Preferred Ooading Modalities for Management of Diabetic Foot Ulcers in Private Clinical Settings: A Survey of Australian Podiatrists

Background Diabetic peripheral neuropathy is a common complication of diabetes mellitus. Neuropathy 25 predisposes patients to diabetic foot ulcers (DFU) due to the loss of protective sensation and 26 associated deformities. Management of foot ulcers are multifactorial, but pressure offloading can be considered as one of the most important aspects of management. According to IWGDF Guidelines, 28 cross study collecting data using an online survey closed podiatry Facebook 26% suggested for more high-risk foot facilities to increase accessibility provide more open communication with multidisciplinary teams and seamless referral for patients with DFU related complications. Finally, 24% wanted improved health funding to support patients with DFU. 16% did not respond to this question. Data from this study shown that 59% of practitioners dealing with DFU patients have less than 5 years working experience. This shows the importance of CPD. The podiatry association and other bodies 286 specialising in wound care (Advanced Practising High-Risk Foot Group) regularly conduct webinars 287 and sessions in this area. However, given the burn-out rate of podiatrists (20), including effects of 288 dealing with the COVID-19 pandemic (21), it may be unrealistic to expect clinicians to undertake 289 further training beyond that required for podiatry registration. presentation of in a private setting steps the between multidisciplinary teams and practitioners with further development of telehealth services. The result of this study suggests a need for qualitative studies to find out how we can better support practitioners to optimally manage patients with DFUs.


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This study shows that practitioners' offloading strategies do not adhere to the IWGDF guidelines. The 49 reasons for not adhering to the guidelines seems to be a clinical practicality rather than evidence-

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In Australia, a recent systematic review of the incidence of diabetic foot disease noted that the overall 71 incidence of diabetic foot disease is lower (1.5%) when compared with the rest of the world (4.8%).

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However, the incidence of in-patient admissions due to foot ulceration is much higher than the rest of 73 the world, with diabetes related amputations being the highest amongst developed nations. A 74 conclusion made from this data was that Australia is doing well to prevent DFU but not in managing 75 them once they developed, resulting in high numbers of admissions and amputations due to diabetes 76 related complications (3).

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In Australia, podiatrists are one of the key carers for DFUs. Podiatric management of DFUs include 78 sharp debridement of necrotic tissue, timely and appropriate wound dressings application, control of 79 the underlying disease process, footwear modification to off load pressure from the DFU, patient 80 education and self-care (4). Pressure offloading can be considered as one of the most important 81 aspects of DFU prevention and management (5).

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Since 2008 the International Working Group on Diabetic Foot (IWGDF) produced evidence-based 83 guidelines to assist with the management of diabetic foot disease and it became the benchmark for 84 clinical practice standards (6). These guidelines are frequently reviewed and updated to include the 85 latest research findings with the latest update in 2019 (7). A section in the IWGDF Guidelines is 86 dedicated to the best practices for offloading of DFU with eight recommendations for the management 87 of DFUs. Non-removable knee-high devices are recommended as the first line of management for 4 non-infected and ischaemic DFU associated with neuropathy (7). A non-removable knee-high 89 offloading device refers to a Total Contact Cast (TCC) which consists of a close fitting plaster or 90 fiberglass cast covering the foot , extending up the leg and ends just below the knee; or an instant 91 Total Contact Cast (I-TCC) which consists of a prefabricated knee-high walking boot that is rendered 92 irremovable by wrapping the device with a layer of casting material.

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TCCs have been considered the gold standard for managing plantar forefoot and midfoot ulcers 94 complicated by neuropathy. The ulcer healing rate using TCCs over a 12-week period was found to 95 be 89.5%, which was significantly higher than the healing rates when using removable walking boots

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(4.8%)(9). Another study by Raspovic and Landorf (2014) found that amongst podiatrists working in 100 high-risk foot settings in public hospitals, semi-compressed felt padding was most commonly used for 101 offloading, with TCCs being the third choice (10). Reasons for low utilisation of TCCs were attributed 102 to high cost, time to apply, fear of complications and lack of expertise (plaster technician) to apply the 103 TCC (11, 12).

