Foot Care and Prevention of Lower Extremity Amputation

Goal Group achievements

The following study outcomes have been presented at national and international scientific meetings including:

Vascular Annual Meeting of the Society for Vascular Surgery in Boston (2018)

Canadian Society for Vascular Surgery Annual Scientific Meeting in Montreal (2018)

Wounds Canada Conference in London (2018)

World Congress of Cardiology & Cardiovascular Health in Dubai (2018)

Outcomes from published projects

  • The economic burden of diabetic foot ulcers in Toronto, Canada
  • A population-based study of all diabetic foot ulcers patients admitted to general internal medicine wards at 7 hospitals in Toronto (2010-2015).
  • We observed that treatment costs were significantly higher for diabetic foot ulcer inpatients when compared to patients with other diabetes-related complications and the top five most costly conditions.
  • This highlights the need and necessity for focused efforts on foot ulcer prevention strategies and informs health policy in that regard.

Population-Based Secular Trends in Lower Extremity Amputation for Diabetes and Peripheral Artery Disease

  • Overall rates of amputations have increased over the last decade, driven by a rise in minor amputations.
  • Major amputations have slightly declined in individuals with PAD; however, have remained stable in those with diabetes.
  • Diabetes-related lower extremity amputations have increased over the last decade. These data support renewed efforts to prevent and decrease the burden of limb loss among patients with diabetes

Regional Variation in Amputation Rates among Patients with Diabetes or Peripheral Arterial Disease: A Blueprint For Improvement

  • This population-based cross-sectional study has identified wide variation in diabetic and PAD-related amputation rates across Ontario’s 14 administrative health regions.
  • The dramatic differences in amputation rates likely reflect major disparity across regions in disease burden as well as foot care.
  • Preventative services, acute care for foot complications and revascularization, rehabilitation, and wound care services must be better integrated.

End-of-Life Care Following Major Amputation for Diabetes or Peripheral Arterial Disease.

  • A population-based retrospective cohort study of all deaths in patients with diabetes or PAD in Ontario, Canada, between 2011 and 2017.
  • Palliative care is underutilized following major amputation in patients with diabetes or PAD and may contribute to reducing total hospital days at the end of life.

Review Study: Peripheral artery disease among Indigenous Canadians: What do we know?

The difficulties and uncertainties associated with Indigenous health research often arise for many reasons — namely, a lack of health care access and surveillance, and a subsequent dearth of relevant information. Thus, further research in this area will not only contribute to an improved understanding of Indigenous health but will also be critical in producing a research and policy landscape conducive to effective, focused public health interventions with Indigenous leaders, health care providers and patients holding vital partnership roles in this process.

Anticipated impact in the next 2 years

Reducing diabetic foot complication through a multidisciplinary chiropodist-based intervention: A Randomized Clinical Trial.
Recently, Diabetes Canada published some staggering statistics on the rate of amputation for those with diabetic foot ulcers, a major and feared complication of diabetes.  Ontario reported one of the worst outcomes among the provinces in Canada, with an estimated lower-limb amputation rate of one every four hours.  According to the International Diabetes Federation, persons with diabetes are 15 to 40 times more likely to require lower limb amputation compared to the general population. Approximately 85% of amputations are preceded by the development of a neuropathic foot ulcer with a lifetime risk for foot ulceration in people with diabetes being 15-25%. Following amputation, the 5-year mortality rate is 50%. [1]

Our Foot Care and Prevention of Amputations Research Program was successful in securing funding for their chiropody-led program to reduce amputations in patients with diabetes and chronic renal failure from the CHIR Operating Grant competition for SPOR Innovative Clinical Trials with Diabetes Action Canada as a funding partner. This study will measure the impact on the quality of life of those affected, the rate of lower-limb amputation and related hospitalization, and hospital readmission.  The study, if successful, has the potential to demonstrate a cost-effective and patient-oriented treatment plan that will improve how diabetic foot ulcers are managed in the Canadian health system.

Pilot defined health care paths for those with diabetic foot ulcers from hospital admission to rehabilitation

Health economic analysis indicates that diabetic foot ulcers leading to prolonged hospitalization and/or amputation are among the highest costs in our health care system. Of the $1.6 billion in direct health care costs in Ontario for diabetes and its complications, $400 million are related to diabetic foot ulcer disease alone. Recent analytics from the GEMINI group at St. Michael’s has revealed that, among 7 Toronto hospitals, the mean in-patient cost for treatment of a diabetic foot ulcer is $22,754 per hospital stay and $48,808 if a major amputation is required.

This team has recently developed a pilot end-to-end health care delivery path at St. Michael’s Hospital in Toronto that tracks patients with diabetic foot ulcers that require intensive treatment from admission to hospital to rehabilitation – a previously fragmented process.  This process is a chiropody led approach that includes assessments from entry into the emergency room to rehabilitation with appropriate triage from internal medicine and vascular surgery.

Multispectral Mobile Tissue Assessment Device (MIMOSA)

MIMOSA is an early-detection tool developed by Dr. Karen Cross, a surgeon-scientist at St. Michael’s Hospital in Toronto, and Dr. General Leung, a magnetic resonance physicist at St. Michael’s, to help diabetics avoid amputations.

Personal glucometers revolutionized diabetes management 35 years ago; a personal device for foot health monitoring could have the same impact on DFU-related amputation through early recognition and intervention. Using this non-invasive technology, we can predict when an ulcer might be forming before it is visible to the naked eye.

The first stage was tested within the hospital system in Toronto and the second phase, which begins in a few weeks, will incorporate other types of health care sites. The third phase of testing will be targeting for rural participants.

Beyond the personal cost to an individual who cannot work, treating diabetic foot ulcers costs the Canadian health care system $547 Million dollars a year. The cost of amputation to the Canadian health care system is 10 to 40 times greater than the cost of effective prevention. We can reduce that cost by 20 to 40 per cent just by having good screening programs. It will also allow healthcare professionals to monitor their patients remotely, eliminating the need for bi-weekly hospital visits and providing access for patients in rural communities without a doctor.

Exploring the association between intensity of preventative health services and amputation rates at the LHIN level

A population-based ecological retrospective cohort study that seeks to answer the following two-part question: Does more intensive regional foot care and greater regional expenditure for amputation prevention services correlate with a lower regional amputation rate? This study will clarify the clinical evidence-basis for health system improvements (e.g. regional foot care and amputation prevention pathways) to reduce amputations.

The data held at the ICES include records of hospitalizations, emergency department visits, physician claims, nursing and allied health care at home, medications, vital statistics and measures of socioeconomic status. Deterministic linkage of these records can provide unique insight into the current burden of diabetic-related foot complications including regional amputation rates, patient groups and regions with limited potential access to foot care and, the clinical course and survival of patients after amputation. Furthermore, these real-world population-based data can be used in economic models to predict the impact on quality of life, amputation rates, survival and health care costs associated with novel regional care pathways.

 Summary

These approaches will help characterize the clinical and economic burden of amputations, clarify the evidence-basis for regional integration of amputation prevention efforts and identify existing local facilitators and barriers to optimal foot care. The resulting data will inform the development of novel integrated regional foot care and amputation prevention pathways necessary to reduce diabetic related amputations across Ontario.

Directly improve health of Ontarians with diabetes at risk of limb loss.
Inform health system innovation through integration of amputation prevention services for patients in every region of Ontario.
Inform the cost-effective allocation of limited healthcare resources for system improvement around foot care and amputation prevention.


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