International Wound Journal ISSN 1742-4801
ORIGINAL ARTICLE
Effective management of patients with diabetes foot ulcers:
outcomes of an Interprofessional Diabetes Foot Ulcer Team
Rajna Ogrin1,2 , Pamela E Houghton3 & G William Thompson4
1 School of Physical Therapy, University of Western Ontario, London, ON, Canada
2 Centre of Wound Management, Royal District Nursing Service Institute, St Kilda, VIC, Australia
3 Faculty of Health Sciences, University of Western Ontario, London, ON, Canada
4 Department of Internal Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
Key words
Diabetes-related foot ulcer; Healing;
Interprofessional care; Patient-centred care;
Quality of life
Correspondence to:
R Ogrin
RDNS Institute
31 Alma Road,
St Kilda
VIC 3182
Australia
E-mail: rogrin@rdns.com.au
doi: 10.1111/iwj.12119
Ogrin R, Houghton PE, Thompson GW. Effective management of patients with
diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team.
Int Wound J 2015; 12:377–386
Abstract
A longitudinal observational study on a convenience sample was conducted between
4 January and 31 December of 2010 to evaluate clinical outcomes that occur when a
new Interprofessional Diabetes Foot Ulcer Team (IPDFUT) helps in the management
of diabetes-related foot ulcers (DFUs) in patients living in a small urban community
in Ontario, Canada. Eighty-three patients presented to the IPDFUT with 114 DFUs
of average duration of 19·5 ± 2·7 weeks. Patients were 58·4 ± 1·4 years of age and
90% had type 2 diabetes, HbA1c of 8·3 ± 2·0%, with an average diabetes duration
of 22·3 ± 3·4 years; in 69% of patients, 78 DFUs healed in an average duration of
7·4 ± 0·7 weeks, requiring an average of 3·8 clinic visits. Amputation of a toe led
to healing in three patients (4%) and one patient required a below-knee amputation.
Six patients died and three withdrew. Adding a skilled IPDFUT that is trained to
work together resulted in improved healing outcomes. The rate of healing, proportion
of wounds closed and complication rate were similar if not better than the results
published previously in Canada and around the world. The IPDFUT appears to be
a successful model of care and could be used as a template to provide effective
community care to the patients with DFU in Ontario, Canada.
Introduction
Foot ulcers in people with diabetes (PWD) are a complex
health problem and require provision for care by many
different health professionals (1). As a result, multidisciplinary diabetes-related foot ulcer (DFU) services have
been developed and have shown to effectively reduce major
amputation rates by over 80% and minor amputation rates by
over 70% (2).
The complexity of the health problems and the increasing specialisation of health care workers involved in care
provision have led to the promotion of an interprofessional
collaborative (IPC) approach to patient care (3). Multidisciplinary care suggests independent input by team members of
different disciplines on the same task, whereas IPC approach
involves participants taking into account the contributions of
other team members (4) and a melding of responsibilities by
team members (3). While research in this area is still growing,
improvement in care effectiveness for persons with chronic
disease (5), higher degrees of work satisfaction in health care
workers (6) and improved patient satisfaction with care (7)
have been shown when using an IPC model.
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Key Messages
• an
Interprofessional Diabetes Foot Ulcer Team
(IPDFUT) model of care can deliver wound healing
outcomes comparable if not improved on care provided
in clinics, published previously
• an IPDFUT was developed and managed 83 patients
over a 12-month period
• in 69% of patients 78 ulcers healed in an average
duration of 7·4 ± 0·7 weeks, requiring an average of
3·8 clinic visits
• amputation of a toe led to healing in three patients (4%)
and one patient required a below-knee amputation
377
R. Ogrin et al.
Team care effectively manages patients with diabetes foot ulcers
Much research has been undertaken to identify and manage
risk factors associated with foot ulcers in PWD, however
there is less information available on the effect of an IPC
approach on patient health outcomes. A new team was
set up in a small rural city in South Western Ontario to
manage PWD who have foot ulcers, utilising a patient-centred
IPC model.
This project aims to evaluate the effectiveness of the
Interprofessional Diabetes Foot Ulcer Team (IPDFUT) by
prospectively collecting data on ulcer healing rates, number
of patients whose ulcers recur, hospitalisations, length of
stay (LOS) in hospital, amputations and quality of life of
patients obtaining care through the IPDFUT, and comparing them to international figures. We describe strategies
used to develop the IPDFUT team and report the clinical
outcomes that can be expected when such a team works
effectively to provide a cohesive and co-ordinated program
of care.
Objective
To evaluate patient health outcomes in PWD with foot ulcers
who received care from IPDFUT including:
(1) Healing rates as measured by percentage reduction in
wound surface area measured after 4 weeks.
(2) Complication rates including lower extremity amputation rates, foot ulcer recurrence and infection rates.
(3) Changes in patient’s quality of life after team involvement and healing of foot ulcer.
(4) Utilisation of health care services: including hospitalisation rates and length of hospital stay of PWD for
foot complications.
Patient outcomes achieved with the IPDFUT approach are
compared to available data collected from the local region in
Ontario, Canada, and to figures reported in the literature when
optimal team-based care is provided in other sites in Canada
and around the world.
