Shan M Bergin

Diabetes foot disease: the Cinderella of Australian diabetes management?

Diabetes is one of the greatest public health challenges to face Australia. It is already Australia’s leading cause of kidney failure, blindness (in those under 60 years) and lower limb amputation, and causes significant cardiovascular disease. Australia’s diabetes amputation rate is one of the worst in the developed world, and appears to have significantly increased in the last decade, whereas some other diabetes complication rates appear to have decreased. This paper aims to compare the national burden of disease for the four major diabetes-related complications and the availability of government funding to combat these complications, in order to determine where diabetes foot disease ranks in Australia. Our review of relevant national literature indicates foot disease ranks second overall in burden of disease and last in evidenced-based government funding to combat these diabetes complications. This suggests public funding to address foot disease in Australia is disproportionately low when compared to funding dedicated to other diabetes complications. There is ample evidence that appropriate government funding of evidence-based care improves all diabetes complication outcomes and reduces overall costs. Numerous diverse Australian peak bodies have now recommended similar diabetes foot evidence-based strategies that have reduced diabetes amputation rates and associated costs in other developed nations. It would seem intuitive that “it’s time” to fund these evidence-based strategies for diabetes foot disease in Australia as well.

Australian Diabetes Foot Network: management of diabetes-related foot ulceration - a clinical update.

Appropriate assessment and management of diabetes‐related foot ulcers (DRFUs) is essential to reduce amputation risk. Management requires debridement, wound dressing, pressure off‐loading, good glycaemic control and potentially antibiotic therapy and vascular intervention. As a minimum, all DRFUs should be managed by a doctor and a podiatrist and/or wound care nurse. Health professionals unable to provide appropriate care for people with DRFUs should promptly refer individuals to professionals with the requisite knowledge and skills. Indicators for immediate referral to an emergency department or multidisciplinary foot care team (MFCT) include gangrene, limb‐threatening ischaemia, deep ulcers (bone, joint or tendon in the wound base), ascending cellulitis, systemic symptoms of infection and abscesses. Referral to an MFCT should occur if there is lack of wound progress after 4 weeks of appropriate treatment.

Comparison of healing rate in diabetes-related foot ulcers with low frequency ultrasonic debridement versus non-surgical sharps debridement: a randomised trial protocol.

BackgroundFoot ulceration has been reported as the leading cause of hospital admission and amputation in individuals with diabetes. Diabetes-related foot ulcers require multidisciplinary management and best practice care, including debridement, offloading, dressings, management of infection, modified footwear and management of extrinsic factors.Ulcer debridement is a commonly applied management approach involving removal of non-viable tissue from the ulcer bed. Different methods of debridement have been reported in the literature including autolytic debridement via moist wound healing, mechanical debridement utilising wet to dry dressings, theatre based sharps debridement, biological debridement, non-surgical sharps debridement and newer technology such as low frequency ultrasonic debridement.MethodsPeople with diabetes and a foot ulcer, referred to and treated by the Podiatry Department at Monash Health and who meet the inclusion criteria will be invited to participate in this randomised controlled trial. Participants will be randomly and equally allocated to either the non-surgical sharps debridement (control) or low frequency ultrasonic debridement (intervention) group (n = 322 ulcers/n = 108 participants).Where participants have more than one ulcer, only the participant will be randomised, not the ulcer. An investigator not involved in participant recruitment or assessment will be responsible for preparing the random allocation sequence and envelopes.Each participant will receive weekly treatment for six months including best practice podiatric management. Each ulcer will be measured on a weekly basis by calculating total area in centimetres squared. Measurement will be undertaken by a trained research assistant to ensure outcomes are blinded from the treating podiatrist. Another member of the research team will assess the final primary outcome.DiscussionThe primary aim of this study is to compare healing rates for diabetes-related foot ulcers using non-surgical sharps debridement versus low frequency ultrasonic debridement over a six month period. The primary outcome measure for this study is the proportion of ulcers healed by the six month follow-up period.Secondary outcomes will include a quality of life measure, assessment of pain and health care resource use between the two treatment modalities.Trial registrationAustralian New Zealand Clinical Trial Registry: ACTRN12612000490875.

The impact of socio-economic disadvantage on rates of hospital separations for diabetes-related foot disease in Victoria, Australia

BackgroundInformation describing variation in health outcomes for individuals with diabetes related foot disease, across socioeconomic strata is lacking. The aim of this study was to investigate variation in rates of hospital separations for diabetes related foot disease and the relationship with levels of social advantage and disadvantage.MethodsUsing the Index of Relative Socioeconomic Disadvantage (IRSD) each local government area (LGA) across Victoria was ranked from most to least disadvantaged. Those LGAs ranked at the lowest end of the scale and therefore at greater disadvantage (Group D) were compared with those at the highest end of the scale (Group A), in terms of total and per capita hospital separations for peripheral neuropathy, peripheral vascular disease, foot ulceration, cellulitis and osteomyelitis and amputation. Hospital separations data were compiled from the Victorian Admitted Episodes Database.ResultsTotal and per capita separations were 2,268 (75.3/1,000 with diabetes) and 2,734 (62.3/1,000 with diabetes) for Group D and Group A respectively. Most notable variation was for foot ulceration (Group D, 18.1/1,000 versus Group A, 12.7/1,000, rate ratio 1.4, 95% CI 1.3, 1.6) and below knee amputation (Group D 7.4/1,000 versus Group A 4.1/1,000, rate ratio 1.8, 95% CI 1.5, 2.2). Males recorded a greater overall number of hospital separations across both socioeconomic strata with 66.2% of all separations for Group D and 81.0% of all separations for Group A recorded by males. However, when comparing mean age, males from Group D tended to be younger compared with males from Group A (mean age; 53.0 years versus 68.7 years).ConclusionVariation appears to exist for hospital separations for diabetes related foot disease across socioeconomic strata. Specific strategies should be incorporated into health policy and planning to combat disparities between health outcomes and social status.

