A Realist Evaluation of a National Model of Care for the Diabetic Foot

Abstract

Introduction: Diabetic foot disease is a common and costly complication of diabetes and is a leading cause of lower extremity amputations worldwide. It requires coordinated input from multi-disciplinary teams (MDT) for prevention, monitoring and treatment. In Ireland, in 2012, the national clinical programme for diabetes recruited additional podiatrists and introduced a model of care for the diabetic foot. It outlined appropriate risk-stratified pathways, with the aim to reduce foot ulcers, lower extremity amputations and hospital costs. However, international evidence suggests complex interventions do not always translate into routine practice. Our aim is to identify and explain which aspects of the model of care are working (or not working), for whom and in what circumstances. Methods: This study is a realist evaluation, adopting a multi-stage mixed-methods design. Analysis of documents pertaining to the design, development and implementation of the model of care and semi-structured interviews with national stakeholders (n=19) were carried out to develop initial theories about how the model of care was intended to work. These theories were tested at a regional level using a multiple case study design (n=4 regions). Interviews are ongoing with local stakeholders including general practitioners, integrated care nurses, podiatrists and endocrinologists (n=15/case), supplemented with analysis of routine activity data. Data will be analysed to refine or revise the initial programme theories. Results: It was envisaged that by publishing and disseminating the model of care document, which outlined appropriate risk stratified pathways and clinical governance at each stage, healthcare professionals would ‘re-align’ their work and the appropriate patients would be referred and managed in the appropriate setting. According to national stakeholders, implementation was hindered from the outset; there were gaps in the pathways across both primary and secondary care because there was variation in existing services and limited new resources to support full implementation of the model of care. Preliminary findings from regional case studies concur, suggesting that health professionals are unable to make appropriate referrals where gaps exist in the pathways, for instance in areas where there are no community podiatrists. However, the regional case studies have also identified additional contextual factors that influence the implementation of the pathways. These factors include an awareness around the diabetic foot and an understanding of the role of podiatrists as well as the presence of an established MDT for diabetes care. Discussions/conclusion: Our realist evaluation suggests that while the successful implementation of the risk-stratified pathways is dependent on the presence of all necessary healthcare professionals along the care continuum, it is also influenced by additional contextual factors, particularly awareness around the diabetic foot and the presence of an established MDT. Lessons learned: It is important that integrated care is adequately resourced across the care continuum. Lack of awareness around the diabetic foot and the role of podiatrists hinders the full implementation of the model of care. Limitations: In the absence of a national diabetes register and audit data, the quantitative component of the study has relied on routine activity data. Future research: Refinement of programme theories is ongoing.