Standardising practices improves ambulatory diabetic foot management and reduces amputations: the Queensland Diabetic Foot Innovation Project, 2006 – 2009

Background Diabetic foot complications are recognised as the most common reason for diabetic related hospitalisation and lower extremity amputations. Multi-faceted strategies to reduce diabetic foot hospitalisation and amputation rates have been successful. However, most diabetic foot ulcers are managed in ambulatory settings where data availability is poor and studies limited. The project aimed to develop and evaluate strategies to improve the management of diabetic foot complications in three diverse ambulatory settings and measure the subsequent impact on ospitalisation and amputation. Methods Multifaceted strategies were implemented in 2008, including: multi-disciplinary teams, clinical pathways and training, clinical indicators, telehealth support and surveys. A retrospective audit of consecutive patient records from July 2006 – June 2007 determined baseline clinical indicators (n = 101). A clinical pathway teleform was implemented as a clinical record and clinical indicator analyser in all sites in 2008 (n = 327) and followed up in 2009 (n = 406). Results Prior to the intervention, clinical pathways were not used and multi-disciplinary teams were limited. There was an absolute improvement in treating according to risk of 15% in 2009 and surveillance of the high risk population of 34% and 19% in 2008 and 2009 respectively (p 92% in perfusion, ulcer depth, infection assessment and management, offloading and education. Hospitalisation impacts recorded reductions of up to 64% in amputation rates / 100,000 population (p < 0.001) and 24% average length of stay (p < 0.001) Conclusion These findings support the use of multi-faceted strategies in diverse ambulatory services to standardise practice, improve diabetic foot complications management and positively impact on hospitalisation outcomes. As of October 2010, these strategies had been rolled out to over 25 ambulatory sites, representing 66% of Queensland Health districts, managing 1,820 patients and 13,380 occasions of service, including 543 healed ulcer patients. It is expected that this number will rise dramatically as an incentive payment for the use of the teleform is expanded

Factors associated with healing of diabetes-related foot ulcers: observations from a large prospective real-world cohort

Factors associated with healing of diabetes-related foot ulcers: observations from a large prospective real-world cohor

Incidence rates of foot-related hospitalisation (admissions and bed days) and amputation (total, minor and major) cases amongst persons with diabetes in the estimated diabetes population (per 1,000 person-years) and general resident population (per 100,000 person-years) in Queensland from 2005 to 2010.

<p>95% CI: 95% Confidence Intervals</p><p>^ Chi-squared tests of trend used unless otherwise indicated</p><p># Rates are standardised to the age and sex distribution of the general resident population in the year 2006 and presented as per 100,000 person-years of the general Queensland resident population</p><p>* <i>p</i> < 0.05.</p><p>Incidence rates of foot-related hospitalisation (admissions and bed days) and amputation (total, minor and major) cases amongst persons with diabetes in the estimated diabetes population (per 1,000 person-years) and general resident population (per 100,000 person-years) in Queensland from 2005 to 2010.</p

ICD codes (ICD-10-AM) used to identify a principal diagnosis of a diabetes foot-related complication.

<p>ICD codes (ICD-10-AM) used to identify a principal diagnosis of a diabetes foot-related complication.</p

Absolute numbers of foot-related hospitalisation (admissions, bed days and average length of stay (ALOS)) and amputation (total, minor and major) cases amongst persons with diabetes, plus, estimated diabetes and general resident population, in Queensland from 2005 to 2010.

<p>Data are number (%); ALOS: average length of stay; IQR: Interquartile range</p><p>^ Chi-squared tests of independence used unless otherwise indicated</p><p># Kruskal-Wallis tests used</p><p>* <i>p</i> < 0.05.</p><p>Absolute numbers of foot-related hospitalisation (admissions, bed days and average length of stay (ALOS)) and amputation (total, minor and major) cases amongst persons with diabetes, plus, estimated diabetes and general resident population, in Queensland from 2005 to 2010.</p

Rate ratios of hospitalisation (admissions and bed days) and amputation (total, minor and major) cases in Queensland from 2005 to 2010 with and without adjustment for sex, age and sex*age groups: results from Poisson regression models using calendar year as a continuous variable.

<p>* <i>p</i> < 0.05</p><p>^Referent Age Category: 0–34 years</p><p>^^Referent: Female*Same Age Category</p><p>RR: Rate ratio; 95% CI: 95% Confidence Intervals</p><p>Rate ratios of hospitalisation (admissions and bed days) and amputation (total, minor and major) cases in Queensland from 2005 to 2010 with and without adjustment for sex, age and sex*age groups: results from Poisson regression models using calendar year as a continuous variable.</p

Rate ratios of hospitalisation (admissions and occupied bed days) and amputation (total, minor and major) cases in Queensland from 2005 to 2010 with and without adjustment for sex, age and sex*age groups: results from Poisson regression models using calendar year as a categorical variable.

<p>* <i>p</i> < 0.05</p><p># Referent year</p><p>RR: Rate ratio; 95% CI: 95% Confidence Intervals</p><p>Rate ratios of hospitalisation (admissions and occupied bed days) and amputation (total, minor and major) cases in Queensland from 2005 to 2010 with and without adjustment for sex, age and sex*age groups: results from Poisson regression models using calendar year as a categorical variable.</p