The Galway Diabetic Foot Study: Epidemiology, Cost, Feasibility, and Implications for Clinical Practice and Policy.

BACKGROUND

Diabetes can cause nerve damage and blood vessel disease in the feet.  This may cause skin and tissue breakdown, which can develop into non-healing wounds (ulcers), which are at risk of infection. This may even result in limb amputation.  Structural deformity leaves bony prominences exposed to increased external pressure on the skin, leaving it at risk of being damaged.  Identification of patients at risk of diabetic foot disease allows early intervention of preventative measures to be taken, and thus reduces the risk of further complications.

This research study led by Dr. Sean Dinneen, Consultant Endocrinologist, Galway University Hospital determined  how common foot problems are in a group of people with diabetes from the West of Ireland. A set of easy to use tests for the screening of nerve damage, structural foot deformity and blood supply to the feet were taught to medical and nursing staff working in local GP practices/health centres.

FINDINGS

563 patients with diabetes attended their general practice for foot screening to assess for the presence of risk factors which might place them at risk of developing diabetic foot ulcers. The study found that some degree of sensory dysfunction in 23 – 25% of patients putting them at risk of foot ulcers due to poor protective sensation. Over 30% of patients reported moderate to severe symptoms associated with nerve damage. Assessment of foot pulses found that 18-40% had signs of poor circulation placing them at risk of poor skin oxygenation and poor healing. 50-60% of patients completed questionnaires to determine psychological well-being. 22% reported symptoms of anxiety and 20% had symptoms of depression.

During the 18 months of the study there was an annual incidence rate of 2.6% for ulceration and 0.35% for amputation. The persons who developed an ulcer, were more likely to be older with a longer duration of diabetes. There was also a strong link with ulcer development and poor diabetes control, abnormal sensation and poor circulation. Additionally, non-attenders for follow up screening had poorer blood sugar control (at first screening) than those that attended follow-up. Using a health economic questionnaire, it was found that foot ulcers led to significantly greater healthcare and patient costs over an 18 month period. These results highlight the potential savings that could be achieved through prevention of foot ulcers.

CONCLUSION

This study found that screening in general practice has the potential to pick up a considerable number of patients with poor sensation and circulation which places them at high risk of developing foot ulceration. Ulcer development places a considerable burden on the person themselves, as well as on the health service.  This study helped to inform the National Model for the Diabetic Foot and aided the business case proposal which resulted in the appointment of community diabetes podiatrist throughout Ireland.

Publications

Prevalence of diabetic foot complications in the west of Ireland: A pilot study. Kelly L., Garrow, A., Dolan C., Kelly S., O’Shea E., Hurley L. Glynn L The Diabetic Foot Journal. The Diabetic Foot Journal, 13(2) 2010

O’Loughlin A, McIntosh C, Dinneen SF, O’Brien T. Basic Concepts to Novel Therapies: A Review of the Diabetic Foot The International Journal of Lower Extremity Wounds. 9(2) 90–102 2010