Setting
The IPDFUT was located in a community-based clinic in
a small rural area in Ontario, Canada. This is a regional
treatment centre for approximately 2·5 million people living
within a 400 km radius. According to the Canadian Health
Care Act, essential health care services must be provided
universally and without cost to the patient, therefore, most
hospital-based care is available to all individuals with diabetes
in Canada. Certain outpatient services (chiropody, physical
therapy and other allied health providers) and medically
required devices (orthotics and footwear) are not covered
within the universal health care plan.
Interprofessional Diabetes Foot Care Team (IPDFUT)
The staff members of the IPDFUT included: a chiropodist
with expertise in managing PWD with foot complications
(DFU chiropodist), a community chiropodist, a wound nurse,
an orthotist, two dietician-diabetes educators and one nursediabetes educator, a social worker, a clinical psychologist,
an infectious diseases physician and a physical therapist.
The IPDFUT underwent structured team building, following a patient-centred, interprofessional conceptual framework
by Orchard et al. (8). This included four 3-hour online sessions and six 2-hour face-to-face workshops. The IPDFUT
developed links with the orthopaedic, vascular surgery and
endocrinology services at the local tertiary teaching hospitals.
Clinical care followed the International Working Group on the
Diabetic Foot (IWGDF) guidelines and consensus documents
(9). Training in clinical care of PWD with foot ulcers was
provided to clinicians who were unfamiliar with the IWGDF
documents in a 2-day workshop prior to the starting of the
clinic services, followed by partnering with a clinician expert
in this field within the IPDFUT clinic.
The IPDFUT started seeing patients in January 2010.
Initially the clinic operated for two half days a week and
increased to three half days per week by June 2010 because
of an increase in the number of referrals.
Clinical care
Methods
Study design
A prospective observational study was conducted on a convenience sample of patients with DFU who attended the IPDFUT
in a small rural city in Canada in 2010. Ethics approval was
obtained through the local university Human Research Ethics
Committee. It was felt to be unethical to have a comparison group not receiving team care, as the region did not
have a multidisciplinary alternative, therefore patient’s health
data are presented descriptively and are broadly compared to
international studies, to ascertain effectiveness of care. There
was no possibility to collect data for patients not seen by
the IPDFUT. Continuous data were expressed as means and
standard deviations. Non-continuous variables were presented
as a percentage. The paired t-test was used to compare variables before and after the intervention. Significance level for
statistical testing was set at 0·05.
378
As mentioned earlier, patient assessment, diagnosis and management was guided by the IWGDF consensus documents and
guidelines, by utilising the study team members and existing
services if patients were already enrolled in other services. The
comprehensive evaluation by the IPDFUT members provided
directions for a program of care that addressed factors known
to interfere with healing and to prevent ulcer recurrence and
new DFU formation. This most often included treating underlying infection, if present, debridement of peri-ulcer callus
and necrotic tissue in the wound base, modifying the wound
dressing protocol, initiating pressure redistribution, providing extensive education, addressing glycaemic level management, diet, exercise and psychosocial aspects. If at all possible, IPDFUT care was linked with local, established, health
care services and resources. For example, if regular dressing changes were required for a patient and a caregiver was
unavailable or unable to undertake them, local home care services were organised to provide this. If the patient consented,
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
R. Ogrin et al.
frequent communication was undertaken by the team with
the local family physician and other health care providers
involved in the patient care regarding what team care was
being provided.
All costs of additional dressings and pressure redistribution
equipment or supplies were paid for by the study funds,
including the time of the health care providers who were
involved in the study; therefore no out-of-pocket expenses
were required by patients for the clinical care provided by
the IPDFUT.
Pressure redistribution is costly, but essential to heal the
majority of wounds in PWD with foot ulcers (10), therefore
the decision was made to fund this through project funds.
The pressure redistribution used by the team predominantly
involved a multilayer felt adhered to the foot (generally of a
minimum 30-mm thickness), used in addition to an air-pump
walker brace device, if the patient could tolerate it. In general,
this padding was kept dry and in place for a week, after
which the patients returned to the clinic for review. Patients
were also asked to reduce their weight-bearing activity.
Total contact casting was tried initially, but found to be
unsuccessful in this clinic setting and patient group. If a walker
brace was not possible, an off-the-shelf rocker soled postoperative shoe was utilised, usually in addition to the padding.
Links were developed with the orthopaedic and vascular
surgeons from the local hospital, with speedy review of
patients when referred. The orthopaedic surgery appointments
were undertaken with the DFU chiropodist in attendance to
facilitate good communication and handover of patient care.
Once healed, patients were provided with long-term pressure redistribution, predominantly custom molded orthotics,
slippers in which the custom orthotics were fitted, in some
instances outdoor shoes and extensive education. Patients were
linked to local foot care services, if available, or provided
guidance on self foot care, if no local services were available or patients could not afford foot care services. The local
family physician and other health care providers involved in
the patient care were notified of any plans. All patients were
advised to contact the team as soon as possible, should there
be any deterioration in the skin integrity of their feet during the study period. When there was deterioration of skin
integrity, the patient contacted an IPDFU team member, and
was seen at the next mutually convenient appointment, with
verbal advice provided on preventing further deterioration
prior to the appointment.
