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01-12-2020 | Research | Uitgave 1/2020 Open Access

# Organizational changes in diabetic foot care practices for patients at low and moderate risk after implementing a comprehensive foot care program in Alberta, Canada

Tijdschrift:
Journal of Foot and Ankle Research > Uitgave 1/2020
Auteurs:
Catherine B. Chan, Kathy Dmytruk, Michele Labbie, Petra O’Connell
Belangrijke opmerkingen

## Supplementary information

Supplementary information accompanies this paper at https://​doi.​org/​10.​1186/​s13047-020-00393-0.

## Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Abbreviations
ABPI
Ankle-brachial pressure index
AADL
Alberta Aids to Daily Living
AHS
Alberta Health Services
DFU
Diabetic foot ulcer
DON SCN™
Diabetes, Obesity and Nutrition Strategic Clinical Network™
GP
General practitioner
HC/LTC
Homecare/long-term care
HRFT
High risk foot team
MD
Medical doctor
NP
Nurse practitioner
PPG
Photoplesthysmography toe pressure
RNAO
Registered Nurses Association of Ontario

## Introduction

Diabetic foot ulcer (DFU) is a severe diabetes complication often leading to lower limb amputations. In Canada in 2011, more than 25,000 prevalent cases resulted in 6036 amputations with a cost per prevalent case of $21,371 CAD [ 1]. International studies have found the 5-year mortality rate after new-onset ulceration to be 43–55%, and as high as 74% for people with diabetes who had a lower limb amputation [ 2]. DFU and lower limb amputations in people with diabetes are potentially preventable in 75% [ 3] and 50–85% of cases, respectively, through screening, early treatment and better self-care practices [ 4]. Clinical pathway development, clinician training and education, and provision of procedural support tools are all shown to increase foot screening and improve treatment [ 5, 6]. Patient education is also recommended as important to reduce risk of diabetic foot complications [ 7]. Efforts to prevent DFU in patients identified at moderate to high risk, have a strong possibility of cost-effectiveness [ 8] probably through reduction of emergency department or inpatient admissions, which are increased by 3-fold in patients with DFU compared with other ambulatory clinic cases [ 9]. Provision of care by multi-disciplinary teams to prevent and manage foot wounds is recommended [ 1012], as is having a structured approach to assessing clinical and metabolic parameters and assigning risk categories to patients [ 13]. In Queensland, Australia, implementation of state-wide protocols for diabetic foot care reduced major amputation by 45% [ 14]. In the jurisdiction of Alberta, Canada, diabetic foot disease was identified in 2013 as a priority for action by the Diabetes, Obesity and Nutrition (DON) Strategic Clinical Network™ (SCN) of Alberta Health Services (AHS) [ 15]. As part of the pathway development process, the DON SCN™ conducted a survey with both quantitative and qualitative elements in order to understand existing foot care services across Alberta. The unpublished survey results identified low screening capacity, barriers to referral, and lack of standardized approaches were supported by self-reported data from people with diabetes. This showed that self-care practices and screening frequencies [ 16] were not in accordance with Diabetes Canada 2013 guidelines for foot care [ 4], a problem also reported for Canada as a whole [ 17]. In 2014, the DON SCN™ began the process of implementing a new care pathway for diabetic foot care focusing on DFU prevention through screening and creation of multidisciplinary High Risk Foot Teams (HRFT) to facilitate referrals. The literature shows that integrated care models for secondary prevention of DFU or LLA are medically and cost-effective [ 8, 18]. However, there is a paucity of literature on efficacious and cost-effective integrated care models for primary prevention of DFU [ 3, 19]. Approaches using multi-disciplinary teams appear to be efficacious but overall quality of the studies is not optimal [ 10]. Based on guidelines of Diabetes Canada [ 4], Wounds Canada [ 20] and the Registered Nurses Association of Ontario (RNAO) [ 21], the Alberta Health Services (AHS) diabetes foot care pathway was developed. It encompasses elements of assessment, planning, implementation and evaluation of foot care strategies for patients using a patient-centred approach and addressing appropriate treatment of comorbidities [ 22]. The pathway also acted upon RNAO recommendations to include professional education and guidelines to cover policy and organizational considerations. It also provided resources to monitor and support quality improvement, develop an effective referral strategy, advocate for client services that promote offloading of pressure to prevent re-ulceration [ 21]. In 2015, the DON SCN™ conducted a pilot project at three sites followed by scale and spread across Alberta. The pathway utilizes HRFT that provide a foot protection service and support primary care. The primary care service performs the initial screening, care for low risk patients, and continued care for patients with healed ulcers once released from specialty care. A screening instrument and modules to support patient education have also been made available along with education on their utilization. HRFT also provide referral to surgeons, providers of specialty footwear and offloading devices, and other supports for patients [ 23]. The aim of current study was to assess the impact of implementing a diabetes foot care clinical