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Diabetic foot amputations: finally, time to act

Cate Swannell
Med J Aust
Published online: 7 June 2020

AUSTRALIA’S least known major health problem – diabetic foot disease – costs the health care system $1.6 billion a year, has mortality rates worse than many cancers, and by 2012 estimates, claims an amputated limb every 2 hours, according to the authors of a Perspective published today by the Medical Journal of Australia.

Diabetic foot disease (DFD) commonly develops from trauma in the presence of peripheral neuropathy or peripheral arterial disease and is complicated by infection. Neuropathy is arguably the critical factor in DFD as it results in patients losing the ability to feel pain, resulting in critically delayed presentation and treatment.

It is Australia’s leading cause of amputation, and we have the second highest diabetes-related amputation rate among OECD countries, with the authors, led by Dr Peter Lazzarini, co-Chair of Diabetic Foot Australia, saying that was “partially attributed to the lack of coordinated interdisciplinary DFD services in Australia”.

“We estimate that less than 10% of the 540 interdisciplinary DFD services needed to manage the 50 000 Australians with DFD are available,” Lazzarini and colleagues wrote. “This was in stark contrast to the European nations that had the lowest diabetes-related amputation rates in the OECD, such as the United Kingdom, Belgium and the Netherlands. The low rates in these nations have been attributed to coordinated nationwide systems that recognise and reimburse accredited interdisciplinary DFD services.

“Additionally, these nations’ systems regularly monitor and report DFD outcomes for national clinical benchmarking and research network purposes. Germany, for example, has nearly 300 accredited DFD services monitoring outcomes and contributing to research in their system, whereas Australia is yet to even enact a system.”

Diabetic Foot Australia has recently launched the Australian diabetes-related foot disease strategy 2018–2022: the first step towards ending avoidable amputations within a generation. The strategy outlines nine key recommendations which “should put Australia firmly on an evidence-based pathway”.

Some recommendations are similar to those published by previous peak national bodies, including increasing access to care (recommendations 1–3), subsidising evidence-based treatment (recommendations 2 and 3), implementing national models of interdisciplinary care (recommendation 4), and reporting national outcomes (recommendation 5).

“However, the need to repeat these recommendations indicates a national failure to act, either because the national DFD burden was considered not severe enough to prioritise, or the recommendations lacked actionable detail or evidence to implement. The new strategy should rectify these failures,” Lazzarini and colleagues wrote. “Unlike previous statements, the strategy outlines many potential areas for action and measures to monitor progress towards achieving each recommendation that can be undertaken by health professionals, researchers and governments; all supported by extensive local and international evidence-based rationale.”

The strategy also “details the national workforces required to enact evidence-based actions to achieve recommendations [and]forecasts the impact of achieving such recommendations on reducing the future national DFD burden,” the authors wrote.

“Last, with DFD causing up to 33% of all diabetes-related clinical costs and receiving less than 0.2% of diabetes-related research funding, it sets out, for the first time, research recommendations in this overwhelmingly underfunded field (recommendations 7–9).”

Lazzarini and colleagues called on “Australian health professionals, researchers and governments to finally act”.

“Investments in this plan should ensure not only a significant financial return on investment to the health budget but, more importantly, save the limbs and lives of Australians.”

  • Cate Swannell


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