Chan et al.

Journal of Foot and Ankle Research (2020) 13:26

https://doi.org/10.1186/s13047-020-00393-0

RESEARCH Open Access

Organizational changes in diabetic foot

care practices for patients at low and
moderate risk after implementing a
comprehensive foot care program in
Alberta, Canada
Catherine B. Chan1,2,3* , Kathy Dmytruk1, Michele Labbie4 and Petra O’Connell1

Abstract
Background: Neuropathy and vasculopathy can lead to costly and debilitating complications in people with
diabetes. The purpose of this study was to evaluate, at an organizational level, uptake of practices included in a
diabetic foot care clinical pathway and associated resources. This research focused on patients at low and moderate
risk in Alberta, Canada between 2014 to 2019.
Methods: Serial surveys (2014, 2019) of practices related to screening and care of the feet of people with diabetes.
Surveys were administered using a combination of targeted and snowball sampling in order to assess the impact of
the clinical pathway first implemented in 2015. The pathway focused on screening, assessment and referral of
patients from primary care. High-risk foot teams (HRFT) were established at six sites to provide increased access to
specialty care. Comparative statistics were performed to assess differences in footcare practices between 2014 and
2019 using two-tailed Fisher’s exact test or Chi-square test.
Results: Respondents (n = 104, 2014 and n = 75, 2019) included personnel from primary health care, home care and
long-term care, acute and emergency care, specialty clinics, diabetes-specific programs and private contractors. The
proportion of primary care and home care/long-term care (HC/LTC) sites providing screening increased significantly
(p < 0.05). A significant increase in the proportion of sites providing assessment for patients designated as moderate
risk also increased from 35% (34 out of 96 sites) to 55% (36 out of 65 sites) (p < 0.05), particularly with respect to
vascular assessment, and the proportion of sites reporting appropriate follow-up intervals according to the pathway
recommendation was also improved.
(Continued on next page)

* Correspondence: [email protected]
1
Diabetes, Obesity and Nutrition Strategic Clinical Network, Alberta Health
Services, 10101 Southport Road, Calgary, Alberta T2W 1S7, Canada
2
Department of Agricultural, Food and Nutritional Sciences, University of
Alberta, 4-126 Li Ka Shing Centre, Edmonton, Alberta T6G 2E1, Canada
Full list of author information is available at the end of the article

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Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 2 of 15

(Continued from previous page)

Conclusion: Provision of a clinical pathway for diabetic foot care along with education and resources led to
increased screening in primary care and HC/LTC settings in Alberta, Canada. HRFT provided primary healthcare
providers with an important option for referral and also provided increased expertise for procedures such as
vascular assessment for patients with moderate risk of ulceration. This comprehensive model has the potential to
reduce progression of foot problems and overall health services utilization. Further analyses of outcomes such as
incident lower limb amputation and long-term cost-effectiveness of pathway implementation are underway.
Keywords: Diabetes, Foot ulcer, Clinical pathway, Prevention, Screening, Wounds and injuries, High risk foot team

