One of the ways to improve diabetic foot care in Canada is to increase the rate of annual foot screening in patients with diabetes, a condition that affects 15% of adult Canadians, panelists agreed during the Canadian Association of Wound Care (CAWC) annual meeting in Toronto.
“The issue is that we will see more [diabetic foot] ulcers because the prevalence of diabetes is going up,” said James Elliott, director of Advocacy and government Relations for the CAWC.
“Ulcers have to be seen earlier, and they have to be prevented in the first place through primary screening [of the feet].”
Other complications such as retinopathy and nephropathy are typically more top of mind when clinicians see patients with diabetes, said Elliott.
A national Australian study concluded that 50% of the population with diabetes were not
examined by a health care professional within a period of one year while eye screening was performed for 80% of that population (Diabetes Care 2004; 27:688–693).
Panelists discussed barriers to improving diabetic foot care, as well as opportunities to improve diabetic foot care, in Canada. Elliott said that Canada should look to the U.K. and its National Health System as a model for preventing diabetic foot disease.
Depending on the health care system, patients with diabetes may have to cover the cost of annual foot screening, which Elliott described as an impediment to effective prevention of a diabetic foot ulcer. This cost may be in place for patients despite the fact that annual foot screening can serve to prevent or delay the development of foot complications like ulcers and their potential progression to lower limb amputations.
Prevention far cheaper than care
In terms of dollars and cents, prevention produces far more cost savings than providing care for advanced state of disease. An analysis that examined 1,677 patients with diabetes regarded as at risk or at high risk for foot ulcers and amputation concluded it would be cost effective or even cost saving to provide prevention measures such as foot screening (Diabetologia 2001; 44:2077–2087).
It is generally agreed that multi-disciplinary and inter-disciplinary care involving health care professionals such as physicians, nurses, chiropodists, and dieticians are needed for optimal care of patients with diabetes, but it may not be clear which member of the team is responsible for annual foot screening, said Elliott.
If patients need to pay out-of-pocket for items such as off-loading shoes that will help a diabetic foot ulcer heal, they may opt to go without these items, said Elliott.
Geography can be a barrier to accessing advanced foot care services, resulting in patients who live further away from a city’s core may have decreased access to services such as Doppler assessments, wound debridement, and gait assessments, a fact that was noted in a survey conducted in Ottawa, noted Elliott.
Carolyn Gall Casey, director, education, Canadian Diabetes Association (CDA), said the CDA encourages annual foot screening as a major preventive measure to avoid diabetic foot disease.
“Part of our guideline strategy is that people should be having their feet screened at least annually during their visit with primary care providers,” said Gall Casey.
Referral patterns continue to be issue
Referral patterns of care vary across Canadian jurisdictions, but that does not have to be a barrier to foot disease care. The fundamental point is that patients who need advanced care receive advanced care, said Gall Casey.
“If there are complications that go beyond primary care, the primary care provider should know where they need to send patients for care,” she said and added that patient education and education of families is an important part of overall prevention of foot disease.
“There should be teaching of people [with diabetes] to check their own feet or ensuring that a family member is checking their feet for them,” she said in an interview with The Chronicle of Skin & Allergy.
“Patients with diabetes need to be their own advocates [for their feet].”
Steps that patients can take include wearing supportive shoes, trimming their toe nails straight across, checking feet for cuts, cracks, bruises, blisters, sores, infections, and unusual markings.
They should change their socks every day, wear shoes that have low heels, and consider wearing orthotics that have been professionally fitted.
They should also avoid walking barefoot both inside and outside the home to avoid foot trauma and avoid cutting their own corns or calluses, she said.
A foot examination by a health professional should check for structural abnormalities, neuropathy, vascular disease, ulceration, and infection, explained Gall Casey.
Gall Casey agreed that low-cost options for care in the community will help to avoid the need for major interventions such as the amputation of lower limbs at a future time.
Messages about the need for improved glycemic control and the need for smoking cessation are being filtered to patients to help them understand the link between their overall health status and how it impacts healing of an ulcer and recurrence of ulcers in the future, said Gall Casey.
This article was previously published in the June 2015 edition of The Chronicle of Skin & Allergy.