A questionnaire for determining prevalence of diabetes related foot disease (Q-DFD): construction and validation

BackgroundCommunity based prevalence for diabetes related foot disease (DRFD) has been poorly quantified in Australian populations. The aim of this study was to develop and validate a survey tool to facilitate collection of community based prevalence data for individuals with DRFD via telephone interview.MethodsAgreed components of DRFD were identified through an electronic literature search. Expert feedback and feedback from a population based construction sample were sought on the initial draft. Survey reliability was tested using a cohort recruited through a general practice, a hospital outpatient clinic and an outpatient podiatry clinic. Level of agreement between survey findings and either medical record or clinical assessment was evaluated.ResultsThe Questionnaire for Diabetes Related Foot Disease (Q-DFD) comprised 12 questions aimed at determining presence of peripheral sensory neuropathy (PN) and peripheral vascular disease (PVD), based on self report of symptoms and/or clinical history, and self report of foot ulceration, amputation and foot deformity. Survey results for 38 from 46 participants demonstrated agreement with either clinical assessment or medical record (kappa 0.65, sensitivity 89.0%, and specificity 77.8%). Correlation for individual survey components was moderate to excellent. Inter and intrarater reliability and test re-test reliability was moderate to high for all survey domains.ConclusionThe development of the Q-DFD provides an opportunity for ongoing collection of prevalence estimates for DRFD across Australia.

Diabetes related foot disease; ‘know thine enemy’.

Background Information describing variation in health outcomes for individuals with diabetes related foot disease (DRFD), across socioeconomic strata is lacking. Focussing on the clinical aspects of foot disease, in individuals with DRFD that reside in areas of known social disadvantage, may not result in the desired clinical outcomes. The aim of this study was to investigate variation in rates of hospital separations for DRFD and the relationship with levels of social advantage and disadvantage.

Does the new low-frequency ultrasonic debridement technology pose an infection control risk for clinicians, patients, and the clinic environment?

BACKGROUND Low-frequency ultrasonic debridement (LFUD) is a technology that uses sound waves conducted through saline mist to debride wound tissue. Whilst this technology purportedly reduces wound-healing times, the airborne mist generated is potentially problematic. Theoretically, the saline mist could carry an increased number of microbes into the surrounding environment, posing an infection control risk to the patient, clinician, and clinical environment. This research aimed to establish the degree and extent to which there is microbial spread during the use of, and following the use of, LFUD. The total number of colony forming units was identified for use of LFUD without the suction attachment (control) and with the suction attachment (intervention). METHODS This was a prospective, observational study with repeated measures across each treatment (before, during, and after). Quota sampling in a 2 × 2 × 2 factorial design was undertaken so that half of the 24 treatments were conducted at each health service (Monash Health vs Peninsula Health), in different treatment environments (inpatient vs outpatient), and half were conducted with and without suction. The use of suction was not randomized but was determined at the treating clinicians discretion. Patients treated in the inpatient environment lay on their beds, whereas patients in the outpatient environment sat in a treatment chair. RESULTS There was higher microbial count during treatment (P < .001) with a higher microbial count associated with lower ultrasound amplitude (P = .028), lower saline flow rate (P = .010), no suction attachment (P = > .001), and a larger wound area (P = .002). All were independently associated with greater microorganism aerosolization. There was no correlation between the type of handpiece selected, the presence of wound infection, and the treatment time or treatment environment. CONCLUSIONS This research has assisted in developing guidelines for cleaning of equipment and environments following treatment, as well as around the use of personal protective equipment required to protect the staff member and the patient during the use of LFUD. Additionally, recommendations have been made regarding the specific LFUD settings to reduce the risk of cross-infection to the clinic environment. These include selecting a higher ultrasound amplitude and saline flow rate as well as the use of suction where clinically possible.

Australia's 'silent pandemic' of diabetes complications: where do feet stand in this pandemic?

Background Diabetes is Australia’s leading cause of kidney failure, blindness (under 60yo), and amputation, plus, causes significant cardiovascular disease. Australia’ sd iabetes amputation rate has increased by 30% in the last decade and is one of the worst in the developed world, yet other Australian diabetes complication outcomes have improved. This paper aims to compare the national burden of disease for the four major diabetes-related complications and the availability of government funding to combat these complications, in order to determine where diabetes foot disease ranks in Australia. Methods Electronic databases, government and health websites were searched for papers (1995 – 2012) reporting Australian national diabetes-related complication numbers, incidence or prevalence rates, burden of disease, economic costs and program funding. Publications reviewed included epidemiological, health economic, evidence-based guidelines, government, Medicare and Pharmaceutical Benefits Scheme reports. Results Foot disease ranked second in numbers affected, deaths, cost per episode and overall burden of disease of the four diabetes complications in Australia. However, 50% of the national evidence-based diabetic foot disease guideline recommendations are funded via Medicare, compared to 100% of other national diabetes complication guideline recommendations. Furthermore, foot disease ranked last for additional program funding. Conclusions Findings suggest foot disease is the second leading cause of burden of disease, yet receives the least available government funding of the four major diabetes complications in Australia. This low level of clinical funding may be a major factor in Australia’s poor end stage foot outcomes (amputation rates) compared to other diabetes end stage outcomes.