Introduction Diabetes Canada 2013 guidelines for foot care [4], a

Diabetic foot ulcer (DFU) is a severe diabetes complica- problem also reported for Canada as a whole [17]. In
tion often leading to lower limb amputations. In Canada 2014, the DON SCN™ began the process of implement-
in 2011, more than 25,000 prevalent cases resulted in ing a new care pathway for diabetic foot care focusing
6036 amputations with a cost per prevalent case of $21, on DFU prevention through screening and creation of
371 CAD [1]. International studies have found the 5- multidisciplinary High Risk Foot Teams (HRFT) to fa-
year mortality rate after new-onset ulceration to be 43– cilitate referrals.
55%, and as high as 74% for people with diabetes who The literature shows that integrated care models for
had a lower limb amputation [2]. DFU and lower limb secondary prevention of DFU or LLA are medically and
amputations in people with diabetes are potentially pre- cost-effective [8, 18]. However, there is a paucity of
ventable in 75% [3] and 50–85% of cases, respectively, literature on efficacious and cost-effective integrated
through screening, early treatment and better self-care care models for primary prevention of DFU [3, 19].
practices [4]. Clinical pathway development, clinician Approaches using multi-disciplinary teams appear to be
training and education, and provision of procedural sup- efficacious but overall quality of the studies is not opti-
port tools are all shown to increase foot screening and mal [10]. Based on guidelines of Diabetes Canada [4],
improve treatment [5, 6]. Patient education is also rec- Wounds Canada [20] and the Registered Nurses Associ-
ommended as important to reduce risk of diabetic foot ation of Ontario (RNAO) [21], the Alberta Health Ser-
complications [7]. Efforts to prevent DFU in patients vices (AHS) diabetes foot care pathway was developed. It
identified at moderate to high risk, have a strong possi- encompasses elements of assessment, planning, imple-
bility of cost-effectiveness [8] probably through reduc- mentation and evaluation of foot care strategies for
tion of emergency department or inpatient admissions, patients using a patient-centred approach and addressing
which are increased by 3-fold in patients with DFU com- appropriate treatment of comorbidities [22]. The path-
pared with other ambulatory clinic cases [9]. Provision way also acted upon RNAO recommendations to include
of care by multi-disciplinary teams to prevent and man- professional education and guidelines to cover policy
age foot wounds is recommended [10–12], as is having a and organizational considerations. It also provided re-
structured approach to assessing clinical and metabolic sources to monitor and support quality improvement,
parameters and assigning risk categories to patients [13]. develop an effective referral strategy, advocate for client
In Queensland, Australia, implementation of state-wide services that promote offloading of pressure to prevent
protocols for diabetic foot care reduced major amputa- re-ulceration [21].
tion by 45% [14]. In 2015, the DON SCN™ conducted a pilot project at
In the jurisdiction of Alberta, Canada, diabetic foot three sites followed by scale and spread across Alberta.
disease was identified in 2013 as a priority for action by The pathway utilizes HRFT that provide a foot protec-
the Diabetes, Obesity and Nutrition (DON) Strategic tion service and support primary care. The primary care
Clinical Network™ (SCN) of Alberta Health Services service performs the initial screening, care for low risk
(AHS) [15]. As part of the pathway development process, patients, and continued care for patients with healed
the DON SCN™ conducted a survey with both quantita- ulcers once released from specialty care. A screening
tive and qualitative elements in order to understand instrument and modules to support patient education
existing foot care services across Alberta. The unpub- have also been made available along with education on
lished survey results identified low screening capacity, their utilization. HRFT also provide referral to surgeons,
barriers to referral, and lack of standardized approaches providers of specialty footwear and offloading devices,
were supported by self-reported data from people with and other supports for patients [23].
diabetes. This showed that self-care practices and The aim of current study was to assess the impact of
screening frequencies [16] were not in accordance with implementing a diabetes foot care clinical pathway and
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 3 of 15