Sample
Eligible patients seen by the new IPDFUT were PWD with a
foot ulcer, aged 18 years or older and were able to attend the
clinic for regular appointments. Patients were also referred by
primary care physicians to the IPDFUT from local hospital
clinics, family practices, home care services and health
practitioners working in the field.
Data collection
All patients who were referred to the IPDFUT from 4 January
to 31 December 2010 with an open DFU were asked to
Team care effectively manages patients with diabetes foot ulcers
participate in the study. After obtaining consent, the following
information from patients was collected during the initial
assessment visit:
(1) Demographic information: patient age and sex.
(2) Medical history: including information about diabetes and related secondary complications (retinopathy, renal disease, obesity, cardiovascular conditions
including hypertension). Type of diabetes; duration
of diabetes; HbA1c (%); presence of diabetes-related
complications including retinopathy, nephropathy,
cardiovascular disease or hypertension.
(3) DFU history including details about how and when
the current ulcer started, past and present wound care
and any details about previous ulcerations of either
foot.
(4) Physical examination (foot characteristics and ulcer
description), foot deformity or amputation, arterial
insufficiency or loss of protective sensation (LOPS).
(5) Wound assessment including location, size, depth,
appearance and the presence of infection.
Clinical outcomes were also collected prospectively over
the time period the patients received care from IPDFUT. This
included measurements of:
(1) Healing rate measured by determining wound surface area using acetate tracing and digitisation using
planimetry.
(2) Complication rate including ulcer recurrences, ulcer
infections, amputations, revascularisations and deaths.
(3) Quality of life using the Cardiff Wound Impact
Schedule (CWIS) (11) measured at baseline and after
treatment in those patients with healed ulcers.
(4) Health service utilisation rate expressed as the number
of patients admitted to hospital and the length of stay
for each admission.
All the data was included on an intention-to-treat basis: data
on patients who died and those who withdrew was kept within
the database for evaluation.
Results
There were 83 PWD seen by the team for foot ulcer management in the 12-month period with demographic data, medical
and diabetes history as shown in Table 1. Three patients withdrew from the study (3·6%): one due to stroke that occurred
after the first appointment, one due to anxiety disorder issues
and one declined to participate, being satisfied with their current care. Assessment of risk factors for amputation identified
95% of patients present with LOPS and a high proportion
of patients with joint deformity (69%). Evaluation of ankle
brachial pressure index (ABPI) suggested that concomitant
peripheral arterial disease was likely in about 12% or 8 of
83 patients, although 14 participants’ arteries were incompressible, previous amputation in 20% and self care issues
in 53% of patients. The majority of ulcers were caused by
a combination of LOPS and joint deformity (34%), trauma
(20%), footwear (15%) and abnormal biomechanics (15%).
Other causes included amputation (8%), dry skin cracks in
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
379
R. Ogrin et al.
Team care effectively manages patients with diabetes foot ulcers
Table 1 Demographic and medical data of patients with diabetes-related
foot ulcers seen by IPDFUT
Original
wounds
Patient number
Number of ulcers
Patient age (mean years ± SEM)
Male (n, %)
Type 2 diabetes (n, %)
Duration of diabetes (mean years ± SEM)
HbA1c (mean % ± SD). Data missing for 16 participants
Presence of retinopathy (n, %). Data missing for 7
participants
Presence of nephropathy (n, %). Data missing for 5
participants
Presence of cardiovascular disease (n, %). Data missing
for 6 participants
Presence of obesity (n, %). Data missing for 6 participants
Presence of hypertension (n, %). Data missing for 2
participants
Diabetes management medications taken (n, %). Data
missing for 2 participants
Insulin only
Oral hypoglycaemic agents only
Both Insulin and oral hypoglycaemic agents
Hypercholesterolaemia agents taken (n, %). Data missing
for 2 participants
Statins taken
Other lipid lowering agent
Hypertension medications. Data missing for 2 participants
Number taken (mean number ± SD)
ACE inhibitors (n, %)
Participants taking antibiotics at first appointment (n, %).
Data missing for 2 participants
Self care issues, n (%)
83
114
58·43 ± 1·37
64 (77%)
75 (90%)
22·27 ± 3·39
8·26 ± 1·95
18 (24%)
24 (31%)
34 (44%)
41 (53%)
64 (79%)
19 (23%)
23 (28%)
37 (46%)
55 (68%)
2 (2%)
1·27 ± 0·85
32 (40%)
27 (33%)
44 (53%)
heels (4%), pressure due to long-term hospital stay (1%), nail
deformity (2%) and oedema (1%).
Foot wound characteristics at baseline are reported in
Table 2, including grading of wounds following the University
of Texas classification system (12).
On average, patients were followed-up by the IPDFUT
for care of their ulcers for a mean period of 10·41 weeks
(median 7·0, range 1–45). Information regarding follow-up
after healing was not collected, as the purpose of the study was
to evaluate the effect of clinical care on healing, rather than
longitudinal outcomes. Patients were discharged after their
wounds had healed, being provided with appropriate pressure
redistribution equipment and either access to regular foot care
or given training to undertake self foot care. However, patients
were strongly encouraged to return to the clinic during the
study period, if the skin integrity of their feet deteriorated.