pathway and associated resources and training on organizational changes in diabetic foot care practices in 2019 compared with the baseline state in 2014 in Alberta, Canada. This research focused on organizational capacity for foot screening and care of low-moderate risk patients. In comparison with responses in 2014 we predict enhanced diabetic foot care practices, particularly at sites with access to HRFT. ## Research methods ### Study design Serial cross-sectional assessments of organizational practices related to foot care of people with diabetes. ### Study setting Health care sites that play a role in the care of diabetic foot screening and treatment across the continuum in Alberta were identified. These were primary health care, home care and long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. Sites that actively participated in implementation of the diabetes foot care pathway, as well as those that did not were included in the survey. The 2019 survey was conducted between February and April. The 2014 survey was conducted in September. ### Participants A convenience sample of representatives of the identified health care sites were recruited, including physicians, nurse practitioners, registered nurses, licensed practical nurses, foot care nurses, orthopedic surgeons, physio- or occupational therapists, dietitians or pharmacists, diabetes educators, clinic managers or any practitioner who had contacted the DON SCN™ about foot care, including private service providers (e.g., foot care nurses, podiatrists). In 2014, the extent of sites and individuals participating in care of patients with diabetic foot disease was less well known; thus snowball sampling initiated with a small number of key contacts was used to distribute the survey as widely as possible. The total number of sites approached to participate was undetermined. In 2019, a list of potential participants were developed based on the previous respondents to the survey in 2014. In addition, we invited attendees at four AHS-sponsored foot care symposia held in 2017 and 2018, and utilized personal knowledge to invite other individuals involved in diabetic foot care as well . This greatly expanded the potential participant list compared with 2014. In both 2014 and 2019, potential participants were contacted by email with an invitation, the study information and a hyperlink to the survey. Potential participants received two email reminders to complete the survey following the initial invitation. Waiver of consent was granted for the 2014 survey by the Research Ethics Board of the University of Alberta. In 2019, informed consent was implied by completion of the survey. ### Intervention A literature review to identify best practice, informed the process of developing the intervention, including the care pathway and ancillary resources. In addition, the Project Lead (author KD) consulted experts in the United Kingdom (UK) regarding their pathway development process and implementation of foot protection teams, which assess and treat patients at risk of, or presenting with DFU [ 24]. The Canadian Agency for Drugs and Technology and Health organized and facilitated a meeting between four provinces, including Alberta, to discuss current foot and wound care practices. Following this, Alberta and New Brunswick teams embarked on pathway development and the implementation of “high risk foot teams” (foot protection teams) similar to what had been implemented in the UK. The New Brunswick team allowed the DON SCN™ to leverage the work they had started in the development of a diabetes foot care clinical pathway. The DON SCN™ struck a working group composed of diabetes educators, primary care physicians and nurses, home care, wound care nurses and nurse practitioners and foot care nurses (licensed practical nurses (LPNs)), including authors KD and ML. The working group developed The Alberta Diabetes Foot Care Clinical Pathway tools and resource toolkit ( Supplementary Materials). It was guided by the tools and resources developed by New Brunswick (diabetic foot screening tool, health provider guide, referral guidelines, patient handouts on low, moderate and high risk foot problems) and Canadian guidelines [ 20, 21, 25]. All tools and resources in the toolkit were vetted with and approved by a provincial steering committee. Members of the steering committee consisted of podiatric surgeons, orthopedic surgeons, dermatologist, physiatrists, endocrinologist, primary care physician, wound care nurses and nurse practitioners, and foot care nurses. The diabetes foot care pathway focussed on three key elements: screening, assessment and referral pathways that could be customized depending on site characteristics. Implementation in primary care and home care/long-term care (HC/LTC) settings focused on screening and assessment supported by a novel screening tool, a risk assessment triage referral form, training from a nurse with specialized wound care training, videos and other supports. Goals for screening and assessment included increased competency of primary care providers to accurately categorize a person with diabetes as low, moderate, high or urgent risk for foot ulceration and amputation, to increase screening rates, and to provide patient education using resources developed by the DON SCN™. Within primary health care, appropriate actions taken on patients with moderate risk feet (i.e., having conditions such as callus, structural deformities or loss of protective sensation) have the potential to reduce risk