Initiative for Quality Improvement and Epidemiology in Multidisciplinary Diabetic Foot Clinics (IQED-Foot) - Results of the 4th data collection (audit years 2013-2014)

This report describes the results of the fourth audit among the recognized diabetic foot clinics in Belgium (hereafter referred to as “centres”). The results are compared to those from previous audits. Four audits have been organised between 2005 and 2014. Across all audits, 5,510 diabetic foot problems of 4,917 unique patients were sampled in 20-34 centres. Foot problems were either a diabetic foot ulcer of at least Wagner grade 2 and/or an active Charcot foot. Data pertained to characteristics at intake and the treatment and outcomes over the course of 6-12 months. After the audit, centres received a feedback report including benchmarking of their performance with regard to a number of quality indicators.

With regard to diabetic foot ulcers, the following conclusions can be drawn:

• Late referral to a centre was associated with higher ulcer severity and poorer outcomes. Referral delay decreased significantly between audits 3 and 4, suggesting that efforts to reduce the delay are working.
• Recommended treatment strategies were widely adopted by the centres. Off-loading of plantar mid and hindfoot ulcers occurred in over 80% of cases. Vascular imaging occurred in nearly 80% of patients with peripheral arterial disease. Revascularization occurred in nearly 70% of patients with severe ischemia. Between-centre variation should be worked on by exchanging practices between centres.
• Half of the ulcers healed during follow-up. Major amputation occurred in fewer than 3% of patients in the latest audit. These results compare favourably to those from other studies, especially if we consider the high severity of ulcers included in IQED-Foot and the high prevalence of comorbidities.
• Secondary prevention was adequate as illustrated by the provision of preventive footwear to nearly 75% of patients and the organisation of a podiatric follow-up in 70% of patients. Here, also, between-centre variation was large and it should be better understood and acted on.
• The scope of the questionnaire was broad. We can expect data collection burden to be relatively high compared to other comparable audit systems. Further efforts are needed to reduce this burden.

With regard to active Charcot foot, the following conclusions can be drawn:

• The treatment and outcomes of active Charcot foot compared favourably to the limited data in the literature. Rates of knee-high immobilisation were high and immobilisation durations were short. However, it seems that the short immobilisation duration was paralleled by a high recurrence rate. This finding deserves further attention. Prospective follow-up data over 1 year (instead of 6 months) may be needed to adequately study outcomes of active Charcot foot.
• Analyses at the level of individual audits and centres were hampered by the limited number of sampled cases of active Charcot foot, due to its rarity. Extending the registration, e.g. by sampling all cases of active Charcot foot during the 1-year inclusion period, should be considered.