Wound healing
Wound healing outcomes are shown in Tables 3 and 4. In
69% of patients receiving care from IPDFUT communitybased clinic, wounds healed in an average of 7·35 ± 0·72
weeks and required 3–4 visits to the clinic. There was no
difference in ages between patients who developed new
380
Table 2 Foot ulcer characteristics documented at baseline (initial visit)
Duration of ulcer (mean weeks ± SD)
Area of ulcer (mean cm2 ± SD). Data missing for four
participants
Depth of ulcer (mean cm ± SD). Data missing for four
participants
Ulcer location, n (%)
Forefoot total
Lesser toes
Hallux
Midfoot total
Rearfoot total
Plantar total
Wound severity [University of Texas grading
system (12)]
1A
Superficial wound, not involving tendon, capsule
or bone, n (%)
1B
1A and infection, n (%)
1C
1A and ischaemia, n (%)
1D
1A and infection and ischaemia, n (%)
2A
Wound penetrating to tendon or capsule, n (%)
2B
2A and Infection, n (%)
3A
Wound penetrating to bone or joint n (%)
3B
3A and infection, n (%)
3C
3A and ischaemia, n (%)
3D
3A and infection and ischaemia, n (%)
Soft tissue infection identified at initial visit, n (%)
Osteomyelitis present at initial visit, n (%)
19·48 ± 28·33
1·93 ± 3·39
0·65 ± 0·87
66 (58%)
21 (18%)
24 (21%)
13 (12%)
13 (12%)
51 (45%)
66 (58)
13 (11)
12 (10)
1 (1)
1 (1)
6 (5)
2 (2)
11 (10)
1 (1)
1 (1)
30 (36%)
20 (24%)
(60·44 ± 11·07 years) or recurrent ulcers (59·13 ± 17·01
years) compared with patients who did not (n = 52;
58·87 ± 11·92 years). However those patients who developed
both new and recurrent ulcers were significantly younger
(n = 5, 45·60 ± 11·55 years) than those who did not develop
any further foot skin breakdown (t(2, 55) = 2·38, p = 0·02)
or patients who only developed a new ulcer (t(2, 21) = 2·63,
p = 0·02).
DFU complication rate
After healing, 32 wounds in 23 patients re-ulcerated. Eightytwo percent of these recurrent wounds were healed in an
average time of 7·22 ± 1·78 weeks (see Table 4). New ulcers
occurred in 23 patients. They were treated by the IPDFUT
and healing occurred in 56% of cases. The average healing
time of these new ulcers was 5·4 ± 0·72 weeks. Five patients
developed both new and recurrent ulcers. Taken together,
original, recurrent and new ulcers totalled to 168 ulcers, where
55% of patients and 67% of ulcers completely healed – that
is, 55% of patients were ulcer-free by the end of the study
period. Table 3 shows the total number of ulcers that healed
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
R. Ogrin et al.
Team care effectively manages patients with diabetes foot ulcers
Table 3 Patient health outcomes – wound healing
Patients with healed ulcers, n (%)
Proportion of ulcers healed (%)
Time to heal (mean weeks ± SD)
Time to heal (median weeks, range)
Number of appointments to healing (median, range)
Time to heal neuropathic wounds (n = 64, 82%) (mean weeks ± SD)
(median weeks, range)
Time to heal neuroischaemic wounds (n = 9, 12%) (mean weeks ± SD)
(median weeks, range)
Time to heal other wounds (n = 5, 6%) (mean weeks ± SD)
(median weeks, range)
Percentage of ulcers healed at:
4 weeks
8 weeks
12 weeks
16 weeks
26 weeks
48 weeks (maximum follow-up, although last ulcer healed at 39 weeks)
Recurrence rate, n (%)
57 (69%)
78/114 = 68%
7·36 ± 6·39
6·00 (1–39)
3·0 (1–30)
7·64 ± 6·45
7·00 (1–38)
1·78 ± 7·00
5·00 (2–20)
3·00 ±2·92
2·00 (1–7)
Percentage of all wounds
28·1
45·6
59·6
64·0
67·5
68·4
13 patients (16%)
22 wounds (19%)
23 patients (28%)
32 wounds (28%)
11 (13%)
2 (2%)
Patients with new ulcers, n (%)
Number of people who developed soft tissue infections, n (%)
Number of people who developed osteomyelitis, n (%)
Percentage of healed wounds
41·0
66·7
87·2
93·6
98·7
100·0
Data provided for 83 patients for their original 114 wounds.
82% of wounds that recurred healed; average healing time 7·22 + 1·78 weeks.
56% of new wounds that developed healed; average healing time 5·4 + 0·72 weeks.
Table 4 Complications for patients while being seen by the IPDFUT
Total
Amputations (n, %)
Hospitalisations (n, %)
Episodes†
Length of hospital stay (days)‡(mean ± SD)
Length of hospital stay (days) (median, range)
Deaths
4 (5%)
Two great toes
One lesser toe
One BKA
16 (19%)
18 episodes
9·76 ± 18·25
4·0 (0·5–73·0)
6 (7%)
Patients with
healed ulcers
Patients with
ulcers that
did not heal
Statistical analysis
(Chi square and student t -test)
3
1 (BKA)*
χ2 (3, N = 114) = 125·5, p < 0·001
10 (12%)
11 episodes
12·9 ± 23·5
4·0 (1·0–73·0)
6
6 (7%)
7 episodes
5·29 ± 4·42
4·0 (0·5–14·0)
0§
χ2 (3, N = 114) = 115·2, p < 0·001
t (2, 15) = –0·84, p = 0·42
N/A
χ2 (3, N = 114) = 57·5, p < 0·001
*Although unknown, we assumed the foot ulcer was unhealed at the time of the below knee amputation (BKA).
