The situation: diabetic foot ulcers were leading to high rates of amputation
Pacific Islands account for eight of the top ten in the world for diabetes prevalence. In 2014 Polynesia and Micronesia had the world’s highest age-standardised diabetes prevalence rate of nearly 25%. With high rates of diabetes also comes a high prevalence of diabetic foot complications and resultant hospitalisations and amputations. This high rate of diabetes is leading to high rates of diabetic foot ulcers and subsequent amputations. With the growing rate of diabetes related foot ulcers and amputation in the Pacific, action is required to reduce the burden of diabetes on individuals, families, communities, the health system and the economy.
The World Health Organisation statistics show that amputation rates in countries with strong diabetic foot management services have decreased by 40-60% in the last 10-15 years. Unfortunately the same reductions are not being seen in low to middle income countries, where in most cases, amputation rates are steadily increasing. In many Pacific countries the only available treatment for patients with diabetic foot ulcers is life saving treatment through antibiotics, surgical debridement or amputation. Many hospital services around the Pacific are overwhelmed with the number of clients with diabetic foot wounds requiring treatment.
What was the response?
Since 2014 Motivation Australia has been collaborating with the Samoa National Health Service (NHS) to establish the Samoa Integrated Mobility Device Services (SIMDES) funded by the Australian Government. The initial part of this project saw the introduction of a wheelchair and walking aid service. During the early stages of this service, it was noted that a large proportion of the clients receiving mobility devices were amputees who had lower limb amputations due to untreated diabetic foot ulcers.
The first step was a feasibility study in the beginning of 2015 to see whether orthotic offloading could be introduced to reduce the number of amputations in Samoa. From this feasibility study came the launch of the NHS multi-disciplinary Diabetic Foot Clinic (DFC) in June 2015.
The DFC was established at Tupua Tamasese Meaole (TTM) hospital in Apia with a core team of Samoa’s only Podiatrist, nurses and an Australia volunteer prosthetist orthotist (with support as required from doctors). The volunteer was later replaced by a Samoan orthotist following the completion of her studies in lower limb orthotics at Mobility India in Bengaluru funded by the SIMDES project.
The clinic provides 3 main services to clients:
- Education relating to diabetes management and foot care
- Wound care including cleaning, debridement and dressings
- Offloading utilising Total Contact Casts (TCC), total contact removable and non removable shoes, foot orthoses, padding and surgical footwear
What were the outcomes?
The clinic has proven to be a success both for the service users and the NHS. Some of the key short term outcomes of the clinic include:
- Improved wound healing for clients
- Exposed NHS staff to a model of multi-disciplinary clinical co-operation
- Improved behaviour and increased compliance of self care by clients
- Increased capacity of nurses to manage wounds, through specialised practice under the guidance of a podiatrist
- Reduced the workload of doctors
- Raised awareness using a series of posters about diabetic foot care around the hospital
- Equipped the NHS with the skills, tools, systems and supplies to deliver offloading for diabetic foot ulcers
The clinic also showed that increased client contact time and consistent education helped improve clients understanding of diabetes and improve diabetes control, through lowered blood glucose levels. Clients’ blood glucose levels continued to decrease over time and reported self-care behaviours improved. These changes coincided with improved healing rates, general health and well-being:
“If this program hadn’t been started, maybe I’d be gone by now”
“With their advice on controlling my blood sugar levels in order for my ulcers to heal, it has changed my diet a lot too. Not only do they focus on my foot wounds, but they’re concerned about my health in general as well”
“I find it very helpful for me, not only is it protecting my wound from getting more infected, but it is also helping me to mobilise better”
“I find this clinic very useful for me as I see my leg healing well. I also see this team putting a lot of effort in to taking care of my leg”
Intended long term impact – If general diabetes health care improves, awareness about diabetic foot care spreads in the community, clients present earlier for treatment and the health service continues to support (and even expands) diabetic foot care; then the long term impact should be a drop in the number of avoidable lower limb amputations due to diabetic foot ulcers. Fewer amputations mean a lower demand for prosthetic devices. This will improve the quality of life for many Samoans and reduce the long term costs of providing health care for the Government of Samoa.
What were the challenges?
- Operating a multi-disciplinary clinic involving staff from a range of departments was a challenge for the NHS. The personnel who work in the DFC experienced the benefits for clients of their work on a daily basis and developed a high degree of ownership over the clinic. Whilst health service managers understood the broader benefits of diabetic foot care, they had to manage competing priorities for limited resources.
- A number of clients presented late with very serious foot wounds and infections, which affected the length and number of appointments. It is hoped that as awareness of the clinic spreads in the community, clients will present earlier for treatment, improving outcomes and reducing both the time required for healing and treatment, and the material supplies required by the DFC.
- Many of the clients presented to the DFC with very high blood glucose levels. These clients were eating poorly, not taking medication as directed, not attending medical appointments and not undertaking appropriate self-care. The consequences of these behaviours greatly affected the ability of their wounds to heal.
What did we learn?
- The importance of early intervention – the later that people with diabetic foot ulcers seek medical advice the higher the risk to them, the longer the treatment (for the client) and the more costly the treatment (to the health service).
- That diabetic foot ulcers can be healed with the use of relatively low cost resources. This is an important contribution to the long term sustainability of the service.
- That healing diabetic foot ulcers through wound care and offloading, represents good value for money as it costs the health service (according to a 2016 study) approximately eight times less than the alternative of acute hospitalisation and surgical intervention.
Motivation Australia would like to acknowledge the work of the Samoa National Health Service (NHS) and NOLA (Nuanua O Le Alofa) on this project. This project is part of the larger Samoa Disability Programme (SDP) coordinated by the Ministry of Women, Community and Social Development (MWCSD). Both the broader SDP and this project are funded by Australian Aid.