of future ulceration. This included educating patients on the importance of routine self-care activities. Moderate risk assessment included inspection for skin and nail abnormalities, assessment of structural deformities (e.g., bunions, hammertoes), assessing whether special footwear was necessary, and evaluating vascular and peripheral nervous function. To address barriers to timely referrals of high or urgent risk patients, in part related to Alberta’s large rural and remote population, HRFT were constituted in strategic locations. Depending on the site, HRFT were led by physicians, nurse practitioners, nurses, licensed practical nurses, or occupational therapists and included at least one other provider, preferably one member holding prescribing privileges for medications, diagnostic testing and referral to specialty care. Such multidisciplinary teams are recommended in various guidelines and are often known as foot protection teams [ 4, 11, 21, 26, 27]. In the Alberta model, HRFT assess and treat patients at risk of a DFU and those with an ulcer present. HRFTs have wound management and debridement expertise, lower leg vascular assessment training, can prescribe footwear through a provincially funded resource for medical aids, Alberta Aids to Daily Living (AADL). AADL is funded by Alberta Health and is mandated to help Albertans with a long-term disability, chronic or terminal illness to pay for basic medical equipment and supplies. However, only specified healthcare professional may prescribe AADL services. Skilled deployment of more complex testing and treatment modalities (e.g. debridement) is essential in preventing ulcers from progressing. Some HRFTs have the ability to perform skin and nail care (nail trimming/callus management) as an adjunct service. Other HRFTs do not provide this service; patients can be referred to a community podiatrist, foot care nurse, or other medically trained provider in the community. HRFT make formal linkages with other referral services such as diabetes clinics, vascular laboratories, occupational therapists or orthotists. HRFT could refer to specialists such as community podiatrists (private practitioners) or podiatric surgeons (focusing on wound management and limb preservation) as outlined in the pathway. In addition to the DON SCN™-sponsored sites, other sites throughout Alberta have developed similar multidisciplinary models of care in primary care or outpatient settings. In addition to the specific pathway intervention, the DON SCN™ also created a number of tools to support screening, assessment and HRFT, which were freely available via a website [ 23] ( Supplemental Materials). Awareness of the pathway was achieved through newsletters, word of mouth, symposiums, and presentations at meetings and conferences. For purposes of comparative analyses, 2014 data were considered as “usual care” controls compared with 2019 post-intervention data as a whole. The 2019 data was also stratified by whether sites accessed HRFT and their practices compared to each other. ### Intervention delivery Between 2014 and 2019, 8 sites (2 North Zone, 2 Edmonton Zone, 2 Central Zone, 1 Calgary Zone, 2 South Zone) received training from the DON SCN™ personnel in all elements of the intervention including use of the clinical pathway and associated resources (toolkit) and established HRFT. Additional education consisted of training in performing a diabetes foot screen, using the pathway tools to navigate the patient to the most appropriate resource and follow-up timelines depending on risk level. This training was provided to anyone requesting it, mainly in primary care settings but also community pharmacists and indigenous healthcare providers. Of 41 Primary Care Networks in Alberta, 14 received in person training while education was provided to personnel in most First Nations health centres in Alberta via videoconference. The wound care nurse provided in-person training, with education on how to use the pathway and perform a foot screen, backed up by videos and a user guide for the tools. Implementation support was provided by the DON SCN™ project team, which included authors KD and PO. More than 1300 healthcare providers attended DON SCN™ sponsored continuing education conferences provided in 2017 and 2018. In addition, the clinical pathway and associated resources were freely available via the internet and a series of e-learning modules was created. Of 390 individuals who enrolled, 62% ( n = 242) completed the e-learning courses. ### Outcomes A customized cross-sectional computer-based survey study was conducted in 2014 and again in 2019, prior to, and following widespread implementation of the diabetes foot care pathway in order to assess its uptake and changes in practice. The data collected compared screening practices, assessment of feet at moderate or high risk for ulceration, and protocols for dealing with urgent cases. The survey items were organized into sections by risk levels (low, moderate, high, urgent) and offered multiple options of care models. Respondents selected options, with more than one option being available for most questions. Respondents could also provide responses to an open-ended question to comment more fully on issues relevant to each risk section (Table 1). The 2014 survey was developed to determine what the current state of foot and wound care was in the province and how currently the different risk levels were being managed. The 2019 survey was a follow-up to determine how the landscape had changed with