Background: We describe the implementation and results of an audit-feedback quality improvement (QI) initiative in Belgian diabetic foot clinics (DFCs).
Methods: Using self-developed software and questionnaires, DFCs (N=35) collected data in 2005, 2008, 2011 and 2014, covering characteristics, history, and ulcer severity, management and outcome of the first 52 patients presenting with a Wagner grade ≥2 diabetic foot ulcer (DFU) or acute Charcot foot that year. QI was encouraged by meetings and by anonymous benchmarking of DFCs.
Results: The first audit-feedback cycle was a pilot study. Subsequent audits, with a modified methodology, had increasing rates of participation and data completeness.
In total, 5,510 episodes were sampled between 2005 and 2014 (5,407 DFUs and 183 acute Charcot feet). Median age was 69 years, median diabetes duration was 14 years, 91% had type 2 diabetes, 65% were male and 48% had renal insufficiency, end-stage renal disease or a prior major cardiovascular event. Fifty-two percent of DFUs were plantar and 26% were both ischemic and deeply infected. Management of DFUs varied between DFCs: 88% of plantar mid-foot ulcers were off-loaded (P10-P90: 64-100%) and 42% of ischemic limbs were revascularized (P10-P90: 22-69%) in 2011. Ulcer healing rate at 6 months was 50% and did not change significantly over time. Major amputation as a first event during the 6-month follow-up declined from 3.5% in 2008 to 2.6% in 2014, but this was paralleled by an increase in death as a first event from 3.3% to 5.2%.
Conclusions: A unique, nationwide QI initiative was established among DFCs, covering ulcer healing, lower-limb amputation and many other aspects of diabetic foot care. The cyclical audits and feedback allow DFCs to focus their QI efforts. Clear nationwide gains in care quality have not been documented between 2005 and 2014, although the short-term outcomes are good for a population with deep DFUs and high comorbidity burden.