associated resources and training on organizational of the University of Alberta. In 2019, informed consent
changes in diabetic foot care practices in 2019 compared was implied by completion of the survey.
with the baseline state in 2014 in Alberta, Canada. This
research focused on organizational capacity for foot Intervention
screening and care of low-moderate risk patients. In A literature review to identify best practice, informed
comparison with responses in 2014 we predict enhanced the process of developing the intervention, including the
diabetic foot care practices, particularly at sites with care pathway and ancillary resources. In addition, the
access to HRFT. Project Lead (author KD) consulted experts in the
United Kingdom (UK) regarding their pathway develop-
Research methods ment process and implementation of foot protection
Study design teams, which assess and treat patients at risk of, or pre-
Serial cross-sectional assessments of organizational prac- senting with DFU [24]. The Canadian Agency for Drugs
tices related to foot care of people with diabetes. and Technology and Health organized and facilitated a
meeting between four provinces, including Alberta, to
discuss current foot and wound care practices. Following
Study setting this, Alberta and New Brunswick teams embarked on
Health care sites that play a role in the care of diabetic pathway development and the implementation of “high
foot screening and treatment across the continuum in risk foot teams” (foot protection teams) similar to what
Alberta were identified. These were primary health care, had been implemented in the UK. The New Brunswick
home care and long-term care, acute and emergency team allowed the DON SCN™ to leverage the work they
care, specialty clinics, diabetes-specific programs and had started in the development of a diabetes foot care
private contractors. Sites that actively participated in im- clinical pathway. The DON SCN™ struck a working
plementation of the diabetes foot care pathway, as well group composed of diabetes educators, primary care
as those that did not were included in the survey. The physicians and nurses, home care, wound care nurses
2019 survey was conducted between February and April. and nurse practitioners and foot care nurses (licensed
The 2014 survey was conducted in September. practical nurses (LPNs)), including authors KD and ML.
The working group developed The Alberta Diabetes
Participants Foot Care Clinical Pathway tools and resource toolkit
A convenience sample of representatives of the identified (Supplementary Materials). It was guided by the tools
health care sites were recruited, including physicians, nurse and resources developed by New Brunswick (diabetic
practitioners, registered nurses, licensed practical nurses, foot screening tool, health provider guide, referral guide-
foot care nurses, orthopedic surgeons, physio- or occupa- lines, patient handouts on low, moderate and high risk
tional therapists, dietitians or pharmacists, diabetes educa- foot problems) and Canadian guidelines [20, 21, 25]. All
tors, clinic managers or any practitioner who had tools and resources in the toolkit were vetted with and
contacted the DON SCN™ about foot care, including pri- approved by a provincial steering committee. Members
vate service providers (e.g., foot care nurses, podiatrists). In of the steering committee consisted of podiatric sur-
2014, the extent of sites and individuals participating in geons, orthopedic surgeons, dermatologist, physiatrists,
care of patients with diabetic foot disease was less well endocrinologist, primary care physician, wound care
known; thus snowball sampling initiated with a small num- nurses and nurse practitioners, and foot care nurses.
ber of key contacts was used to distribute the survey as The diabetes foot care pathway focussed on three key
widely as possible. The total number of sites approached to elements: screening, assessment and referral pathways
participate was undetermined. In 2019, a list of potential that could be customized depending on site characteris-
participants were developed based on the previous respon- tics. Implementation in primary care and home care/
dents to the survey in 2014. In addition, we invited at- long-term care (HC/LTC) settings focused on screening
tendees at four AHS-sponsored foot care symposia held in and assessment supported by a novel screening tool, a
2017 and 2018, and utilized personal knowledge to in- risk assessment triage referral form, training from a
vite other individuals involved in diabetic foot care as well . nurse with specialized wound care training, videos and
This greatly expanded the potential participant list com- other supports. Goals for screening and assessment in-
pared with 2014. In both 2014 and 2019, potential partici- cluded increased competency of primary care providers
pants were contacted by email with an invitation, the study to accurately categorize a person with diabetes as low,
information and a hyperlink to the survey. Potential partic- moderate, high or urgent risk for foot ulceration and
ipants received two email reminders to complete the sur- amputation, to increase screening rates, and to provide
vey following the initial invitation. Waiver of consent was patient education using resources developed by the
granted for the 2014 survey by the Research Ethics Board DON SCN™. Within primary health care, appropriate
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 4 of 15