the implementation of the pathway and HRFT. The 2014 and 2019 surveys were similar with the 2019 version modified to include HRFT as a referral option. In this report the focus was on screening and assessment of individuals with low and moderate risk of foot ulcer. Table 1 Definition of variables Question number Variable Definition / options General Questions 1 Health zone Geographic region within Alberta (North, Edmonton, Central, Calgary, South) or other (e.g. Federal) 2 Area of practice Primary care network, home care, long-term care community (e.g. chronic disease management nurses working in the community), outpatient departments, wound clinics, other 3 Identification of site Free text (e.g. specific clinic or hospital site) 4 Footcare related continuing education For all staff in setting within past 2 years; DON SCN sponsored symposia in 2017 or 2018; DON SCN-led workshops in various settings as part of intervention roll-out; Diabetes Canada sponsored events; other 5 Basic foot screening offered Yes/No If Yes to #5, then… 6 Screening tool used AHS screening tool (2019 only), 60-s foot screening tool, other (free text) 7 Screening setting Free text 8 Risk category seen Low, moderate, high risk, urgent care required, other Questions regarding moderate-risk patients 9 Formalized clinic for assessment Yes (HRFT or other), no If Yes to #9, then… 10 Management of skin/nail abnormalities Perform skin/nail care in practice area; provide list of foot/nail care providers in the community; refer to podiatrist or footcare nurse (i.e. private services), refer to HRFT, other (free text), none of the above 11 Management of structural deformities Provide education regarding self-management; refer to podiatrist or orthopedics; other (free text), none of the above 12 Management of footwear Provide education/information regarding footwear selection; refer to HRFT; provide referral for footwear/orthotics through AADL; refer for footwear/orthotics without AADL authorization; other (free text), none of the above 13 Management of vascular problems Perform vascular assessment; refer to HRFT; refer to general practitioner; refer to vascular lab, other (free text), none of the above 14 Vascular assessment tests performed ABPI; PPG; Pedal pulses; refer to HRFT; other (free text) 15 Management of loss of protective sensation Treat neuropathic pain (free text); refer to physician/nurse practitioner for treatment of neuropathic pain; refer to HRFT 16 Reassessment frequency 1–3 months; 4–6 months; 7–12 months; no formalized schedule; other (free text) 17 Any other comments about moderate risk patients Free text 18 Assess high risk/urgent patients Yes/No. If yes to these, a series of questions was asked. These responses are not reported in this article. ### Data analysis Data were downloaded from the host server to an Excel spreadsheet by an individual not part of the study team, then anonymized by removing any personal information prior to providing to the study team. Following cleaning to remove duplicate responses (as determined by site-related information, i.e., identical answers to questions 1–3 in Table 1, resulting in n = 3 and n = 7 responses removed), the categorical data were coded. Qualitative data (comments) were retained verbatim but were not analyzed for this study. Descriptive statistics were compiled. Comparative statistics were performed to assess differences in footcare practices between groups using two-tailed Fisher’s exact test or Chi-square test. ## Results Total unique responses in 2014 and 2019 were 104 (denominator unknown) and 75 (out of 1005 email invitations, with invitations to multiple personnel at a single site possible), respectively (Table 2). In both years, about 40% ( n = 44 in 2014 and n = 29 in 2019) of responses came from registered nurses. Although the proportion of licensed practical nurses responding increased nearly 5-fold, the overall mix of respondents’ areas of practice was not significantly different between 2014 and 2019 ( p = 0.051). By site, the respondents represented all five health zones in Alberta although the proportion from Calgary zone increased, while that from North zone decreased ( p < 0.05). In both sampling years, the most responses came from sites providing primary health care, HC/LTC and outpatient services, totalling 58% ( n = 100 out of 172 in 2014) and 62% ( n = 57 out of 91 in 2019) of responses (noting that some sites provided multiple types of services), with similar proportions between years ( p > 0.05). Table 2 Respondent and site characteristics in 2014 ( n = 104) and 2019 ( n = 75) 2014 2019 P-value* Profession of Respondent N % n % 0.051 Registered Nurse 44 42 29 39 Licensed Practical Nurse 4 4 14 19 Manager or Instructor or Educator 22 21 15 20 Physiotherapist or Occupational Therapist or Pharmacist or Registered Dietitian 8 8 10 13 Physician or Nurse Practitioner 9 9 5 6 Other 5 5 2 3 No response 11 11 0 0 Zone North 39 38 16 21 0.022 Edmonton 27 25 20 27 Central 18 17 13 17 Calgary 6 6 16 21 South 13 13 8 11 Federal or provincial 1 1 2 3 Area of practice (more than 1 answer possible) Total 172 responses % Total 91 responses % Primary health care 24 14 21 23 0.27 Outpatient 33 19 13 14 Acute care 20 12 8 9 Wound clinic 19 11 7 8 Homecare or long-term care (HC/LTC) 43 25 23 25 Community care 19 11 8 9 Other a 11 6 11 12 No response 3 2 0 0 Service level provided Basic foot screening 58 56 55 73 0.016 No 44 19 No response 2 1 Assesses for moderate risk 34 33 36 48 0.044 No 62 29 No response 8 10 Assesses