To our knowledge, this is the first mixed methods study that evaluated the private podiatrists’ experiences and methods in assessing the diabetic foot in Flanders, Belgium. The results of this study provided information that could help to ultimately develop a national diabetic foot assessment guideline.
The most important finding was the limitation of non-invasive tests used for the vascular assessment of the diabetic foot. PAD is an independent risk factor for subsequent diabetic foot ulceration (15). Studies have shown that it is present in up to 50% of patients presenting with a DFU (16, 17). Moreover, previous research has established that diabetic patients with PAD were five times more likely to have undergo a lower-extremity amputation (LEA) and had higher mortality compared to non-diabetic patients (18–20). The UK NICE guidelines recommend to assess the vascular status as an important predictor of ulceration in the diabetic foot (21). Considering this evidence, it seems that identification of PAD in diabetic patients is key in minimizing the risk of LEA. The results of the survey and interviews showed that the vascular assessment in private podiatry practices in Belgium solely exists of a medical history and palpation of the pedal pulses. There is no further examination of the vascular system, unlike other countries such as the UK or United States (21, 22). Nevertheless, the IWGDF guidelines suggest that the presence of palpable foot pulses cannot be used in isolation to reliably exclude PAD (23). Pedal pulse examination has a poor sensitivity and is not independently sufficient to conclusively diagnose PAD (24, 25). Therefore, a more objective evaluation such as a doppler or ABPI must be included into the diabetic foot assessment. Barshes et al. (26) has shown that using noninvasive testing such as doppler or ABPI is more accurate and cost-effective in identifying PAD among diabetic patients (26).
However, the results of the interviews of this study indicated that the lack of podiatry consultation reimbursement and referral pathways hinders private podiatrists in Belgium to invest in the equipment needed for noninvasive testing.
This highlights that the quality of diabetic foot assessments could be improved by reformation of the current reimbursement strategy and referral pathways for diabetic foot care in Belgium.
Since 1999, the IWGDF has developed international clinical practice guidelines for the prevention and management of the diabetic foot (11). These guidelines are systematically developed statements to assist health care professionals’ decisions, to standardize the diabetic foot care and improve the quality of health care (27, 28).
The IWGDF advises that those guidelines may have to be adapted based on local circumstances taking into account accessibility to health care resources and various cultural factors (11). Several studies have shown that developing a national diabetic foot assessment guideline, based on the international recommendations, not only increases the frequency of diabetic foot assessments (29, 30) but also reduces the incidence of diabetes-related LEA (31, 32). However, in Belgium, the international recommendations have not yet been implemented into a national diabetic foot assessment guideline. This could be the reason why only 66% of all podiatrists reported to use guidance documents or guidelines for the assessment of the diabetic foot. Solely 6% of these podiatrists are using the IWGDF guidelines. It also raises a question to what are the other 34% using? Although, with only a response rate of 14%, we do not have a true representative sample of private podiatrists in Flanders, Belgium and these results must therefore be interpreted with caution.
Another possible explanation for the low adherence to diabetic foot assessment guidelines could be the variety of available guidelines or guidance documents published by various organizations and experts in the field (33, 34). This could create confusion among podiatrists as to which guidelines should be adopted in clinical practice and explains why 9 different guidelines or guidance documents were identified as being used in private podiatry practices in Flanders, Belgium.
Moreover, studies have shown that there is a high variability in the recommended methods for the diabetic foot assessment and a lack of consistency regarding the levels of evidence and grades of these recommended methods between different guidelines (33, 35, 36).
As a result, the variation of guidelines used in private podiatry practice in Flanders, Belgium could lead to differences in interpretation of the diabetic foot risk stratification system between podiatrists and affect the quality of diabetic foot care ultimately received by the patient.
The concerns regarding the inconsistent interpretation of the diabetic foot risk stratification system among private podiatrists were widespread in the interviews. This concern could be explained by the lack of adherence to these systems, which was apparent in the survey results.
Diabetic foot risk stratification systems are designed to determine the appropriate management and assessment frequency of the diabetic foot (34). Studies of Boyko et al. (37) and Leese et al. (38) showed that risk stratification systems based on the IWGDF guidelines have an excellent ability in accurately quantifying and defining an individual’s risk of developing a DFU. Moreover, it provides a more accurate prediction of the foot ulcer risk than the individual results considered in isolation (37). The survey results indicated that one-third of the podiatrists are not using any risk stratification system. As a result, it could be assumed that these podiatrists determine the patients’ risk based on individual predictors potentially resulting in inconsistent diabetic foot risk scores.
Podiatrists that did use a risk stratification system, most frequently rely on the system provided by the Belgian NIHDI (39) (Table 3) which is based on the on the Coleman’s risk stratification (40, 41). Although this system is provided by the Belgian Institute, it is important to note that this risk stratification has never been adapted to the latest research or recommendations of the IWGDF. Moreover, there are no studies that have validated this risk stratification system, which could explain why there could be inconsistencies in the diabetic foot risk stratification between podiatrists.
Table 3
Risk stratification system NIDHI & IWGDF
Risk Group
|
Risk classification Belgian NIDHI (39)
|
IWGDF guidelines (10)
|
0
|
-
|
no LOPS or PAD
|
1
|
Loss of protective sensation (LOPS)
|
LOPS or PAD
|
2
|
A) Moderate foot deformities such as prominence of metatarsal heads, hyperkeratosis and/or flexible hammer- or claw toes and/or moderate hallux abducto valgus (< 30°).
