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

Abstract

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.

Clinical characteristics of inpatients with diabetic foot ulcer admitted with non-ulcer complaints: a retrospective study

“…In fact, diagnosis and treatment delay is common in China and even worldwide (1,2). Implementation of the multidisciplinary team approach and development of the system of tiered diagnosis and treatment have proven to be e cient (3,(27)(28)(29). However, it seems more di cult to improve the e ciency of the management of DFU patients with non-ulcer complaints.…”

Foot self‐care behaviour in primary care patients with diabetic foot ulcers: Structural equation modelling of psychological predictors

“…NHGP consists of seven polyclinics that serve the central and northern parts of Singapore and provides a comprehensive range of health services including diabetic foot wound care management. NHGP is part of Diabetic Foot in Primary and Tertiary (DEFINITE) Care 30 that is an inter‐institutional and multi‐disciplinary team care at a healthcare cluster in Singapore with an aim to provide optimal care for patients with DFU. Nurses at NHGP actively participate in regular DFU wound care dressings and patient education on wound/foot self‐care behaviours every 3–5 days until wound closure.…”

Multi‐disciplinary diabetic limb salvage programme in octogenarians with diabetic foot ulcers is not futile: An observational study with historical controls

“…16 In Singapore, a LEA prevention programme implemented in tertiary care clinics has demonstrated encouraging results in reducing the incidence of both minor and major LEA, as well as improving cardiovascular health by improved glycaemic and lipid control. 17,18 Nevertheless, the effect of patients' age on LEA outcomes and healthcare utilisation as well as the effects of a multi-disciplinary DLS programme in individuals aged ≥80 years have not been investigated. Thus, this study aimed to examine the association between age group (individuals aged ≥80 years and those aged <80 years old) and the outcomes and evaluate the effectiveness of the DLS programme in reducing LEA and mortality rates and optimising healthcare utilisation among individuals aged ≥80 years as compared to a historical control group.…”

“…DLS, a highly complex procedure involving various techniques to remove any dead tissue and replace devitalised infected bone so that the lower limb can be preserved as much as possible with reduced risk of future infections and can function properly for ambulation, should be considered as a first‐line approach in treating patients with DFUs 16 . In Singapore, a LEA prevention programme implemented in tertiary care clinics has demonstrated encouraging results in reducing the incidence of both minor and major LEA, as well as improving cardiovascular health by improved glycaemic and lipid control 17,18 . Nevertheless, the effect of patients' age on LEA outcomes and healthcare utilisation as well as the effects of a multi‐disciplinary DLS programme in individuals aged ≥80 years have not been investigated.…”