for high risk 34 33 35 47 0.019 No 60 28 No response 20 12 * p-value < 0.05 by Chi-squared Test or Fisher’s Exact Test was considered significant. Analyses did not include “no response” as an option aOther includes categories with < 5 responses: Rural diabetes program, emergency department or intensive care unit, private/independent service, rehabilitation centre, renal clinic, other Figure 1a and Table 2 shows that the proportion of all respondents providing basic foot screening increased from 2014 to 2019 ( p < 0.05), and this increase was still significant when non-respondents were included in the group not providing screening. An analysis by geographically organized health zones, showed the main increases were in North ( p < 0.05) and Central ( p = 0.056) zones, which are primarily rural (Table 3). The main contributors to increased foot screening practices were primary care and HC/LTC sites (Fig. 1b, Table 3), with none of the other areas of practices changing significantly. In 2019 compared with 2014, 5% ( n = 1) versus 30% ( n = 6) of primary care sites did not provide basic screening ( p < 0.01). Similarly 40% ( n = 7) versus 53% ( n = 19) of HC/LTC sites did not provide basic screening in 2019 compared with 2014 ( p < 0.05) (Table 3). In 2019, one-third of respondents had adopted the screening tool developed as part of the DON SCN™ resource toolkit (Table 3). Table 3 Basic Foot Screening – Characteristics of Sites Provide Basic Screening 2014 2019 P-value* Yes No Yes No Zone N N % Yes N N % Yes North 17 21 45 12 3 80 0.031 Edmonton 17 10 63 11 9 55 0.77 Central 8 9 47 11 2 85 0.056 Calgary 4 2 67 13 3 81 0.59 South 11 2 85 6 2 75 0.62 Federal or provincial 1 0 100 2 0 100 ND Total of all respondents 58 44 57 55 19 74 See Table 2 Non-respondents 2 1 Area of practice (more than 1 answer possible) Primary or family practice 14 6 70 20 1 95 0.005 Outpatient 11 7 61 10 3 77 0.452 Acute care 8 11 42 3 4 43 1.00 Wound clinic 8 8 50 7 0 100 0.052 Homecare, long-term care 17 19 47 16 7 60 0.018 Community care 12 5 71 7 1 88 0.623 Other 6 2 75 8 4 67 1.00 No response 1 0 0 0 Screening Tool Used N % N % 60 s foot screening tool 50 62 16 31 AHS foot screening tool 18 35 Other 31 39 18 35 * p-value < 0.05 by Fisher’s Exact Test was considered significant, comparing “yes” vs “no responses”. ND, not done In total, 35% ( n = 34 out of 96 sites) and 55% ( n = 36 out of 65 sites) respondents indicated that their site provided assessment of moderate risk patients in 2014 and 2019, respectively (Fig. 1a, Table 2), a significant increase ( p < 0.05). Of the respondents, the main providers of moderate risk assessment were primary care and HC/LTC, together accounting for 43% ( n = 18) and 39% ( n = 22) of the sites providing this service in 2014 and 2019, respectively, which was not significantly different. However, more outpatient ( p < 0.05) and wound clinics ( p < 0.01) reported provision of care for moderate risk patients in 2019 than 2014 (Table 4). The service model utilized for moderate risk assessment, in 2014, was most often a hospital or clinic team. In 2019, there were 13 sites reporting utilization of HRFT, which did not exist in 2014. Table 4 Assessment of Moderate Risk – Characteristics of Sites Have a formalized clinic 2014 2019 P-value Yes No Yes No Zone N N % Yes N N % Yes North 11 28 28 5 6 45 0.30 Edmonton 11 12 48 11 7 61 0.53 Central 5 12 29 7 4 64 0.12 Calgary 3 1 75 5 10 33 0.26 South 4 8 33 6 2 75 0.17 Federal or provincial 0 1 0 2 0 100 ND Total 34 62 35 36 29 55 See Table 2 Non-respondents 8 10 Area of practice (more than 1 answer possible) Primary or family practice 10 9 53 13 7 65 0.52 Outpatient 4 14 22 7 4 64 0.048 Acute care 5 13 28 3 3 50 0.362 Wound clinic 4 11 27 6 0 100 0.004 Homecare, long-term care 8 28 22 9 10 47 0.07 Community care 6 10 38 3 4 43 1.00 Other 5 2 71 4 3 57 1.00 Type of service (more than 1 answer possible) HRFT 13 Hospital/clinic team 25 20 Home care 5 4 See referrals 4 2 Services provided (more than one answer possible) Skin & nail abnormalities N [%] N [%] Total number of sites (formalized and unformalized clinics) 96 39 Skin or nail care provided 44 [46] 21 [54] 0.45 Provide list of foot/nail care providers in the community 33 [34] 26 [67] 0.001 Refer to podiatrist or footcare nurse 33 [34] 29 [74] < 0.001 Refer to HRFT 11 [28] None of the above 8 [8] 1 [3] Other 2 [2] 3 [8] Structural deformities (bunions, hammertoes) Total number of sites 95 [100] 39 Provide education regarding self-management 47 [49] 30 [77] 0.004 Refer to podiatrist or orthopedics 63 [66] 31 [79] 0.007 Other 13 [14] 3 [8] ND None of the above 12 [13] 0 ND Footwear problems Total number of sites / no answer 96 39 Provide information/education regarding appropriate footwear selection 76 [79] 35 [90] 0.22 Refer to HRFT 18 [46] Refer for footwear / orthotics through AADL 50 [52] 20 [51] 1.00 Refer for footwear / orthotics without AADL authorization 26 [27] 14 [36] 0.31 None of the above 7 [7] 1 [3] ND Other 20 [21] 4 [10] ND Services provided for vascular problems Total number of sites 96 [100] 39 Perform vascular (lower limb) assessment 62 [65] 36 [92] 0.001 Refer to HRFT 19 [49] Refer to GP for assessment 36 [38] 23 [59]* 0.035 Refer to vascular lab for assessment 24 [25] 15 [38] 0.14 Other 13 [14] 4 [10] ND If vascular assessment performed, procedures used Out of 62 Out of 36 ABPI 44 [71] 16 [44] 0.011 PPG (toe pressures) 37 [60] 17 [47] 0.29 ABPI + PPG (gold standard) 32 [52] 14 [39] 0.29 Pedal pulses 38 [61] 34 [94] < 0.001 Other 4 [6] 5 [14] ND