B) Severe foot deformities.
|
LOPS + PAD
LOPS + foot deformity
PAD + foot deformity
|
3
|
PAD
History of DFU
Amputation
Charcot
|
LOPS or PAD and one or more of the following:
• History of foot ulcer
• LEA (minor or major)
• End-stage renal disease
|
In addition, it should be pointed out that risk stratification systems are developed not only to determine the patients risk of developing a DFU but also to determine the frequency of diabetic foot assessments and provide patients with the appropriate education to prevent complication development (11). However, the Belgian risk stratification system does not provide a diabetic foot screening frequency or management plan for patients at risk of developing a DFU. Furthermore, diabetic patients only receive a refund for their podiatry consultations twice a year independent of their risk of developing a DFU.
This ultimately influences the frequency of the diabetic foot assessments especially in patients of low socioeconomic status. In Belgium, 19,8% of the population are at risk of poverty or social exclusion (42). Moreover, the Belgian Health Survey in 2018 has shown that undiagnosed or poorly controlled diabetes is 3 times more common in diabetic patients of low socioeconomic status (43). Consequently, as poorly controlled diabetes is an important risk factor of developing diabetic foot complications, these patients could be at higher risk of developing a DFU and should be screened more frequently (37, 44). However, the current reimbursement strategy does not allow these patients to schedule more than 2 podiatry visits a year, as they have to pay the other visits out of their own pockets. This shows that the reimbursement strategy should be reviewed as it is a barrier to patients receiving the care that they need if they are at high risk of developing diabetic foot complications.
This research has highlighted that there is a need for implementing uniform international recommended diabetic foot assessment guidelines and risk stratification systems. Moreover, implementation of these guidelines will ultimately improve the performance of diabetic foot assessments in private podiatry practices (45, 46). Research has shown that organizing educational interventions such as focus groups, presentations or developing informational leaflets or handouts help to improve the podiatrists’ performance of diabetic foot screening (47, 48).
However, regular screening is only 1 of the 5 cornerstones of DFU prevention according to the IWGDF guidelines (11). Diabetic foot screening alone is not sufficient in reducing the risk of LEA (49). Good management of the diabetic foot should focus on prevention, treatment and requires close coordination between different groups of health care professionals by establishing diabetic foot care pathways (50). The “putting feet first” campaign in the UK, released jointly by Diabetes UK and the National Health Care Service, has defined diabetic foot care referral pathways and services to which each diabetic patient should have access (Table 4) (50). Introduction of these pathways in several regions in the UK has contributed to the improvement of diabetic foot care. The results of the latest National Diabetes Foot Care audit of 2019 (51) showed that due to the establishment of these pathways, patients with less severe or severe ulcers are more likely to be alive and ulcer free at 12 weeks. Moreover, some studies have demonstrated that the integration these pathways are correlated with the reduction in diabetes-related LEA (52, 53).
Table 4
Diabetic foot care across all settings (55)
Commissioners and service providers should ensure that the following are in place:
• A foot protection service: prevention of diabetic foot problems, treatment and management of diabetic foot problems in the community.
• MFCS: management of diabetic foot problems in hospital and in the community that cannot be managed by the foot protection service.
• Robust protocols and clear local pathways for the continued and integrated care of people in primary and secondary care. The protocols should set out the relationship between the foot protection service and the MFCS.
• Regular reviews of treatment and patient outcomes, in line with the National Diabetes Foot Care Audit.
|
In Belgium there are established multidisciplinary foot care services (MFCS) in secondary care funded by the Belgian National Health Care system. However, there are no defined services in primary care, foot protection services or referral pathways to ensure integrated care between primary care and secondary care. Moreover, the study of Van Acker et al. indicated that diabetic patients in Belgium bare more of the cost of preventive diabetic foot care than they do for curative or amputation care (54).
As a result, the patients’ motivation for prevention of diabetic foot problems is low since the cost for prevention is paid by the patients whereas the cost for treatment of a DFU is paid by the National Health Care system. This shows that there is a need for change in the organizing the diabetic foot care in primary care and change the perspective from curative to a more preventative diabetic foot care.
Limitations
The generalizability of this study is subject to certain limitations. Firstly, invitation for the survey and interviews were solely sent out to private podiatrists in Flanders, Belgium. Moreover, only a small proportion of private podiatrists responded (14%). In order to generalize the results nationally, this study should be repeated including private podiatrists in Wallonie and measures should be undertaken to improve the response rate such as using social media to boost the survey responses or collaboration with the Belgian National Podiatric Medical Association. Secondly, the survey was constructed based on a literature research, however its validity and reliability were not assessed. Thirdly, the survey limited the researcher in her ability to further explore the content of the different risk stratification systems used in private podiatry practice. The second most reported risk stratification used was the “SIMS risk stratification system”. This system was developed in 1988 (13) and introduced in the neighboring country the Netherlands. According to diabetic foot assessment guidelines in the Netherlands, their risk stratification system has been adapted in 2006 to the current IWGDF guidelines. However, the term “SIMS” was kept as podiatrists kept associating the term with diabetic foot risk stratification (56). As a result it is possible that Belgian private podiatrists reporting the use of the “SIMS risk stratification system” actually use the current IWGDF guidelines, not the original reported system of 1988, which could have influenced the results related to this survey question.
Lastly, the audit reports from the MFCS in secondary care in Belgium provide the only data available on national diabetic foot care. The lack of organization of primary care services for the diabetic foot results in a gap of knowledge on the current diabetic foot assessment methods and foot care. Furthermore, it makes it impossible to analyze how the current practice in primary care could influence the results of the audit report from the MFCS.
Future research on DFU incidence and referral patterns of diabetic foot in primary care and analysis of the cost of preventive diabetic foot care compared to the cost of LEA could provide more insight on current practice. Such research can provide valuable information for policy makers to change in the current diabetic foot care.