most common cause of lower limb amputation [5]. The average hospital stays for diabetic foot ulcer and amputation admissions are 12 and 26 days respectively [1,4]. Diabetic foot complications also account for 8% of total deaths secondary to diabetes [1,4]. As Australia has a rapidly increasing diabetes prevalence (currently 7%), with 19.6% of those at risk of foot ulceration, the growing national diabetic foot burden requires equally considerable national evidence based management interventions to combat this significant growing burden [2,4].

Despite both the detrimental and costly effects of diabetic foot complications, effective treatments and preventions are possible [4]. Appropriate care has been shown to significantly reduce diabetes-related amputation rates [6-9]. Internationally a significant effort has been made to reduce diabetic foot complications and a large body of research now exists [10-13]. In Australia health care service providers have made substantial recent investments to try and improve care and patient outcomes for people with diabetic foot complications [4,10,12]. Best practice guidelines based on systematic reviews of the literature for the prevention and treatment of diabetic foot complications are now widely available [4,11-13].

Despite the availability of diabetic foot guidelines and the evidence for their use in improving patient outcomes, the recommendations found within these guidelines are not always adhered to in clinical practice [14-18]. Studies performed in the US report low compliance with certain guideline recommendations in diabetic foot care [14,15]. One large study of US podiatrists found a very low rate of use of the gold standard offloading treatment of total contact casting, but it did not report compliance with any other best practice guideline recommendations [15]. The elements that influence the use of guidelines in clinical practice are complex and multifaceted including individual clinician factors, broader system factors, and guideline specific factors [17,19,20].

Podiatrists play a central role in providing care for diabetic foot complications [21-23]. Most of the recommendations outlined in Australian National Evidence-Based Guideline on the Prevention, Identification and Management of Foot Complications in Diabetes apply directly to care provided by podiatrists [4]. However, there is limited literature examining how podiatrists’ clinical practice reflects evidence based practice in Australia [10,16]. One study surveying podiatry centres in Victoria reported over 60% of centres broadly used clinical guidelines when managing patients with diabetic foot disorders but did not provide further detail about compliance with specific guideline recommendations [16]. It has also been identified that the Australian Government’s Medical Benefits Schedule (MBS) does not attribute funding to many of the key evidence based recommendations outlined in the Australian guidelines, such as total contact casting or other devices rendered irremovable [24]. This shortfall in Australian Government MBS rebates for patients needing evidence based diabetic foot care in the private sector is generally supplemented via State Government funding in the public sector, therefore potentially providing public sector podiatrists greater access to evidence based diabetic foot resources than their private sector colleagues [24]. To the best of the authors’ knowledge, no studies have examined how diabetic foot care guideline recommendations are being utilised in Australia and are they utilised differently in different sectors. The aim of this study is to investigate the extent to which podiatrists in Australia are meeting current best practice guideline recommendations for the management of diabetic foot complications and to identify any differences between private and public podiatrists.

This cross-sectional study of Australian podiatrists was conducted using an online survey between May and June 2013. The school level ethical review committee at the School of Population Health, University of Queensland approved the study.

Table 4 reports podiatrists at least “often” utilise best practice for six of the ten diabetic foot ulceration assessment and management items. The other four items scored “sometimes” or less often, including grading ulcers according to the validated University of Texas Wound Classification System, use of topical hydrogel dressings, use of total contact casts and use of removable cast walkers rendered irremovable. Public compared to private podiatrists reported higher rates of use for all these items (p < 0.001), except use of topical hydrogel dressings.

Table 5 indicates the majority of respondents (74%) had access to specialist multi-disciplinary teams and at least “often” utilised these teams to refer patients with complex foot ulceration and Charcot’s neuroarthropathy. Public podiatrists reported greater access to these teams (82%) compared to private podiatrists (66%) (p < 0.01). Public podiatrists were more likely to refer patients with diabetic foot ulceration to these teams “often” (5 (4–6)) compared to “sometimes” for those in the private sector (4 (3–6)) (p <0.001). A small percentage of respondents had access to expert consultation via telehealth (11%); public podiatrists (20%) had greater access than private (1%) (p <0.001).

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].

This study provides useful initial information on Australian podiatrists’ clinical management of patients with diabetic foot disease. It appears podiatrists are generally implementing best practice guidelines in the management of diabetic foot disease with some key exceptions and these exceptions require further investigation. Identifying the barriers and enablers around these guideline recommendations would help to inform policy and funding decisions in this important area and hopefully lead to improved diabetes health outcomes, improved amputation rates and significantly reduced costs on the broader Australian health system.