This study was the first to survey NZ podiatrists on their practices related to the prevention of DFD. The results indicate that the screening of the very low to moderate risk foot was undertaken more frequently than guideline recommendations, but that the screening of the high-risk foot was in alignment with international guidelines. Podiatrists indicated that they were generally applying recommendations for instructions on foot self-care, foot self-management, and treatment of risk factors or pre-ulcerative signs on the foot. Partial application of recommendations was found for the routine wearing of appropriate footwear, surgical interventions, foot-related exercise and weight-bearing activities, and integrated care. Only one recommendation on the provision of structured education was identified as not being applied in practice.
Less than half of respondents reported that they would screen the very low to moderate risk foot as per the guideline recommendation, indicating a high level of inconsistency between podiatrists in terms of screening frequency. This finding indicates a there maybe overscreeing of people with low or very low risk of DFD. Although there is evidence that screening prevents the development of DFD in the high-risk population, there is limited evidence that population screening reduces risk of DFD for all people with diabetes (17, 18, 19). This reinforces the need for the development of national guidelines for the prevention of DFD.
In the diagnostic tests employed by podiatrists in order to identify the at-risk foot, our findings showed that all respondents were consistent with the recommendations of both the 2019 IWGDF prevention guidelines and the NZSSD risk stratification system (20). Manual pulse palpation continues to be the most frequently employed vascular assessment employed by podiatrists, despite concerns around its accuracy, interpretation and prognostic utility in detecting the presence of peripheral arterial disease (21, 22). This finding is consistent with a similar survey by Tehan (23), which identified that podiatrists in Australia and NZ continue to rely on subjective vascular assessment testing methods such as pedal pulse palpation, over objective measurements such as the ABI and TBI. In the application of tests relating to the detection of peripheral neuropathy, all respondents indicated the utilisation of the 10g monofilament in clinical practice, which has been found to provide the most consistent results in the prediction of foot ulceration (22).
In relation to education provision, podiatrists appear to be mostly providing this through 1:1 verbal education, with the provision of structured education the least used form of all patient education modalities. The quality of evidence that structured education alone is effective in achieving clinically relevant reductions in foot ulcer risk is low, with a lack of association between structured education and clinically meaningful reductions in foot ulcer risk reported (24). However, the IWGDF prevention guidelines recommends structured education as preferable to other educational modalities as part of a larger movement away from didactic models of care in which the patient is a passive recipient of standardised information, and towards the integration of psychosocial model and patient centred programs (25, 26, 27). The survey findings are consistent with previous research which has shown that implementing diabetes self-management education into routine clinical care can be challenging, as much of diabetes management centres around changing the behaviours of the individual with often multidimensional risk factors (28, 29, 30).
Education and encouragement of exercise and daily walking was more often than not recommended by NZ podiatrists. Despite NZ podiatrists advocating for the importance of physical exercise and mobility, the results indicate that the education provided to patients around exercise is still largely based on the clinician’s individual experience. Exercise has been identified as potentially playing an important role as an intervention in the non-pharmacological treatment of DFD, including on the progression of diabetes-related peripheral neuropathy (31). However, despite an increased number of studies investigating the provision of foot and mobility-related exercise as an intervention to prevent foot ulcers there continues to be a small research evidence base in this area (24, 32). The findings of our survey may indicate that clinicians need further support in the application of research in the provision of foot-related exercises and weight-bearing activity in the prevention of DFD.
The results surrounding multidisciplinary teams indicate there is widespread establishment in NZ, but the delivery of preventive care more broadly through other integrated modalities of care such as Māori healthcare providers and telemedicine remains limited. For people with diabetes, integrated care has the potential to improve outcomes, disability, morbidity, and mortality, with the utilisation of integrated health being associated with a reduction in first presentations of diabetes-related foot ulcerations (33, 34).
Partial application of footwear recommendations was identified, with more podiatrists utilising off-the-shelf therapeutic over custom-made footwear. Podiatrists in NZ indicated the preferential use of prefabricated insoles over custom insoles. This is consistent with the evidence on orthotic interventions, with previous research identifying a positive association between the use therapeutic footwear and foot orthotics in foot ulcer prevention (35).
These survey findings should be interpreted in respect to limitations. Firstly, the sampling technique may have resulted in sampling bias. As the study undertaken was voluntary and entitled ‘diabetic foot care research’ and promoted through public health networks as well as through social media, it may be that most respondents were podiatrists who had experience in, or an interest with, the care of people with diabetes. The respondents to our survey were found to be broadly representative of the private podiatry workforce (73% versus 80% in overall employment), with a higher proportion of public podiatrists responding (21% versus 8% in the overall employment) (14). Secondly, using a non-validated survey tool decreases the reliability and external validity of our results. This limitation was minimised by the basing of the concept and questions on a similar survey undertaken by Quinton et al. in Australia (15) and referencing several questions and wording from the IWGDF prevention guideline (25). It was further minimised by the undertaking of piloting with a small sample of experienced podiatric clinicians. Thirdly, the study had a low response rate (16% of NZ podiatrists with annual practising certificates). However, this response rate is approximately double that than the 8% reported by Quinton et al. (15) in their similar study on diabetes-related foot assessment practices of podiatrists in Australia and slightly higher than Yuncken et al. (29) who had a 10% response rate in a survey of podiatrists on the provision of education to people with diabetes. Additionally, previous research has identified that only a small percentage of the podiatry profession in NZ work primarily with people with diabetes on a daily basis (22%) (14) which may have contributed to the low response rate.