A range of ehealth initiatives are helping to alleviate the burden of diabetic foot disease in Australia. Will Turner reports.

Foot complications affect more diabetics in Australia than any other major health issue besides cardiovascular disease. Ulcers, damaged nerves and blood vessels in the lower limbs can lead to hospitalisation and be life threatening by causing organs to fail and the need to amputate if infections take hold.

Yet despite this reality, Australia is doing poorly in providing adequate healthcare for people with foot disease. Australia’s diabetes amputation rate is the second worst in the developed world at 18 amputations per 100,000 people compared to the OECD average of 12. Furthermore a recent study in the Medical Journal of Australia revealed amputation rates per head of population are on the increase at a rate of 30 percent.

The paradox is cost effective evidence-based solutions not only exist, but are being used in other parts of the world to reduce foot-related hospitalisation, amputation and costs. In the UK for example, integrated care models have led to half the amputation rates of Australia.

Nationally recognised research leader in diabetic foot disease, Peter Lazzarini (pictured), said a key aspect of solving the problem in Australia is improving the use of IT to enhance teamwork amongst doctors, nurses, podiatrists and a range of specialists who look after diabetic patients. 

Lazzarini, who is a senior research fellow at the Queensland University of Technology’s School of Clinical Sciences, said bringing expertise together is currently difficult because of funding arrangements. He said despite all other diabetes-related recommendations by the National Health and Medical Research Council (NHMRC) being funded by the federal government.  “Medicare only funds half of the NHMRC guideline clinical recommendations for diabetic foot disease,” he said.

Mr Lazzarini said the evidence base is now strong for integrating electronic records, remote monitoring and video conferencing into foot disease care models, with these innovations changing clinical practice in some parts of the country.

One example is the Queensland Statewide Clinical Network’s “Diabetic High Risk Foot” electronic record, which has helped to improve early intervention, referral and diagnosis across Queensland. 

At the same time, electronically available research-based clinical pathways and screening checklists are assisting primary care professionals to determine next steps in treatment and whether there is need for specialist advice.

Mr Lazzarini said taking things from paper to electronic means you can more readily collect and analyse data to assess how effectively patients are being treated across the state, which helps to determine areas needing improvement and raise standards across the board. 

He also said the PCEHR is likely to reduce the often disjointed communication between the different professionals seeing diabetic patients whether they have foot disease or other complications.

Remote access to specialist advice is also playing a part in keeping diabetics with foot complications out of hospital. Mr Lazzarini said store-and-forward telehealth systems which enable foot specialists to assess images of patients with emerging foot problems have been shown to pick up on emerging complications before they become serious. He added this is an IT innovation the NHMRC has recently recognised in its recommendations for diabetes foot care. 

Mr Lazzarini said a 2011 study demonstrated the benefits of store-and-forward technology are maximised when used in conjunction with video conferencing, particularly in rural areas where local health professionals are dealing with rates of diabetic foot ulcer hospitalisation which are four times that of metropolitan areas. 

As with so many areas of preventive healthcare, mobile devices are now also beginning to play their part in addressing the problem. Mr Lazzarini said QUT is primed to do a study in 2013 looking into the efficacy of foot ulcer patients using their smartphone camera to capture and send photos of their foot and short text descriptions to their podiatrist or doctor three times a week as an adjunct to a face to face appointment. 

“We think this will achieve better outcomes on a few fronts: it helps identify and address problems much earlier, clinicians and patients are less tied up by potentially unnecessary visits and the health system avoids the cost of poor outcomes,” he said.

Developments in technology are also helping with a variety of aspects of foot disease prevention, such as patients using mobile devices to track their number of steps per day. On the clinical side, researchers at Columbia University in United States have developed non-invasive technology to detect peripheral arterial disease, one of the complications which can lead to foot amputations.

Mr Lazzarini said Australia is likely to remain a place with only “pockets of excellence” in regard to team-based diabetic foot care without the federal government showing consistency in its Medicare funding. According to a recent article Mr Lazzarini co-wrote for The Conversation, no less than ten expert national groups have recommended the multidisciplinary foot care team strategies endorsed by the NHMRC, and the international evidence for its validity is incontrovertible. 

He said the response from Canberra to pressure on the issue has been “positive”, but action has not been forthcoming: “Unfortunately we are currently in a political environment where an investment proven to bring about savings is nonetheless considered a short term cost to be avoided.”

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The Challenge: Improving the timeliness and coordination of care for diabetics at risk of foot disease.

The Approach: Multidisciplinary foot care teams working together, making use of electronic records, remote monitoring and telehealth to enhance the level and speed of information and knowledge sharing.

The Outcomes: Trials in Australia using these technologies have demonstrated dramatic reductions in hospitalisation and amputation rates.

The Lessons Learned: Building the evidence base for these investments is critical, but even so tight fiscal situations can delay governments making the necessary public health funding.

The Upside for:

Clinicians: The range of health professionals involved in treating a diabetic patient with foot disease have greater access to each other’s opinion and advice, leading to greater confidence in their role in seeing quality care being delivered. 

Patients: Have more timely access to clinical expertise to intervene in deteriorating situations which can keep them out of hospital and away from the possibility of amputation and organ failure.