Refer to HRFT 17 [47] Services provided for loss of sensation / neuropathic pain Out of 91 Out of 39 Refer to MD/NP for treatment of neuropathic pain 83 [91] 28 [72]** 0.007 Refer to HRFT 18 [46] Address neuropathic pain in their clinic 6 [7] 5 [13] 0.30 Other 2 [2] 1 [3] ND None 0 2 [5] ND Frequency of reassessing patients with moderate risk 1–3 months 15 [16] 8 [21] 0.62 4–6 months 11 [12] 11 [28] 0.039 7–12 months 8 [8] 3 [8] 1.00 No formalized schedule 48 [53] 7 [18] < 0.001 Other 7 [8] 9 [23] ND Statistical analysis used Fisher’s Exact Test Abbreviations: ABPI Ankle-brachial pressure index, AADL Alberta Aids to Daily Living, GP General practitioner, HRFT High risk foot team, MD Medical doctor, NP Nurse practitioner, PPG Photoplethysmography toe pressure, ND Not done With regard to the services provided, between 2014 and 2019, there were significant increases in the proportion of sites providing patients with lists of foot/nail care providers in the community ( p < 0.001) and sites providing referrals to podiatrists or footcare nurses ( p < 0.001) (Fig. 2a, Table 4). Similarly, for practices related to structural deformities, an increased proportion of sites provided relevant education ( p < 0.01) and provided referrals to podiatrists or orthopedic specialists ( p < 0.01) (Fig. 2b, Table 4). However, no differences in education about footwear or referral to providers of specialty footwear were detected (Fig. 2c), with the exception that referral to HRFT was a new option available in 2019. In 2019 a significantly (p < 0.01) bigger proportion of respondents reported that their sites performed assessment of vascular problems than in 2014 (Fig. 2d, Table 4). These included referral to general practitioners ( p < 0.05) along with HRFT and vascular laboratories. Finally, services provided for loss of sensation and neuropathic pain were found to be similar between service models, with referral to a physician or nurse practitioner predominating but HRFT referred to by nearly half of the sites in 2019 (Table 4). Frequency of reassessing patients with moderate risk changed, with a smaller proportion of clinics not having a formalized schedule ( p < 0.001) and more clinics reassessing at 4–6 months in 2019 vs 2014 ( p < 0.05) (Table 4). We compared practices in assessing and caring for moderate risk patients reported by sites utilizing specified HRFT ( n = 13) compared with those utilizing other models of care delivery (other types of clinical teams) ( n = 20) using 2019 data. The areas of practice represented in the two care models were not significantly different ( p > 0.05) (Table 5). The sites reporting HRFT were located more in urban areas than the clinic/hospital teams ( p < 0.05). More clinic/hospital teams than HRFT provided skin and nail care (75% versus 63%, ( n = 15 versus n = 5, p < 0.1). Referral to podiatrists and assessment of structural deformities was similar between care models. HRFT were more likely to hold AADL authorization than other sites ( p < 0.1), meaning that patients could be referred and have a portion of costs covered by Alberta’s publically-funded insurance plan. With regard to assessment of vascular problems, all sites provided this service but clinic/hospital teams were more likely to refer patients to their general practitioner ( p < 0.05). HRFT were more likely to assess pedal pulses than clinic/hospital teams ( p < 0.1) but no differences were detected in use of other diagnostic modalities. Finally, with regard to assessing loss of protective sensation, practices were similar between the care models (Table 5). Table 5 Comparison between sites utilizing HRFT vs other care models for assessing moderate risk patients All HRFT Clinic/ hospital team P-value N unique sites 36 13 20 PHC 10 5 5 0.574 Outpatient 6 3 3 Acute care 1 0 1 Wound clinic 4 2 2 HC/LTC 9 5 4 Community care 1 0 1 Private/independent 2 0 2 Multiple areas of practice 6 1 5 N for geographical location: 0.015 Metro & Urban 21 11 8 Rural 10 2 7 Remote 2 0 2 First Nations 3 0 3 Services provided N (%) N (%) Skin and nail care Provide skin & nail care 5 (38) 15 (75) 0.067 Provide a list of community resources 11 (85) 13 (65) 0.264 Refer to podiatrist 9 (69) 18 (90) 0.184 Assess structural deformities Provide education 11 (85) 17 (85) 1.00 Refer podiatrist or orthopedic specialist 11 (85) 18 (90) Other 0 2 (10) Address footwear problems Provide education 13 (100) 19 (95) 0.501 Refer to AADL 9 (69) 7 (35) 0.0799 Refer without AADL authorization 8 (62) 8 (40) 0.296 Other 5 (38) 5 (25) Assess vascular problems Perform vascular assessment 13 (100) 20 (100) 1.00 Refer to GP 5 (38) 16 (80) 0.0265 Refer to vascular lab 10 (77) 10 (50) 0.1595 Vascular assessment methodology ABPI 7 (54) 8 (40) 0.4928 PPG 9 (69) 8 (40) 0.151 ABPI + PPG 7 (54) 7 (35) 0.472 Pedal pulses 12 (92) 12 (60) 0.0560 Perform all 3 tests 7 (54) 7 (35) 0.472 Other 1 (8) 1 (5) Assess loss of protective sensation Refer to physician 10 (77) 18 (90) Treat neuropathic pain 3 (23) 2 (10) Statistical analysis using Fisher’s Exact Test. For discussion purposes, p < 0.1 was considered significant given the small number of sites available for comparison Abbreviations: AADL Alberta Aids to Daily Living, ABPI Ankle-brachial pressure index, GP General practitioner, HC/LTC Homecare/long-term care, PHC Primary health care, PPG Photoplethysmography toe pressure Metro, urban, rural and remote were defined according to Alberta Health Services and Alberta Health criteria [ 28]. N = 3 sites responded “other” (one referred