Moving forward with research and care for diabetic foot disease

Abstract

Earlier this year, the charity Diabetes UK opened a pop-up store near Brick Lane in London with a display of 135 individual shoes—but unlike at other pop-ups in the area, nothing was for sale. Instead, the outlet was part of an ongoing campaign intended to raise awareness about the issue of diabetes-related amputations, with the shoes in the display representing the average 135 such amputations taking place in England each week. According to the charity, up to 80% of these amputations could potentially be avoided with improved diabetes management and expert foot care. Diabetic foot disease is a leading cause of amputations, and the fear of losing a leg or foot to amputation is shared by many patients with diabetes. But high-quality research into treatment and prevention of foot ulcers lags far behind other aspects of clinical diabetes research. Meanwhile, the tremendous economic costs associated with the treatment of foot ulceration—the most common cause of hospital admission in people with diabetes and the most expensive complication of the disease—challenge health systems around the world. In a recent study from Queensland, Australia, researchers investigated the inpatient burden caused by foot-related conditions, reporting that 4·6% of all hospital inpatients had active diabetic foot disease, nearly half of whom were admitted to hospital because of the condition. The investigators estimated that across the country this proportion amounts to about 27 600 hospital admissions per year, at a cost of AUS$350 million. The researchers also noted that that people admitted because of diabetic foot disease had rarely received the recommended multidisciplinary foot care believed necessary to properly treat their disease in the year preceding their admission. They argue that if appropriate screening and referral to multidisciplinary teams had taken place, many of these admissions—as well as many amputations and deaths—could have been prevented. This situation is mirrored elsewhere. In the most recent National Diabetes Inpatient Audit in England and Wales, more than two-thirds of inpatients did not have a specific diabetic foot risk examination while in hospital. Furthermore, despite previous audits highlighting the importance of multidisciplinary diabetic foot care teams, 31% of hospital sites still did not have such teams available. What can be done to improve this situation? Countries need to give greater priority to prevention and care of diabetic foot disease in order to tackle the economic and societal costs of hospital admissions and amputations. In countries where little is known about the burden and consequences of diabetic foot disease, efforts should be made to raise awareness and collect data for health-system planning. For countries with strong health systems, regular foot assessment should be available to everyone with diabetes, and care pathways should be universally available to ensure that all patients with potential foot problems are identified and have timely access to expert preventive care, advice, and treatment. Looking beyond such recommendations, in this issue of The Lancet Diabetes & Endocrinology, Prashanth Vas and Michael Edmonds propose a one-stop shop approach to microvascular screening, combining neuropathy screening with that for retinopathy and nephropathy, to improve early detection of peripheral neuropathy. The authors note, however, that existing foot screening strategies, which aim to detect loss of protective sensation, are unable to detect neuropathy early enough to allow adequate prevention. Although work is needed to establish a consensus about which assessments could be used in screening for peripheral neuropathy, these proposals are worthy of further exploration. Research into care for diabetic foot disease also faces long-running issues. Glycaemic control and reduction of macrovascular risk factors are pivotal, but the evidence base is weaker for many other aspects of diabetic foot management, and high-quality research is urgently needed. Also in this issue, William Jeffcoate and colleagues have produced a set of reporting standards to guide researchers, setting out required details and markers of quality for research into the prevention and management of diabetic foot ulcers. Many of the recommendations will be recognisable to researchers across different fields, but the availability of specific guidance appropriate for foot ulcer studies should help to ensure that study designs are more robust and results better reported, improving the evidence to guide care in the future. There is a long road ahead for the management of diabetic foot disease, but these contributions should help to ensure that researchers and clinicians put their best foot forward.