Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an <scp>Asian</scp> population: A case‐control study

Lo, Zhiwen Joseph; Chandrasekar, Sadhana; Yong, Enming; Hong, Qiantai; Zhang, Li; Chong, Lester Rhan Chaen; Tan, Glenn Wei Leong; Chan, Yam Meng; Koo, Hui Yan; Chew, Tiffany; Sani, Nur Faezah; Cheong, Keet Yeng; Cheng, Leighton Ren Qin; Tan, Audrey Hui Min; Muthuveerappa, Sivakami; Lai, Tina Peiting; Goh, Cheng Cheng; Ang, Gary Yee; Zhu, Zhiwei; Hoi, Wai Han; Lin, Jaime; Chew, Daniel Ek Kwang; Lim, Brenda; Yeo, Pei Shan; Liew, Huiling

doi:10.1111/iwj.13672

Cited by 10 publications

(14 citation statements)

References 36 publications

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“…Both NICE and IWGDF guidelines affirmed the strong evidence of MDT approach in DFU management, 10,11 because MDT allows for DFU‐related healthcare professionals (such as vascular surgeons, endocrinologists, podiatrists and wound nurses) to provide a continuum of care from the SOC to admission and subsequently after inpatient discharge back to outpatient postoperative care, in a seamless and holistic fashion, addressing key issues of revascularisation, wound care, offloading footwear, diabetic control and patient education 19‐21 . Within one of our tertiary institutions, we had previously demonstrated the benefits of an MDT LEAPP clinics at a tertiary hospital, which significantly decreased mean time from referral to index clinic visit (38.6–9.5 days, P < .001), increased outpatient podiatry follow‐up (33%–76%, P < .001) and decreased 1‐year minor (14%–3%, P = .007) and major LEA rates (9%–3%, P = .05) 12 . Scaling up these benefits across the other tertiary hospital within our healthcare cluster and in collaboration with our 7 primary care polyclinic network, we are now able to demonstrate sustained benefits within our catchment population through inter‐institutional MDT DFU care, with significant 80% reduction in minor LEA (13.7 from 68.9 per 100000 population, P < .001), 35% reduction in major LEA (8.0 from 12.4 per 100000 population, P = .005) and significantly improved cardiovascular profile (glycemic and lipid control).…”

Section: Discussionmentioning

confidence: 89%

“…[19][20][21] Within one of our tertiary institutions, we had previously demonstrated the benefits of an MDT LEAPP clinics at a tertiary hospital, which significantly mean time from referral to index clinic visit (38.6-9.5 days, P < .001), increased outpatient podiatry followup (33%-76%, P < .001) and decreased 1-year minor (14%-3%, P = .007) and major LEA rates (9%-3%, P = .05). 12 Scaling up these benefits across the other tertiary hospital within our healthcare cluster and in collaboration with our 7 primary care polyclinic network, we…”

Section: Discussionmentioning

confidence: 99%

“… 19 , 20 , 21 Within one of our tertiary institutions, we had previously demonstrated the benefits of an MDT LEAPP clinics at a tertiary hospital, which significantly decreased mean time from referral to index clinic visit (38.6–9.5 days, P < .001), increased outpatient podiatry follow‐up (33%–76%, P < .001) and decreased 1‐year minor (14%–3%, P = .007) and major LEA rates (9%–3%, P = .05). 12 Scaling up these benefits across the other tertiary hospital within our healthcare cluster and in collaboration with our 7 primary care polyclinic network, we are now able to demonstrate sustained benefits within our catchment population through inter‐institutional MDT DFU care, with significant 80% reduction in minor LEA (13.7 from 68.9 per 100000 population, P < .001), 35% reduction in major LEA (8.0 from 12.4 per 100000 population, P = .005) and significantly improved cardiovascular profile (glycemic and lipid control). Through DEFINITE Care, involving both medical and surgical disciplines with a nuclear team ‘captained’ by passionate institutional leads and supported by ancillary team members, we were able to implement across the healthcare cluster a comprehensive risk‐stratified DFS surveillance system (STEP programme), clear referral algorithms from primary care to tertiary institutions, MDT LEAPP clinics at hospitals, MDT inpatient care pathways and coordinated co‐management care between primary care (regular wound dressings, diabetes control, patient‐carer education) and tertiary care (revascularisation, surgical wound care planning and offloading) post discharge from inpatient diabetic limb salvage (DLS) procedures.…”

Section: Discussionmentioning

confidence: 99%

“…There is strong evidence for a multi‐disciplinary team (MDT) approach in the management of DFU and LEA prevention, as recommended by both National Institute for Health and Care Excellence (NICE) and International Working Group on Diabetic Foot (IWGDF) guidelines 10,11 . Within our institution, a pilot case‐cohort study in 2018 on the clinical and economic outcomes of an MDT approach in DFU management (Lower Extremity Amputation Prevention Programme [LEAPP] Clinic) demonstrated a significant decrease in mean time from referral to index clinic visit (38.6–9.5 days, P < .001), increase in outpatient podiatry follow‐up (33%–76%, P < .001), decrease in 1‐year minor LEA rate (14%–3%, P = .007) and decrease in 1‐year major LEA rate (9%–3%, P = .05) 12 . Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86 million for patients within the LEAPP cohort.…”

Section: Introductionmentioning

confidence: 99%

“…10 , 11 Within our institution, a pilot case‐cohort study in 2018 on the clinical and economic outcomes of an MDT approach in DFU management (Lower Extremity Amputation Prevention Programme [LEAPP] Clinic) demonstrated a significant decrease in mean time from referral to index clinic visit (38.6–9.5 days, P < .001), increase in outpatient podiatry follow‐up (33%–76%, P < .001), decrease in 1‐year minor LEA rate (14%–3%, P = .007) and decrease in 1‐year major LEA rate (9%–3%, P = .05). 12 Simulation of cost avoidance demonstrated an annualised cost avoidance of USD $1.86 million for patients within the LEAPP cohort. As such, within our healthcare cluster of 7 primary care polyclinics and 2 tertiary hospitals, we scaled up DFU programs as a health service innovation, to coordinate the care of patients with DFU from primary care to tertiary care, with subsequent co‐management between primary and tertiary care until complete DFU healing.…”

Section: Introductionmentioning

confidence: 99%

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Diabetic foot in primary and tertiary (DEFINITE) Care: A health services innovation in coordination of diabetic foot ulcer (DFU) Care within a healthcare cluster ‐ 18‐month results from an observational population health cohort study

Tan

Chandrasekar

et al. 2022

International Wound Journal

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Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter‐institutional and multi‐disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster ‐ an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700‐bed and 800‐bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013–2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12‐months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18‐months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013–2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low‐density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18‐month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.

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Section: Discussionmentioning

confidence: 89%