†Two patients (one in each group) were admitted to hospital on two occasions.
‡Length of hospital stay was calculated per episode of admission (not per patient).
§One healed their original and a new ulcer, however this person did not heal an additional new ulcer prior to death.
at 4-week intervals. The mean healing time of all ulcers was
6·6 ± 5·9 weeks, taking an average of four appointments.
Data on the number of people who developed soft tissue
infections and osteomyelitis are presented in Table 4.
Four patients required lower leg amputations, all of whom
had bone destruction and septic arthritis identified at the
time of initial visit (see Table 2). Three of the four patients
were immediately referred to orthopaedic surgery where two
underwent toe amputation and one a below-knee amputation.
The fourth patient was treated by the IPDFUT for 6 weeks and
underwent toe amputation after antibiotic treatment proved
unsuccessful (see Table 4).
Six people died during the study period (see Table 4).
Quality of life
The average CWIS scores for all patients with DFUs who
completed the questionnaire at the time of the initial assessment were 69·92 ± 2·60 social life; 63·84 ± 2·42 physical living; 36·74 ± 2·12 well being; 6·14 ± 0·26 global quality of
life; 5·62 ± 0·26 satisfaction with quality of life.
Re-evaluation of CWIS at least 2 weeks after wound
closure revealed that there was significant improvement
across all domains of the CWIS, as shown in Table 5. Of
note, only 36 of the total 83 patients (44%) completed CWIS
on the second occasion, approximately 2 weeks after the
wound closure, whereas 55% were ulcer-free by the end of
this study. A comparison of the values for each domain of
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
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R. Ogrin et al.
Team care effectively manages patients with diabetes foot ulcers
Table 5 Patient quality of life before and after treatment by Interprofessional Diabetes Foot Ulcer Team (IPDFUT) resulting in ulcer healing (n = 36)
Initial assessment
After wound
healed
Difference between preand post-IPDFUT, repeated
measures t -test
70·89 ± 4·09
63·45 ± 3·76
36·43 ± 2·98
6·25 ± 0·43
6·21 ± 0·52
82·44 ± 3·21
84·36 ± 3·03
58·43 ± 4·05
7·47 ± 0·37
7·36 ± 0·45
t (1, 35) = –3·00, p = 0·005
t (1, 35) = –6·40, p < 0·001
t (1, 34) = –6·30, p < 0·001
t (1, 35) = –3·10, p = 0·004
t (1, 35) = –2·33, p = 0·025
Cardiff Social Life (mean ± SEM) (n = 36)
Cardiff Physical Symptoms (mean ± SEM) (n = 36)
Cardiff Wellbeing (mean ± SEM) (n = 35)
Cardiff Global quality of life (mean ± SEM) (n = 36)
Cardiff satisfaction with quality of life (mean ± SEM) (n = 36)
the CWIS revealed that mean scores obtained at baselines
were similar for individuals with and without healed wounds
(data not shown). There were also no differences detected
in other variables (age, duration of diabetes, baseline wound
duration, ulcer area and depth) compared for patients who did
and did not complete the CWIS after healing. Patients who
developed both new and recurrent foot ulcers during their
treatment in the IPDFUT had reduced global quality-of-life
subscale of the CWIS at baseline (4·40 ± 4·04) compared
with those who developed new ulcers (6·33 ± 2·64), (t(2,
21) = 2.17, p = 0.05).
Hospital admissions
While patients were receiving care from the IPDFUT team, 16
individuals were admitted to hospitals, 2 of whom were admitted twice (total hospital admission episodes = 18), data shown
in Table 4. One patient who had an unhealed ulcer underwent
revascularisation during hospitalisation. Five admissions were
unrelated to the foot ulcer (bowel surgery, stroke, heart failure,
non-specific infection, day surgery). There were no significant
differences between hospitalisation rate and duration in individuals who had healed or unhealed wounds while they were
seen by the IPDFUT.
Length of hospital stay for patients admitted into hospital
are shown in Table 4.
Discussion
This was a prospective, observational study on a convenience
sample and included a community-based IPDFUT in Ontario,
Canada, which was developed, implemented and evaluated,
with data collected over a 12-month period. There was no
local multidisciplinary group in the region to compare it to,
and given the international consensus (9) that team care is
necessary to effectively manage this patient group, it was
considered unethical to undertake a randomised controlled
trial to compare this service to current care.
In the year 2010, the interprofessional team saw 83 PWD
who were referred to the clinic with 114 original foot ulcers.
