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.

Keywords: diabetic foot ulcers; diabetic limb salvage; health services innovation; lower extremity amputation; multi-disciplinary team.

FIGURE 1

Anonymized 2020 online poll results amongst primary care diabetic foot wound care providers, comprising doctors, nurses and podiatrists, on their views on current diabetic foot wound care (n = 138). DFU: diabetic foot ulcers; NHG: National Healthcare Group (our healthcare cluster comprising of 7 primary care polyclinics and 2 tertiary hospitals).

FIGURE 2

Pre‐DEFINITE healthcare ecosystem for patients with DFU. DEFINITE: diabetic foot in primary and tertiary; DFS: diabetic foot screening; DFU: diabetic foot ulcer; GP: general practitioner; KTPH: Khoo Teck Puat Hospital; LEAPP: lower extremity amputation prevention programme; MDT: multi‐disciplinary team; STEP: screening & surveillance, treatment and escalation programme; TTSH: Tan Tock Seng Hospital.

FIGURE 3

Post‐DEFINITE healthcare ecosystem for patients with DFU. DEFINITE: diabetic foot in primary and tertiary; DFS: diabetic foot screening; DFU: diabetic foot ulcer; GP: general practitioner; KTPH: Khoo Teck Puat Hospital; LEAPP: lower extremity amputation prevention programme; MDT: multi‐disciplinary team; STEP: screening & surveillance, treatment and escalation programme; TTSH: Tan Tock Seng Hospital.

FIGURE 4

DEFINITE Programme Logic. DEFINITE: diabetic foot in primary and tertiary; DFU: diabetic foot ulcer; DM: diabetes mellitus; LEA: lower extremity amputation; LEAPP: lower extremity amputation prevention programme; MDT: multi‐disciplinary team; NHG: National Healthcare Group; NHGP: National Healthcare Group Polyclinics; STEP: screening & surveillance, treatment and escalation programme; TTSH: Tan Tock Seng Hospital.

FIGURE 5

Unique patients with DFU recruited within DEFINITE Care. DEFINITE: Diabetic Foot in Primary and Tertiary; NHGP: National Healthcare Group Polyclinics; KTPH: Khoo Teck Puat Hospital; TTSH: Tan Tock Seng Hospital.