actions taken on patients with moderate risk feet (i.e., newsletters, word of mouth, symposiums, and presenta-
having conditions such as callus, structural deformities tions at meetings and conferences.
or loss of protective sensation) have the potential to re- For purposes of comparative analyses, 2014 data were
duce risk of future ulceration. This included educating considered as “usual care” controls compared with 2019
patients on the importance of routine self-care activities. post-intervention data as a whole. The 2019 data was
Moderate risk assessment included inspection for skin also stratified by whether sites accessed HRFT and their
and nail abnormalities, assessment of structural deform- practices compared to each other.
ities (e.g., bunions, hammertoes), assessing whether spe-
cial footwear was necessary, and evaluating vascular and Intervention delivery
peripheral nervous function. Between 2014 and 2019, 8 sites (2 North Zone, 2 Edmonton
To address barriers to timely referrals of high or ur- Zone, 2 Central Zone, 1 Calgary Zone, 2 South Zone) re-
gent risk patients, in part related to Alberta’s large rural ceived training from the DON SCN™ personnel in all ele-
and remote population, HRFT were constituted in stra- ments of the intervention including use of the clinical
tegic locations. Depending on the site, HRFT were led pathway and associated resources (toolkit) and established
by physicians, nurse practitioners, nurses, licensed prac- HRFT. Additional education consisted of training in per-
tical nurses, or occupational therapists and included at forming a diabetes foot screen, using the pathway tools to
least one other provider, preferably one member holding navigate the patient to the most appropriate resource and
prescribing privileges for medications, diagnostic testing follow-up timelines depending on risk level. This training
and referral to specialty care. Such multidisciplinary was provided to anyone requesting it, mainly in primary care
teams are recommended in various guidelines and are settings but also community pharmacists and indigenous
often known as foot protection teams [4, 11, 21, 26, 27]. healthcare providers. Of 41 Primary Care Networks in
In the Alberta model, HRFT assess and treat patients at Alberta, 14 received in person training while education was
risk of a DFU and those with an ulcer present. HRFTs provided to personnel in most First Nations health centres
have wound management and debridement expertise, in Alberta via videoconference. The wound care nurse pro-
lower leg vascular assessment training, can prescribe vided in-person training, with education on how to use the
footwear through a provincially funded resource for pathway and perform a foot screen, backed up by videos
medical aids, Alberta Aids to Daily Living (AADL). and a user guide for the tools. Implementation support was
AADL is funded by Alberta Health and is mandated to provided by the DON SCN™ project team, which included
help Albertans with a long-term disability, chronic or authors KD and PO. More than 1300 healthcare providers
terminal illness to pay for basic medical equipment and attended DON SCN™ sponsored continuing education con-
supplies. However, only specified healthcare professional ferences provided in 2017 and 2018. In addition, the clinical
may prescribe AADL services. Skilled deployment of pathway and associated resources were freely available via
more complex testing and treatment modalities (e.g. the internet and a series of e-learning modules was created.
debridement) is essential in preventing ulcers from pro- Of 390 individuals who enrolled, 62% (n = 242) completed
gressing. Some HRFTs have the ability to perform skin the e-learning courses.
and nail care (nail trimming/callus management) as an
adjunct service. Other HRFTs do not provide this ser- Outcomes
vice; patients can be referred to a community podiatrist, A customized cross-sectional computer-based survey
foot care nurse, or other medically trained provider in study was conducted in 2014 and again in 2019, prior to,
the community. HRFT make formal linkages with other and following widespread implementation of the dia-
referral services such as diabetes clinics, vascular labora- betes foot care pathway in order to assess its uptake and
tories, occupational therapists or orthotists. HRFT could changes in practice. The data collected compared
refer to specialists such as community podiatrists (pri- screening practices, assessment of feet at moderate or
vate practitioners) or podiatric surgeons (focusing on high risk for ulceration, and protocols for dealing with
wound management and limb preservation) as outlined urgent cases. The survey items were organized into sec-
in the pathway. In addition to the DON SCN™-spon- tions by risk levels (low, moderate, high, urgent) and of-
sored sites, other sites throughout Alberta have devel- fered multiple options of care models. Respondents
oped similar multidisciplinary models of care in primary selected options, with more than one option being avail-
care or outpatient settings. able for most questions. Respondents could also provide
In addition to the specific pathway intervention, the responses to an open-ended question to comment more
DON SCN™ also created a number of tools to support fully on issues relevant to each risk section (Table 1).
screening, assessment and HRFT, which were freely The 2014 survey was developed to determine what the
available via a website [23] (Supplemental Materials). current state of foot and wound care was in the province
Awareness of the pathway was achieved through and how currently the different risk levels were being
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 5 of 15

