How to Cope With the Increasing Burden of the Diabetic Foot

The diabetic foot continues to be an inexorable menace, both for the individual patient and for the health system.^1,2 Certainly, considerable progress has been achieved during the past 30 years,^3,4 but the rising prevalence of diabetes mellitus and prolonged patient survival ⁵ have created the need for efficacious and readily available foot care for a larger number of patients. In Western societies, these patients now increasingly present with ischemia due to peripheral arterial disease, requiring timely successful revascularization.^6,7 The latter needs to be routinely incorporated into the rapid evaluation and management of both patient and foot pathology.^8,9

In this setting, Manu et al., in the current issue of the journal, ¹⁰ describes the transformation of the multidisciplinary diabetic foot clinic to a day unit, in an endeavor to address the increased therapeutic demands and to improve outcomes. The reorganized foot clinic can now offer same-day investigation of new and/or deteriorating foot lesions with results of these investigations immediately available: this is essential to avoid catastrophes. Thus, urgent same-day treatment can be offered with casting for neuropathic ulcers and Charcot osteoarthropathy, aggressive infection control with parenteral antibiotic administration via peripherally inserted central catheters, and Duplex arterial imaging for early revascularization. ¹⁰ Impressively, such treatment can be offered on an open-access basis, not only allowing patients to freely visit the clinic when they notice a new/worsening foot problem but also accepting new patients self-presenting for foot-related pathology. ¹⁰ In the vast majority of cases, no hospital admission was required, despite the huge increase in the number of patients examined, as compared to when the foot clinic was inaugurated more than 30 years ago. ¹¹ As might be anticipated, the center’s approach led to high patient satisfaction and high attendance rates. ¹⁰

What are the clinical implications of these new data? In the face of the large patient numbers and the complexities of their foot lesions, treatment should be promptly offered. The therapeutic strategy should include same-day evaluation of infection and ischemia and, ideally, urgent initiation of treatment including revascularization. If practiced vigorously by engaged personnel, this can not only avoid delays in management but also reduce hospital admissions, thereby lowering cost and reducing complications. This modern scheme is one step further than the classical diabetic foot clinics, which years ago revolutionized foot care, leading to reduced amputations.^11,12 At the same time, urgent patient referral and even emergency self-referral should be facilitated and encouraged.^1,13 We believe that smooth liaison between primary health care and hospital-based clinics can and will promote timely expert referrals. Indeed, widespread awareness of the diabetic foot and its alarming signs throughout all health care levels can help patients’ access to expert teams when needed and avoid sinister outcomes. ¹³ An example of promoting knowledge is training of medical students, nurses and others in recognition of peripheral arterial disease and in accurate measurement of Ankle-Brachial Index^14,15: we argue that such a skill, based as it is on simple, reliable technology, may be transferred to practitioners within the primary/community setting. These steps will help not only in Western societies with traditionally high levels of investments in health care but also in emerging countries, such as China, India, and the Middle East, where diabetes and its complications are growing faster by comparison.

In conclusion, this new study has shown that urgent same-day multi-expert patient evaluation and treatment can avoid unnecessary delays and hospital admissions, thereby improving care of the diabetic foot. ¹⁰ The example set by the team at King’s College Hospital now needs to be followed and further improved. Indeed, when treating the diabetic foot, one should act, like the Shakespearean character, “Better three hours too soon than a minute too late.” ¹⁶