Because many patients had either recurrent or new ulcers
that had developed over the course of their treatment, the
total number of foot ulcers treated over the 1-year period
was 168. The patient population recruited into this study
included those with primarily type 2 diabetes (90%) present
for an average of 22 years, three quarters of them were taking
insulin with or without oral hypoglycaemic agents. Many of
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the patients in the study had coexisting conditions commonly
associated with long-standing diabetes including hypertension
(79%) and obesity (53%). Between 24 and 31% of patients
in this study had developed serious complications of diabetes
such as nephropathy and retinopathy. The majority of wounds
were relatively small and superficial, with the majority located
on the forefoot and more commonly on the plantar surface
of the foot. Subjective review of their history with foot
wounds revealed that more than half (57%) of the patients
had a previous foot ulcer and often they had self care issues,
reducing their ability to manage their foot care effectively,
such as obesity, arthritis, poor vision (preventing them from
reaching or seeing their feet) (13), depression and other
psychosocial issues (14). At the time of inclusion, all the PWD
were receiving care from primary physicians and/or home care
nursing services and despite this their wounds remained open
for an average of over 5 months. In addition, 36% of patients
had a soft tissue infection and 24% had osteomyelitis at the
time of their initial visit. After the commencement of IPDFUT
service to this group of patients with a history of non-healing
wounds, 69% of wounds has healed in an average of 7·35
weeks.
Our clinical outcomes are superior to those reported in
another Canadian site located in Manitoba (15). Rose et al.
involved a team of surgeons and foot specialists who provided
a hospital-based service to outpatients in the community with
DFUs. Comprehensive foot care was provided over a 2year period to 325 people with 697 DFUs and complete
healing was achieved in 41% of patients in an average
healing time of 47 ± 59 weeks. The healing rates reported
after 4 weeks of care from the IPDFUT team was 28%, far
superior to those reported when PWD and DFU received
current community-based care that is typically provided in
Ontario. Shannon et al. reported that patients with DFUs had
a 12% chance of completely healing after 4 weeks of current
community-based care and that mean healing time for all
types of chronic wounds treated in this region of Canada
was 24 weeks (16). However, in 2006 a new systematic and
multidisciplinary approach in another region of Ontario was
piloted and evaluated after 4 weeks, including physician and
nurse DFU assessment and management and the inclusion of
chiropody, providing pressure redistribution to 60% of the
patients in the study (10). This input saw surface areas reduce
significantly, by almost 60% (t = 2·31; p = 0·023), indicating
a high likelihood of complete healing (17). These figures
compare very well with that of the IPDFUT. However this
Canadian project was undertaken over 3 months with patient
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
R. Ogrin et al.
intervention of 4-weeks duration, and no further detail was
given regarding how this care was provided. While it is
anticipated that full healing would have occurred at a similar
timeframe as in this study, we do not have this information.
A mean healing time of 7·3 weeks achieved by the IPDFUT
was also comparable with healing outcomes reported by
other international groups having experience in treating PWD
with foot ulcers. In an US study, the average time taken
to heal neuropathic ulcers was approximately 11 weeks, for
neuroischaemic ulcers was 18 weeks and for ischaemic ulcers
was 19 weeks (18). Mean time to healing of DFUs reported
from sites in the UK was 11·1 weeks (19,20). In another UK
study comparing four clinics, mean time to healing varied
between 4·3 and 13 weeks (21), with a median of 14·5 weeks
(22). Mehmood et al. treated PWD having foot ulcers in
Pakistan, and healed the wounds in an average of 11·5 weeks
(23).
The proportion of patients who had completely healed
wounds in this study was 69%. This rate of healed
ulcers is comparable to that of other studies performed
in Sweden [(24) – 65%], Scotland [(25) – 75%], France
[(26) – 78%] and superior to the number reported from
Australia [(27) – 28%] although in the latter study, patients
were primarily from an aboriginal group of individuals. In
the USA, data on healing times for DFU were collected using
large Medicare databases, and showed that 47% of ulcers
healed by 20 weeks (28). This healing outcome is similar to
what we achieved only after 8 weeks of care by using the
IPDFUT (46% of patients were completely healed) care.
The relatively short healing time and greater proportion
of healed wounds achieved by the IPDFUT may be because
of the lower incidence of ischaemia (12%) and younger age
(58 years) of the patients included in this study. The average
age of participants in other studies was in their 60s (15,25,29).
In several large observational studies, arterial disease was
present in up to 50% of the patients with a DFU (19,30,31).
Only 12% of subjects in the IPDFUT study had clinical
signs of ischaemia. While the patients in this study were
slightly younger and had a lower incidence of peripheral
arterial disease, the duration of diabetes was at higher levels
compared with other groups (15). However, a third of patients
in this study had soft tissue infection, and almost a quarter
had osteomyelitis at baseline – where approximately half of
these patients healed during the study period. We also raise
the point that a barrier to DFU healing in Canada may include
the lack of universal funding for adequate off loading. As this
was provided for all patients in this study, it may explain the
improved healing rates in comparison with other Canadian
data.
Reulceration
In this study the recurrence rate of ulcers was 19%, while 28%
of participants developed new ulcers – five participants had
ulcers that recurred and developed new ulcers as well. In total,
37·3% of patients had further problems with skin breakdown
after the initial ulcer healed. These rates of re-ulceration are
comparable to other reports from Australia which reported
a 45% re-ulceration rate (32) and from the UK which had
Team care effectively manages patients with diabetes foot ulcers
a 40% re-ulceration rate (30). A French study evaluated a
multidisciplinary diabetes foot care team which showed an
impressive re-ulceration rate of only 11% (26). While reulceration is never a desirable outcome and there is always
room for improvement in preventive measures that help to
protect further skin injury, the re-ulceration rates obtained
by the IPDFUT compare favourably to that of other centres.