Table 1 Definition of variables

Question number Variable Definition / options
General Questions
1 Health zone Geographic region within Alberta (North, Edmonton, Central, Calgary, South)
or other (e.g. Federal)
2 Area of practice Primary care network, home care, long-term care community (e.g. chronic
disease management nurses working in the community), outpatient
departments, wound clinics, other
3 Identification of site Free text (e.g. specific clinic or hospital site)
4 Footcare related continuing education For all staff in setting within past 2 years; DON SCN sponsored symposia in
2017 or 2018; DON SCN-led workshops in various settings as part of
intervention roll-out; Diabetes Canada sponsored events; other
5 Basic foot screening offered Yes/No
If Yes to #5, then…
6 Screening tool used AHS screening tool (2019 only), 60-s foot screening tool, other (free text)
7 Screening setting Free text
8 Risk category seen Low, moderate, high risk, urgent care required, other
Questions regarding moderate-risk patients
9 Formalized clinic for assessment Yes (HRFT or other), no
If Yes to #9, then…
10 Management of skin/nail abnormalities Perform skin/nail care in practice area; provide list of foot/nail care providers
in the community; refer to podiatrist or footcare nurse (i.e. private services),
refer to HRFT, other (free text), none of the above
11 Management of structural deformities Provide education regarding self-management; refer to podiatrist or
orthopedics; other (free text), none of the above
12 Management of footwear Provide education/information regarding footwear selection; refer to HRFT;
provide referral for footwear/orthotics through AADL; refer for footwear/
orthotics without AADL authorization; other (free text), none of the above
13 Management of vascular problems Perform vascular assessment; refer to HRFT; refer to general practitioner; refer
to vascular lab, other (free text), none of the above
14 Vascular assessment tests performed ABPI; PPG; Pedal pulses; refer to HRFT; other (free text)
15 Management of loss of protective sensation Treat neuropathic pain (free text); refer to physician/nurse practitioner for
treatment of neuropathic pain; refer to HRFT
16 Reassessment frequency 1–3 months; 4–6 months; 7–12 months; no formalized schedule; other
(free text)
17 Any other comments about moderate Free text
risk patients
18 Assess high risk/urgent patients Yes/No. If yes to these, a series of questions was asked. These responses
are not reported in this article.

managed. The 2019 survey was a follow-up to determine related information, i.e., identical answers to questions
how the landscape had changed with the implementa- 1–3 in Table 1, resulting in n = 3 and n = 7 responses re-
tion of the pathway and HRFT. The 2014 and 2019 sur- moved), the categorical data were coded. Qualitative
veys were similar with the 2019 version modified to data (comments) were retained verbatim but were not
include HRFT as a referral option. In this report the analyzed for this study. Descriptive statistics were com-
focus was on screening and assessment of individuals piled. Comparative statistics were performed to assess
with low and moderate risk of foot ulcer. differences in footcare practices between groups using
two-tailed Fisher’s exact test or Chi-square test.
Data analysis
Data were downloaded from the host server to an Excel Results
spreadsheet by an individual not part of the study team, Total unique responses in 2014 and 2019 were 104 (de-
then anonymized by removing any personal information nominator unknown) and 75 (out of 1005 email invita-
prior to providing to the study team. Following cleaning tions, with invitations to multiple personnel at a single
to remove duplicate responses (as determined by site- site possible), respectively (Table 2). In both years, about
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 6 of 15

Table 2 Respondent and site characteristics in 2014 (n = 104) and 2019 (n = 75)
2014 2019 P-value*
Profession of Respondent N % n % 0.051
Registered Nurse 44 42 29 39
Licensed Practical Nurse 4 4 14 19
Manager or Instructor or Educator 22 21 15 20
Physiotherapist or Occupational Therapist or 8 8 10 13
Pharmacist or Registered Dietitian
Physician or Nurse Practitioner 9 9 5 6
Other 5 5 2 3
No response 11 11 0 0
Zone
North 39 38 16 21 0.022
Edmonton 27 25 20 27
Central 18 17 13 17
Calgary 6 6 16 21
South 13 13 8 11
Federal or provincial 1 1 2 3
Area of practice (more than 1 answer possible) Total 172 responses % Total 91 responses %
Primary health care 24 14 21 23 0.27
Outpatient 33 19 13 14
Acute care 20 12 8 9
Wound clinic 19 11 7 8
Homecare or long-term care (HC/LTC) 43 25 23 25
Community care 19 11 8 9
Othera 11 6 11 12
No response 3 2 0 0
Service level provided
Basic foot screening 58 56 55 73 0.016
No 44 19
No response 2 1
Assesses for moderate risk 34 33 36 48 0.044
No 62 29
No response 8 10
Assesses for high risk 34 33 35 47 0.019
No 60 28
No response 20 12
*p-value < 0.05 by Chi-squared Test or Fisher’s Exact Test was considered significant. Analyses did not include “no response” as an option
a
Other includes categories with < 5 responses: Rural diabetes program, emergency department or intensive care unit, private/independent service, rehabilitation
centre, renal clinic, other

