- Title
- Diabetes and minor foot amputation: patterns of podiatry service utilisation and factors associated with poor clinical outcomes
- Creator
- Linton, Clare
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2021
- Description
- Masters Research - Master of Philosophy (MPhil)
- Description
- This thesis presents the outcomes of a retrospective clinical audit of people with diabetes undergoing minor foot amputations in the Central Coast Local Health District (CCLHD) in 2017 and also investigates the predictive capacity of toe systolic blood pressures (TSBP) and the toe-brachial pressure index (TBPI) in identifying healing outcomes following minor amputation in people with diabetes. Minor and major amputations of the lower limb, tissue breakdown, chronic ulceration and infection are some of the complications experienced with diabetes related foot disease (DFD), which results from complications associated with diabetes. While minor foot amputation leads to less disability and functional decline when compared to major amputations, they are reported to have high rates of post-surgical delayed healing, infection, and risk of subsequent, more proximal amputation. In order to reduce the cascade from tissue breakdown to amputation, early detection of complications is vital. Clinic based non-invasive vascular assessments such as TBPI and TSBP are required to assist in categorisation of the level of risk and to prevent or minimise complications. However, although established for diabetes related foot ulcer healing, there are no clear thresholds for these measurements to predict healing post minor foot amputation. In addition to timely non-invasive vascular lower limb assessments, management in a multidisciplinary high risk foot services (HRFS) is advised for people with diabetes who are at high risk of DFD including amputation. These clinics have the potential to reduce complications, assist in prevention of DFD and decrease the frequency and severity of amputations. Podiatrists play a key role in HRFS as they specialise in the prevention, diagnosis and treatment of foot and lower leg conditions including the conservative management of the foot with diabetes. Consequently, a clear understanding of podiatry service utilisation both prior to, and post, minor foot amputation, provides an opportunity to improve service provision to high-risk groups. Initially by systematic review and meta-analysis of the available literature we demonstrated that although TBPI or TSBP thresholds for prediction of healing post minor amputations in the foot in people with diabetes varied considerably between the studies, all of the nine studies identified reported improved healing outcomes where mean TSBPs was ≥30 mmHg, with a range of 30–83.6 mmHg. The meta-analysis showed that TSBP values <30 mm Hg are associated with 2.09 times the relative risk of non-healing (RR=2.09, 95% CI: 1.37 to 3.20, p=0.001). The subsequent retrospective clinical audit of the CCLHD podiatry services was conducted in two parts. The first investigation focussed on compliance and explored patient compliance to podiatry attendance guidelines and CCLHD compliance to podiatry service benchmarks for people with an at-risk foot. This review revealed that people with diabetes undergoing a minor foot amputation were underutilising the CCLHD Podiatry Services. This was particularly evident in relation to low rates of access prior to minor foot amputations with less than half, 42% (n=31), of the study patients attending any of the available clinics within the CCLHD Podiatry Services in the 12-month period leading up to their minor foot amputation. The second part of the audit focused on patient healing and clinical outcomes following their minor foot amputation. This study revealed a high rate of healing (74%) at a twelve-month follow-up in people with diabetes undergoing minor foot amputations despite a high rate of multiple comorbidities (70%) and a history of previous foot amputations (33%). Poor clinical outcomes (defined as non-healing, further amputation or death in the 12 month follow up period) were almost six times more likely (RR 5.75, 95% CI: 0.85 to 38.7, p=0.013) in those aged greater than 60 years, and twice as likely (RR 2.42, 95% CI: 1.3 to 4.4, p=0.005) in those who had a debridement procedure during the hospital stay, or those who did not attend the CCLHD podiatry services post-amputation. These results underscore the importance of early identification of those at higher risk of poor outcomes and highlight the need for a multidisciplinary team to be involved for follow up for a minimum of 12 months post-minor foot amputation. Follow up is not only required for orthotic offloading and medical grade footwear but to ensure this group of high-risk people are carefully monitored to reduce the risk of further amputations and interventions. Following the clinical audit, ongoing improvements to services include greater inpatient focus, expanding the multidisciplinary HRFS to provide more accessible locations, providing education for those highlighted to be at high risk (including daily monitoring of feet, identification of early signs of infection and seeking medical assessment for any foot trauma), and actions to initiate and encourage referral pathways both prior to, during and following hospitalisation. These steps will increase access to the CCLHD podiatry services and help reduce risk of minor foot amputations.
- Subject
- diabetes; minor foot amputation; healing; podiatry; high risk foot clinic; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1429426
- Identifier
- uon:38711
- Rights
- Copyright 2021 Clare Linton
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 2 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 250 KB | Adobe Acrobat PDF | View Details Download |