More research is necessary to identify factors leading to reulceration as the IPDFUT provided patients with orthotics and
footwear, as well as slippers to wear at home. In addition,
patient-centred information and regular education was also
provided to all participants. Ongoing preventive care of the
feet for this high-risk population of PWD is an area that
requires further development.
Infection
Infection was identified at the initial visit in 36% of the
study patients. In a Europe-wide study, 54% of patients with
DFU had a wound infection at baseline upon admittance to
specialist clinics (33), and up to 45% in two UK specialist
DFU clinics (19,25), considerably higher than the rates in this
study. In this study, 13% of patients seen by the IPDFUT
developed a soft tissue infection during management. This
is a very low rate of infection, however comparison to
other clinical outcomes is limited, as this aspect was seldom
reported in the other studies that reported baseline infection
only. This value is also low when considering the high initial
ulcer infection rate.
The signs of infection can be very subtle in PWD who have
hyperglycaemia and a reduced inflammatory response. Therefore the trained and experienced clinicians of the IPDFUT may
have contributed to these lower infection rates. DFU infection
is a serious complication of foot ulcers which can be limband life-threatening. Therefore, reducing infection rate could
prevent more serious complications.
Quality of life
Measurement of quality of life in people with DFUs prior
to commencing IPDFUT care revealed that this patient
group had a low average value for all levels of sub-scores
of the CWIS, compared to data of people with unhealed
wounds obtained from the original creators of the CWIS
(11). It is unsurprising that there are lower values on the
CWIS, because this measures the impact of the wounds on
patients’ lives (11), and foot ulcer management significantly
reduces the weight-bearing ability of patients and thereby their
activeness.
The CWIS was repeated in 36 patients with healed wounds
and found to be significantly higher in all components after
wound closure. This data further supports the CWIS as a
tool to differentiate state of healing (11,34). Unfortunately we
decided not to include patients who had unhealed wounds at
the conclusion of the study to repeat the CWIS. We therefore
cannot directly compare the CWIS scores of people with
unhealed and healed wounds. In retrospect this was a lost
opportunity, although given that this tool focuses on wound
specific factors, we likely would not have seen a difference
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
383
R. Ogrin et al.
Team care effectively manages patients with diabetes foot ulcers
between healed and unhealed, and a more generic health tool
would have been more informative.
Time to heal and numbers healed
In terms of time to heal, it appears the IPDFUT has comparable healing rates to other groups, however, that there are
fewer patients with peripheral arterial disease present in this
study must be taken into consideration. In several large observational studies, peripheral arterial disease was present in up
to 50% of the patients with a DFU and was an independent
risk factor for amputation (19,30,31). This may go in some
way to explain some of the benefits obtained by the IPDFUT.
The number healed by the IPDFUT is comparable to international studies, although some studies have higher numbers of healed patients. As mentioned earlier, the participants
recruited into the IPDFUT in the later stages of the study may
have required more time to heal.
Amputations
Lower limb amputations are an unfortunate and serious
complication affecting approximately 1-2% of PWD and 85%
of lower extremity amputations are preceded by a foot ulcer
(35). This rate of amputation is much higher in PWD who
have wounds that are deeper, are infected and ischaemia is
present (12). Clinical research has shown that up to 80% of
lower extremity amputations are preventable with appropriate
team management and by following best practices (36). The
number of amputations that occurred in this study was low
(4 of 83 people or 4·8%), with three of the four being minor
(toe amputations). All of these amputations were required in
people who were assessed at baseline and found to have longstanding septic arthritis. This included one participant who
underwent treatment for osteomyelitis by the team prior to
amputation of the great toe, in order for the participant to be
assured that all avenues were explored and that amputation
was necessary for resolution. Similar rates of amputation were
found in patients seen by the IPDFUTs undertaken in the
international study clinics, with rates hovering around 6–11%
of patients (26,19,22,30). Higher amputation rates have also
been reported, with amputations performed in 15% (20) and
26% of patients (33). With the IPDFUT cohort having lower
levels of peripheral arterial disease, we would expect lower
amputation rates because it has been well established that
arterial disease is a significant risk factor for amputation in
PWD and foot ulcers (12,37,38).
Hospitalisations
In Ontario, standard care of 86 people with DFUs in 2002
resulted in 57·1% being admitted into hospital with an average
length of stay of 28·7 ± 28·1 days (39). At the major tertiary
hospital servicing this study region in 2009 there were 74
hospital admissions for PWD with a foot complication over
a 3-month period in the year prior to commencing the
IPDFUT service, with a median length of stay of 21·8 days.
Re-admissions for the same problem occurred in 59 cases.