40% (n = 44 in 2014 and n = 29 in 2019) of responses Calgary zone increased, while that from North zone de-
came from registered nurses. Although the proportion creased (p < 0.05). In both sampling years, the most re-
of licensed practical nurses responding increased nearly sponses came from sites providing primary health care,
5-fold, the overall mix of respondents’ areas of practice HC/LTC and outpatient services, totalling 58% (n = 100 out
was not significantly different between 2014 and 2019 of 172 in 2014) and 62% (n = 57 out of 91 in 2019) of re-
(p = 0.051). By site, the respondents represented all five sponses (noting that some sites provided multiple types of
health zones in Alberta although the proportion from services), with similar proportions between years (p > 0.05).
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 7 of 15

Figure 1a and Table 2 shows that the proportion of all 2019 compared with 2014, 5% (n = 1) versus 30% (n = 6)
respondents providing basic foot screening increased of primary care sites did not provide basic screening
from 2014 to 2019 (p < 0.05), and this increase was still (p < 0.01). Similarly 40% (n = 7) versus 53% (n = 19) of
significant when non-respondents were included in the HC/LTC sites did not provide basic screening in 2019
group not providing screening. An analysis by geograph- compared with 2014 (p < 0.05) (Table 3). In 2019, one-
ically organized health zones, showed the main increases third of respondents had adopted the screening tool de-
were in North (p < 0.05) and Central (p = 0.056) zones, veloped as part of the DON SCN™ resource toolkit
which are primarily rural (Table 3). The main contribu- (Table 3).
tors to increased foot screening practices were primary In total, 35% (n = 34 out of 96 sites) and 55% (n = 36
care and HC/LTC sites (Fig. 1b, Table 3), with none of out of 65 sites) respondents indicated that their site pro-
the other areas of practices changing significantly. In vided assessment of moderate risk patients in 2014 and
2019, respectively (Fig. 1a, Table 2), a significant increase
(p < 0.05). Of the respondents, the main providers of
moderate risk assessment were primary care and HC/
LTC, together accounting for 43% (n = 18) and 39% (n =
22) of the sites providing this service in 2014 and 2019,
respectively, which was not significantly different. How-
ever, more outpatient (p < 0.05) and wound clinics (p <
0.01) reported provision of care for moderate risk pa-
tients in 2019 than 2014 (Table 4). The service model
utilized for moderate risk assessment, in 2014, was most
often a hospital or clinic team. In 2019, there were 13
sites reporting utilization of HRFT, which did not exist
in 2014.
With regard to the services provided, between 2014 and
2019, there were significant increases in the proportion of
sites providing patients with lists of foot/nail care providers
in the community (p < 0.001) and sites providing referrals
to podiatrists or footcare nurses (p < 0.001) (Fig. 2a, Table
4). Similarly, for practices related to structural deformities,
an increased proportion of sites provided relevant educa-
tion (p < 0.01) and provided referrals to podiatrists or
orthopedic specialists (p < 0.01) (Fig. 2b, Table 4). However,
no differences in education about footwear or referral to
providers of specialty footwear were detected (Fig. 2c), with
the exception that referral to HRFT was a new option avail-
able in 2019. In 2019 a significantly (p < 0.01) bigger pro-
portion of respondents reported that their sites performed
assessment of vascular problems than in 2014 (Fig. 2d,
Table 4). These included referral to general practitioners
(p < 0.05) along with HRFT and vascular laboratories.
Finally, services provided for loss of sensation and neuro-
pathic pain were found to be similar between service
models, with referral to a physician or nurse practitioner
predominating but HRFT referred to by nearly half of the
sites in 2019 (Table 4). Frequency of reassessing patients
with moderate risk changed, with a smaller proportion of
clinics not having a formalized schedule (p < 0.001) and
more clinics reassessing at 4–6 months in 2019 vs 2014
Fig. 1 a – Proportion of all respondents performing foot screening, (p < 0.05) (Table 4).
or assessing moderate or high risk patients with diabetes. b – We compared practices in assessing and caring for
Proportion of respondents providing primary health care or HC/LTC moderate risk patients reported by sites utilizing speci-
services that reported providing foot screening for patients with
fied HRFT (n = 13) compared with those utilizing other
diabetes. *p < 0.05, **p < 0.01 with Fisher’s Exact Test
models of care delivery (other types of clinical teams)
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 8 of 15

