Deborah E. Schoen

Temporal trends in initial and recurrent lower extremity amputations in people with and without diabetes in Western Australia from 2000 to 2010

AIMS To examine temporal trends in lower extremity amputations in people with type 1 diabetes, type 2 diabetes and cardiovascular disease (CVD) without diabetes in Western Australia (WA) from 2000 to 2010. METHODS We used linked health data to identify all non-traumatic lower extremity amputations in adults aged ≥20 years with diabetes and/or CVD from 2000 to 2010 in WA. Annual age- and sex-standardised rates of total, initial and recurrent amputations, stratified by major and minor status, were calculated for type 1 and type 2 diabetes, and CVD without diabetes, from the at-risk population for each group. Age- and sex-adjusted trends were estimated from Poisson regression models. RESULTS 5891 lower extremity amputations were identified. Peripheral vascular disease (71%), hypertension (70%) and chronic kidney disease (60%) were highly prevalent. Average annual rates of total amputations were 724, 564 and 66 per 100,000 person-years in type 1, type 2 diabetes and CVD without diabetes respectively. Rates of initial amputations fell significantly by 2.4%/year (95% CI -3.5, -1.4) in type 2 diabetes, with similar declines for type 1 diabetes and CVD without diabetes (interaction p=0.96), driven by large falls in major amputations. There was limited improvement in recurrence rates overall, with recurrent minor amputations increasing significantly in type 2 diabetes (+3.5%/year, 95% CI +1.3%, +5.7%). CONCLUSION Lower extremity amputation rates have declined at a population level in people with diabetes and CVD without diabetes, suggesting improvements in prevention and management for this high-risk patient group, however limited declines in recurrent amputations requires further investigation.

Clinical decision support software for diabetic foot risk stratification: development and formative evaluation

BackgroundIdentifying people at risk of developing diabetic foot complications is a vital step in prevention programs in primary healthcare settings. Diabetic foot risk stratification systems predict foot ulceration. The aim of this study was to explore the views and experiences of potential end users during development and formative evaluations of an electronic diabetic foot risk stratification tool based on evidence-based guidelines and determine the accuracy of the tool.MethodsFormative evaluation of the risk tool occurred in five stages over an eight-month period and employed a mixed methods research design consisting of semi-structured interviews, focus group and participant observation, online survey, expert review, comparison to the Australian Guidelines and clinical testing.ResultsA total of 43 healthcare practitioners trialled the computerised clinical decision support system during development, with multiple software changes made as a result of feedback. Individual and focus group participants exposed critical design flaws. Live testing revealed risk stratification errors and functional limitations providing the basis for practical improvements. In the final product, all risk calculations and recommendations made by the clinical decision support system reflect current Australian Guidelines.ConclusionsDevelopment of the computerised clinical decision support system using evidence-based guidelines can be optimised by a multidisciplinary iterative process of feedback, testing and software adaptation by experts in modern development technologies.

An electronic diabetes foot risk calculator

Background The MMEx Diabetes Foot risk calculator was designed in response to the WA Department of Health’s High Risk Foot Model of Care to improve the systematic approach to screening and treatment for high risk foot complications and the 2011 National Health and Medical Research Council’s (NHMRC) National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes that state, “a solution to the current impasse on the integration of decision support tools into medical software is needed urgently” and “any trained health professional can complete a foot risk stratification”. Teaching foot assessments is straightforward, but practitioners have difficulty with risk stratification and deciding appropriate follow-up and referral.

Diabetes foot care education movies for Aboriginal people: Bran nue leg

Adequate knowledge of diabetes is crucial to diabetes care and the prevention of diabetes complications. Aboriginal people are three times more likely than non-Aboriginal people to have diabetes in Australia. In Western Australia, Aboriginal people experience significantly higher rates of lower extremity amputation than nonAboriginal people, and 98% of these amputations are diabetes related. Additionally, Aboriginal people may experience barriers to accessing or utilising diabetes education in Western Australia. The need for culturally appropriate diabetes education for Aboriginal people appears in four current Western Australia Department of Health documents.

Benchmarking healing times for diabetic foot ulcerations and investigating the influence of peripheral arterial disease and infection

Methods Data was collected prospectively between October 2004 and September 2008 for all patients with diabetes who presented with a DFU. All DFU that healed within the time frame of the study were included. Data was collected for the following variables: presentation date, healing date, gender, location, presence of peripheral neuropathy (PN), presence of PAD, presence of infection (STI or OM), and whether the DFU was reviewed on the Multidisciplinary Foot Ulcer Clinic (MDFUC).

A retrospective audit of active Charcot neuroarthropathy in a tertiary hospital podiatry department

Background Charcot Neuroarthropathy (CN) is a major foot complication of diabetes which may lead to debilitating foot deformity, recurrent ulceration and lower limb amputation. Podiatrists play a key role along the continuum of the disease from diagnosis to treatment to long-term follow-up and monitoring. The aim of this clinical audit was to gather data on patients managed with active CN in a tertiary hospital podiatry department.