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In Australia, most practising podiatrists do not work in public settings with support for high-risk foot 106 conditions. Examples of these private practice or similar primary care settings include privately owned 107 podiatry clinics, aged care facilities and community clinics. Patients with DFUs will often be managed 108 by podiatrists working in these private and primary care settings. It is not known how patients with 109 DFUs are managed in these settings, specifically if IWGDF guidelines for offloading are adhered to.

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As it is not feasible to collect data from every private primary care setting in Australia, the way 112 patients are managed may be inferred from practitioners' perception. This study aimed to survey the    10 -12 gathered data regarding participants' offloading preference and reasons. There were four 136 offloading modalities for participants to choose from and these were taken from the IWGDF guidelines 137 namelynon-removable knee-high offloading devices, removable knee-high offloading devices, 138 ankle-high removable devices, and standard therapeutic footwear (7). Question 13 sought 139 participants' thoughts regarding how DFU management can be improved in a primary care setting. As 140 participants were anticipated to be busy clinicians, the survey was kept short, taking no longer than 15 141 minutes to complete to encourage participation.

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Participant data were analysed descriptively and quantitatively. All data was analysed using SPSS    Participants were asked to provide their reasons for their choice particularly their first choice.

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The study found that standard therapeutic footwear in conjunction with regular podiatry treatment was

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To understand the rationale behind current practices, this study also collected data regarding the 223 reasons behind the practitioners' ranking preferences.

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Results from this study showed that convenience and accessibility strongly influenced the selection of 226 therapeutic footwear as the first choice of offloading modality. This implies that practitioners may have 227 felt that therapeutic footwear were more convenient and accessible to use. Standard therapeutic 228 footwear such as Darco, can be purchased from specialised shoe shops or ordered from local 229 suppliers, which would naturally make this modality more accessible to both practitioner and patient.

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In addition, since most practitioners also provided regular wound debridement and dressing, this may

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The choice of a removable knee-high device was attributed to patient compliance and satisfaction.

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Patients may be reluctant to use the non-removable device as this hinders them from their regular 251 activities, and practitioners may be seeking a compromise by using a removable device. Studies have 252 11 shown that patients spend 75% of the their active time not wearing their prescribed removable 253 offloading device reducing its effectiveness (17). Ironically, the patient's ability to indulge in regular 254 activity and be comfortable, which is seen as positive to the patient, is a hindrance to wound healing.

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On the contrary, when using non-removable devices, patients cannot remove the device themselves.

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This is termed 'forced compliance' (16). Non-removable devices slow the patient down by reducing 257 stride length and activity, thereby promoting wound healing (8).

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To resolve this issue, the use of I-TCC may be suggested. A I-TCC is a removable knee-high boot, 259 that is rendered irremovable by wrapping it with a plaster cast after it has been fitted on the patients'

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The formation of multi-disciplinary community centres with services such as nursing services to 301 change wound dressings, diabetes care management and education, radiology, pharmacology, and 302 potentially plaster casting services may meet the needs of podiatrists and patients alike. These multi-303 disciplinary services can provide a one-stop service for patients to access a range of support services 304 and will serve podiatrists and other allied professionals in private practice within a catchment area.

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Patients will be able to have faster and more convenient access to the community service compared 306 to being referred to a high-risk foot service within the hospital. Further qualitative studies need to be 307 done to find out a good model of care that is financially viable and meets the clinical needs of all 308 stakeholders.

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Although not one of the top reasons, high cost of a device was identified as one of the reasons for 312 choosing a modality and the patients' ability to afford treatment over the long term will influence 313 practitioner's treatment choices. This results in sub-optimal care placing an economic burden on the 314 patient as well as the health system. The treatment of DFUs was reported to be a significant 315 economic burden on patients and the health care system with an annual expenditure of US$9 -13 316 billion in the US. By optimising care with evidence-based principals an annual cost savings of AUD 317 2.7 billion over 5 years can be generated (23).

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Practitioners could educate patients on the concept of cost-effectiveness (higher cost over a short 319 period vs lower costs over a long period), and that evidence-based care will result in better outcomes, 320 be more cost-effective and even result in cost savings (24).

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In