to home care, two were themselves referral sites) ## Discussion Diabetic foot diseases compromise the quality of life of people with diabetes [ 29] and are costly to the health system [ 1, 30]. Yet in Canada, primary prevention practices such as screening are performed less frequently than for other co-morbidities of diabetes such as hypertension [ 16, 31]. Comprehensive foot care practices including screening and measures to prevent ulcer development are recommended, with multidisciplinary teams involved in patient care for people with diabetes. Multidisciplinary teams such as foot protection services or HRFT have been deployed in a number of jurisdictions to increase screening and risk stratification [ 32], access to specialized care [ 10, 11] and reduce outcomes such as severe infection and lower limb amputations [ 32, 33]. In Alberta, Canada foot protection services, named HRFT, supported by the DON SCN™ were first constituted in 2015 at three pilot sites and have since spread with a total of six operational sites in the province. A clinical care pathway, training in foot screening, referral guidance and additional resources were provided. The combination of these activities was shown to increase screening activity, particularly in primary health care and HC/LTC settings along with increased proportion of reporting sites that provide services for the assessment of moderate-risk patients. Both clinical and cost-effectiveness are essential to sustaining innovations in healthcare delivery. Interventions targeting healthcare organizations to improve secondary prevention of DFU are effective in reducing ulcer recurrence and lower limb amputations [ 21, 33]. Moreover, timely access to wound care specialists results in less severe presentation and faster healing than when access to specialists is delayed [ 8, 34]. Preliminary exploration of lower limb amputation rates in Alberta after 1-year follow-up indicated a small reduction of 0.5% and a significant net monetary benefit of$3000 per patient-year, consisting of $3500 health utilization cost avoidance versus$500 intervention cost [ 35]. When foot protection services were implemented in a hospital in Ireland they were proven to reduce DFU and be cost-effective [ 36]. Likewise, a Scottish analysis found a 0.3% reduction in lower limb amputation after introducing a national strategy for screening and risk stratification [ 32].
From our survey, which components of the clinical pathway, resource toolkit and training were found most valuable in facilitating organizational change could not easily be identified. However, a separate survey conducted by the DON SCN™ only in primary care settings (for program evaluation purposes) found that the most used resources were the foot screening tool, followed by the Diabetes Foot Risk Assessment Triage Referral form and its associated process guidelines, and the patient resource. These materials were used by more than 30% of the respondents. E-learning modules and the Provider’s Guide for the pathway were used by less than 25% of respondents (K. Dmytruk and M. Mainville, personal communication). Annual screening is recommended in Canada and internationally [ 26, 37]. A review of the utility of screening in primary care of all people with diabetes yielded only weak evidence for benefit [ 38] but in the context of a comprehensive care plan, is the first step to identifying risk and ensuring that people with diabetes can access specialized care expeditiously [ 26]. Our survey found an overall increase in screening from 57 to 74% of respondents predominantly in primary health care and HC/LTC sites, which is important, because foot problems identified early increases the potential to avoid overt ulceration [ 39]. Uptake of the AHS foot screening tool was strong in 2019, likely due to the training provided in its use. Unfortunately, actual screening rates on individual patients in primary health care and HC/LTC are not easily tracked. However, based on the data presented here, we predict that individuals self-reporting an annual foot screen would increase from the 40% recorded in a cohort prior to implementation of the diabetes foot care pathway [ 16]. To further increase uptake of diabetes foot screening into clinical practice, embedding the screening tool into the electronic medical records would allow for automated reminders and tracking of foot screens performed.
An online patient education resource and handouts for each risk level were developed by the DON SCN™. Patient education is recommended [ 26] even though evidence for effectiveness is conflicting [ 40, 41]. In particular, a single education session focused only on increasing knowledge is unlikely to provide lasting behaviour change [ 41]. Individuals with diabetic foot disease express complex emotional and behavioral responses to their condition and may feel they lack control over their ability to prevent re-ulceration [ 42], thus the provision of simple leaflets may be insufficient support.
