Diabetic foot care in Sweden

Abstract: Diabetes mellitus (DM) is a growing global disorder associated with several complications that include micro- and macrovascular disturbances. Conditions affecting the foot make up one of the major complications of the disease. The overall aim of this thesis was to investigate how developed the diabetic foot care is in Sweden, with the ultimate goal being to identify areas needing improvement. This thesis is based on two papers: In Paper I, a national inventory was made of a caregiver’s organization for diagnosis and treatment of diabetic osteoarthropathy, using a questionnaire addressed to all Swedish hospitals with an emergency department for orthopedic patients. There was a 95% response rate. Three respondents reported never having had any contact with patients with diabetic osteoarthropathy, resulting in an analysis of 57 questionnaires. Most of the respondents (79%) specified an absence of established procedures for managing patients with osteoarthropathy. The most common diagnostic method was clinical diagnosis and conventional plain radiography (95%). MRI or scintigraphy was used by 19% and 10.5% of the respondents, respectively. As a treatment method, 84% used a total contact cast, and 38% orthoses. Two clinics indicated a treatment duration of less than 3 months, thirty clinics (53%) a treatment duration of 3-6 months, and sixteen clinics (28%) a duration of 6-12 months. Only four clinics indicated duration longer than 12 months, while two clinics did not provide any treatment. We noticed a lack of adequate guidelines for the optimal management of diabetes osteoarthropathy. In Paper II, the objective was by a questionnaire to investigate at a national level the organization of multidisciplinary team (MDT) care of patients with diabetes mellitus (DM) and foot complications in all Swedish hospitals, and to what extent they are in line with the Stockholm Consensus Statement from an 1998 assembled expert panel on how to organize treatment and prevention of foot lesions in patients with DM. The response rate was 92 %. Eighty-four percent of the responding hospitals have a foot team. Most of the teams have access to an internal medicine specialist, chiropodist and orthotist. Fewer teams have reported access to an orthopaedic surgeon and infectious disease specialist, and only half to a vascular surgeon. In the joint MDT evaluations of outpatients, the majority report regular input of an internal medicine specialist, podiatrist and orthotist. Approximately 50 % report presence of an infectious disease specialist and orthopaedic surgeon, but only a few of a vascular surgeon. When evaluating hospitalized patients there is a reduction in attendance of all specialists. There is low registration of amputation rate and healed foot ulcers. The existence of adequate guidelines could not be confirmed. Conclusion: The inventory of the management of patient with DM and osteoarthropathy indicates a national need for an improvement in knowledge as well as guidance regarding the early diagnosis and optimal treatment of this condition. Regarding the recommendations in the Stockholm Consensus Statement, they are mostly adopted among large and medium-sized hospitals in contrast to small, which could reflect an unequal health care at a national level. Vascular surgeons seldom attend MDT evaluations, and there is a low regular input of infectious disease specialists oriented toward orthopedic infections. There is a remarkable decrease in attendance of all specialists in MDT evaluations of hospitalized patients. We find no support for the ability of hospitals to evaluate their work by potential quality control markers. Our study indicates that national surveys can be valuable in evaluating healthcare organization and management of patient with DM and foot complication.