Of the 4.6 million people are diagnosed with type II diabetes mellitus in RSA, 3.2 out of 1000 live in Gauteng. This study found 1565 amputations over 30 months (we excluded 297 records from the 1862 amputations) at the tertiary and central hospitals in Gauteng. We argue that each recorded amputation in this study represents a missed opportunity to implement basic preventative measures and limb salvage measures at the PHC level. Most importantly, though, each amputation represents a person and a family whose lives have changed completely.
Due to the nature of the healthcare delivery structure in RSA, most diabetic patients receive their care from a public healthcare system consisting of primary healthcare clinics, community healthcare centres, and hospitals. The public sector healthcare system is structured around a strict hierarchical referral mechanism to stop patients from presenting at hospitals with minor ailments.[34, 35] In this system, the PHC facilities are the first point of contact for patients and, in some cases, the only available form of healthcare services. If the need arises, patients are referred from the PHC level to more advanced treatment levels of care. In this study, we submit that the incidence of diabetic-related amputations indicates poor or inadequate care of diabetic patients at PHC clinics. Therefore, additional studies need to interrogate the foot health services received by diabetic patients at the PHC level to identify potential failures or inadequacies at this level.
The PHC level focuses on health promotion, disease prevention, early recognition of complications, health maintenance, patient education, diagnosis, and treatment of acute and chronic illnesses. The PHC was adopted post-1994 in RSA as the best-suited approach to attain better-quality public health outcomes and meet RSA goals of equitable healthcare service delivery for all its citizens.[37, 38] Therefore, the healthcare delivery system in RSA is ideal in the early recognition and management of DFCs, as the critical features of PHC include prevention, early recognition, and correct referral to a higher setting. However, despite the RSA government allocating 8.5% of gross domestic product (GDP) to healthcare, the health outcomes remain relatively poor compared to other middle-income countries with similar GDP percentage expenditure on health.[35, 39]
When considering clinical outcomes in diabetic patients, we should include our ability to deal with DFCs across the continuum of care and preventing amputations. The findings of this study suggest we may still be a long way off from achieving improved health outcomes for diabetic patients. Foot ulcers precede 84% of amputations in diabetic patients; therefore, early recognition of DFCs that might predispose diabetic patients to DFUs is critical. In this study, 73% of all first amputations were major amputations.
We suggest that this finding alone indicates insufficient diabetic foot care these patients receive at the PHC level. Moreover, it signifies delayed identification, recognition or referral to a hospital and insufficient care at PHC, among other factors. Therefore, there is a need to consider placing evidence-based prevention programmes at PHC facilities. These can include patient and carer education, risk stratification, early detection, foot ulcer treatment by a multidisciplinary team, and periodic observation, which can diminish the amputation rates. In areas where such measures exist, amputation rates are significantly decreased by 49–85%.[41, 42] In this study, the researchers could not find any record of foot assessments, risk stratification or interventions at the PHC level. Early identification and risk stratification of DFCs at the PHC level will ensure early referral to the hospital for swift treatment of DFCs. Such an approach will ensure that DFCs are managed appropriately, reducing the number and severity of diabetic-related foot amputations. We argue that by the time the patient arrives with a septic foot ulcer at a hospital, it is too late to consider and effectively implement limb salvage initiatives.
Therefore, it is time to consider early targeted interventions at lower levels of care. Such interventions can include integrating structured foot health services or measures at PHC directed at patient education, identifying risk and prevention of complication at this level. Adequately trained healthcare professionals (ideally podiatrists) can offer such services or train others to provide essential foot care services. Podiatrists at the PHC level can identify and treat pre-ulcerative risk factors known to be strong predictors of future ulceration, such as blisters, fissures, calluses, ingrown or thickened toenails, and fungal infections. Such a foot health service should occupy a central role in foot health and can take on a gate-keeping role to reduce the rate of DFCs and subsequent amputations seen in hospitals. Having these services at PHC facilities will ensure that the first step of identifying and quantifying the degree of risk for foot ulceration in all patients is accessible at the first point of entry (into the healthcare system) or contact (with healthcare professional).
This study does not intend to speak to the socio-economic impact of diabetic-related foot amputations. However, it is essential to highlight some of the factors we feel might influence the socio-economic outcomes of patients who had amputations. In this study, 71% of all amputations were in patients younger than 64 years, 26.3% younger than 55 and 44.7% between 55-64, respectively, which indicate a high proportion of amputations in the economically active group. Furthermore, it is essential to note that most patients 98%who had an amputation earn between ZAR 0.00 - 70 000.00 or USD 0.00-4754.41 per annum. The amputation of a foot or lower limb renders future employment prospects of most of these patients limited or non-existent. These findings have far-reaching socio-economic implications, requiring further studies to quantify this aspect.
South Africa has a shortage of podiatrists, as there is one institution in the country that trains these professionals, and most of the limited graduates work in the private sector. However, developing clinical practice guidelines (CPGs) can help direct the limited services and coordinate diabetic patient care in the interim. This approach can help define a standardised and efficient approach to prevention, treatment and referral of diabetic foot complications/ulceration and consequent amputations.