When screened patients present with skin, nail, anatomical or sensory abnormalities but not skin breakdown or ulceration, they are defined as moderate-risk in the AHS-developed screening tool and the pathway recommends footcare education and referral to a footcare nurse or podiatrist by the family physician or HRFT [ 23]. In 2019, about half of respondents referred such patients to family physicians, the other half to HRFT (with some overlap). Improvement in practices for moderate-risk patients in 2019 included more sites following the recommended [ 23] 4–6 months follow-up increasing 1.7-fold and an increased proportion of sites performing vascular assessment, which requires performing specific diagnostic tests by 1.3-fold compared with 2014. Training and video modules of assessment were provided to facilitate uptake. Patients with peripheral artery disease have 2-fold higher risk of major lower limb amputation [ 43] so the increased proportion of sites performing vascular assessment is encouraging because a systematic review found that timely referral of patients with peripheral artery disease can reduce morbidity and mortality [ 44]. Access to HRFT following community-level screening is important, in particular forming networks with a HRFT hub [ 32]. It was facilitated in the clinical care pathway by the Triage Referral Form provided to those in primary care performing screening.
We identified differences in clinical practices between clinic/hospital teams and HRFT, which received specific training in the pathway and resource toolkit use. Specifically, clinic/hospital teams were more likely to provide skin and nail care than HRFT, which was associated with their service to mainly remote and First Nations communities. This might reflect lack of community services (e.g., podiatry) for such care. Indeed, inspection of the sites providing skin/nail care by the clinic/hospitals revealed that 12 out of 12 rural/remote/First Nations sites provided this service versus only 3 out of 8 urban sites. Provision of such services in rural settings is important, perhaps even more so in First Nations communities because the prevalence of neuropathy is high and patients tend to be younger than in non-First Nations populations [ 45, 46]. Referral of patients to family doctors versus a specialized vascular laboratory was noted for the clinic/hospital teams, possibly also related to access variation imposed by geography. Referral practices for therapeutic footwear did not change but this may be more related to restrictions on prescribing and insurance coverage than lack of attention to pathway recommendations. Because properly-fitted footwear is important for preventing ulcers [ 47], development of policies and clear criteria for more universal provision of therapeutic or custom footwear and offloading inserts would be beneficial.
The strengths of this study include attempts to reach a broad base of respondents from all settings where diabetic foot care is performed, and ability to compare with data collected prior to implementation of the diabetic foot care pathway. However, we acknowledge some weaknesses. The customized survey was not validated and selection bias is probable because sites with a strong interest or expertise in diabetic foot care were more likely to respond than those with less investment in that area. Moreover, the professions of non-respondents were unable to be fully documented because of the untargeted recruitment, particularly in 2014. Also, sites receiving multiple invitations to participate may have designated the most knowledgeable member of the team to respond to the survey to avoid duplication of effort. Nurses may have been over-represented (about 40% of respondents), however, nurses play an important role in foot screening and foot care and thus may be the most knowledgeable of their site’s practices. Although we were unable to directly compare sites’ responses in 2019 versus 2014, we could document trends in improved diabetic foot care practices in Alberta. Ability to assess the benefits of HRFT was limited by the small number of respondents and differences in geography between HRFT and the comparator group of hospital/clinic teams. Finally, this analysis provides an overview of the uptake of the comprehensive diabetes foot care clinical pathway and resource toolkit but further work should include validation of the foot screening tool and evaluation of the effectiveness of the patient education resources to improve self-care.
In conclusion, this study supports that a multi-faceted, concerted approach to improve diabetic foot care improves awareness of healthcare providers and uptake of appropriate screening in primary care and HC/LTC settings in Alberta, Canada. Provincial outreach and training provided by the DON SCN™ facilitated uptake of the clinical pathway. Preliminary data are consistent with cost avoidance and reduction in foot-related complications in persons with diabetes and are consistent with reports from other jurisdictions. HRFT provide increased expertise for assessment and procedures for patients with moderate risk of ulceration so that individuals screened in primary healthcare, homecare or other settings can be referred. This comprehensive model has the potential to reduce progression of foot problems and overall health services utilization.

## Supplementary information

Supplementary information accompanies this paper at https://​doi.​org/​10.​1186/​s13047-020-00393-0.

## Acknowledgments

The assistance of Christine Goertzen is greatly appreciated. Respondents are thanked for their participation.

### Ethics approval and consent to participate

The study was approved by the University of Alberta Research Ethics Board Pro00086515. Participants implied consent by clicking the hyperlink to complete the survey in 2019. Waiver of consent was granted for the 2014 survey, which was examined retrospectively.

Not applicable.

### Competing interests

The authors declare they have no competing interests.
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