Twenty four patients required an amputation; a rate of 32%
384
(unpublished data, London Health Sciences Centre, Ontario,
Canada). For the duration of the study, 19% of IPDFUT
patients were admitted into hospital with a mean length of
stay of 10·2 days. Other studies show that 35·7% of patients
required hospitalisation, with a mean length of stay of 26·9
days (26) and 45·7% of patients required hospitalisation, with
average hospital stay of 16·1 days (33). This study results
compare favourably to these. Again, IPDFUT patients had
low rates of peripheral arterial disease, and this may have
contributed to the lower length of stay, and low numbers
requiring hospitalisation.
Deaths
Six of the patients who were referred to the IPDFUT died
over the course of the 1-year study. This represents a
7% death rate and is reflective of the severity of illness
in people with long-standing diabetes (more than 20-years
duration). Many patients had multiple co-morbid conditions
and advanced cardiovascular disease. The death rate is similar
to the 4% and 6% reported previously in a Europe-wide study
(33) and a UK–US comparative study (20), respectively. A
higher proportion of patients died in studies where patients
were followed-up for longer periods. Pound and colleagues
followed-up patients in the UK for an average of 31 months
and 13·8% of study patients died (30), and 16·7% of patients
died in a 4-year study based in the UK (19). This study
followed-up patients for a very short duration [average 10
weeks, range 1–48 weeks] and therefore comparisons should
be limited. However, these data confirm that diabetes causes
advanced aging and premature deaths occur all too frequently
in this patient group (40).
Limitations
This is an observational study with a convenience sample of a
relatively small proportion of people estimated to have DFU
in this region. Diabetes affects over 816,000 people, or 8·8%
of Ontario’s population (41) and it has been estimated that
one in four PWD will develop a foot ulcer some time in
their lives (42), with up to 6·8% having a foot ulcer at any
one time (37). On the basis of these statistics, approximately
14,960 people in this region will have a DFU in any year.
Although we accepted all PWD having a foot ulcer who were
referred to the service over the 1-year time frame, this form
of recruitment is likely to have high sampling bias because
it would attract those individuals who were either motivated
to change or who did not have pre-existing known vascular
compromise. There were limited other management options
available for these people with a high risk for serious foot
complications. Most were being managed by their primary
care physician with or without home nursing care. There
was only one other specialist wound centre and the waiting
times were prohibitive for an initial appointment (up to
8 months).
This study was limited by the lack of a control population
apart from the benchmarking of patients to act as their own
comparator.
© 2013 The Authors
International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd
R. Ogrin et al.
Patient education and empowerment were important components of team care and patients were constantly reminded
of simple measures such as the need to use pressure
redistribution, and reduced weight-bearing activities; however,
the patient education was not evaluated.
While the quality of life questionnaire was completed for
all patients at baseline, we were limited to draw conclusions
on the impact of team care on this aspect as only patients
who were healed completed the questionnaire. However, given
that this questionnaire assesses the impact of a wound on
various aspects of living, this likely would not have altered
much in those with wounds that did not heal. Including a
general quality of life audit tool to measure change and
compare relative disability with other disorders would have
been useful.
This study was funded by a 1·5-year grant which severely
limited our ability to follow-up patients for an extended period
of time. The average follow-up time was only 10 weeks, with
a range between 1 and 48 weeks. This follow-up time is much
shorter than those currently reported in the literature between
6 months and 4 years in some studies (30,38). Therefore,
the complication rates including ulcer recurrence, amputation
and death rates are likely underestimated and comparisons
to other’s outcomes are limited. However, the fact that these
serious complications were recorded at any rate shows how
precarious the health status of this patient group is and
providing such a service requires very skilled practitioners
who are very vigilant in their monitoring of patient status
and provide a careful watch for rapid changes in medical
conditions.
Recruitment of patients to the IPDFUT was staggered, with
the final participant recruited 8 weeks before clinic closure,
therefore in patients recruited at the latter end of the study
wounds may not have had enough time to heal, and longer
average time to healing may also have increased if the study
had a longer duration.
Conclusion
The IPDFUT patient health outcomes was superior to those
obtained in this and other regions in Canada in the published
literature. Care provided by the IPDFUT to an existing group
of individuals with long standing DFUs produced healing
times that were more in line with international standards. The
IPDFUT healed ulcers relatively quickly, amputations were
few and minor and hospitalisation durations were short. It is
important to note that the number of patients with reduced
arterial flow in the IPDFUT cohort is relatively low, and
this may contribute to the good results obtained. Universally
funded off-loading in this population also likely contributed
to the results. Overall, these comparisons suggest that the
IPC patient-centred approach is able to produce good health
outcomes in patients and we recommend that this model of
health care be implemented within current health services.
Acknowledgements
We gratefully acknowledge HealthForceOntario for funding
this project; Carole Orchard for her significant support in the
Team care effectively manages patients with diabetes foot ulcers
grant application and team development; Southwest Ontario
CCAC for their support of this project; Dr. Mark Macleod
and Dr. Guy de Rose for their contributions to patient
care and willingness to be involved with the IPDFUT;
Dr. Irene Hramiak for supporting the project; Stewart Harris
and his team for supporting this project; Coloplast, ConvaTec,
Covidien, Molnlyke, Smith & Nephew, Systagenix and 3M for
their generous donation of wound dressing supplies, and all of
the IPDFUT team members for their unstinting contributions
to the project. The views expressed in this article are the
views of the authors, and do not necessarily reflect those of
HealthForceOntario.
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