Table 3 Basic Foot Screening – Characteristics of Sites

Provide Basic Screening 2014 2019 P-value*
Yes No Yes No
Zone N N % Yes N N % Yes
North 17 21 45 12 3 80 0.031
Edmonton 17 10 63 11 9 55 0.77
Central 8 9 47 11 2 85 0.056
Calgary 4 2 67 13 3 81 0.59
South 11 2 85 6 2 75 0.62
Federal or provincial 1 0 100 2 0 100 ND
Total of all respondents 58 44 57 55 19 74 See Table 2
Non-respondents 2 1
Area of practice (more than 1 answer possible)
Primary or family practice 14 6 70 20 1 95 0.005
Outpatient 11 7 61 10 3 77 0.452
Acute care 8 11 42 3 4 43 1.00
Wound clinic 8 8 50 7 0 100 0.052
Homecare, long-term care 17 19 47 16 7 60 0.018
Community care 12 5 71 7 1 88 0.623
Other 6 2 75 8 4 67 1.00
No response 1 0 – 0 0 –
Screening Tool Used N % N %
60 s foot screening tool 50 62 16 31
AHS foot screening tool – 18 35
Other 31 39 18 35
*p-value < 0.05 by Fisher’s Exact Test was considered significant, comparing “yes” vs “no responses”. ND, not done

(n = 20) using 2019 data. The areas of practice represented system [1, 30]. Yet in Canada, primary prevention prac-
in the two care models were not significantly different (p > tices such as screening are performed less frequently
0.05) (Table 5). The sites reporting HRFT were located than for other co-morbidities of diabetes such as hyper-
more in urban areas than the clinic/hospital teams (p < tension [16, 31]. Comprehensive foot care practices in-
0.05). More clinic/hospital teams than HRFT provided skin cluding screening and measures to prevent ulcer
and nail care (75% versus 63%, (n = 15 versus n = 5, p < 0.1). development are recommended, with multidisciplinary
Referral to podiatrists and assessment of structural deform- teams involved in patient care for people with diabetes.
ities was similar between care models. HRFT were more Multidisciplinary teams such as foot protection services
likely to hold AADL authorization than other sites (p < 0.1), or HRFT have been deployed in a number of jurisdic-
meaning that patients could be referred and have a portion tions to increase screening and risk stratification [32],
of costs covered by Alberta’s publically-funded insurance access to specialized care [10, 11] and reduce outcomes
plan. With regard to assessment of vascular problems, all such as severe infection and lower limb amputations
sites provided this service but clinic/hospital teams were [32, 33]. In Alberta, Canada foot protection services,
more likely to refer patients to their general practitioner named HRFT, supported by the DON SCN™ were first
(p < 0.05). HRFT were more likely to assess pedal pulses constituted in 2015 at three pilot sites and have since
than clinic/hospital teams (p < 0.1) but no differences were spread with a total of six operational sites in the prov-
detected in use of other diagnostic modalities. Finally, with ince. A clinical care pathway, training in foot screening,
regard to assessing loss of protective sensation, practices referral guidance and additional resources were pro-
were similar between the care models (Table 5). vided. The combination of these activities was shown to
increase screening activity, particularly in primary
Discussion health care and HC/LTC settings along with increased
Diabetic foot diseases compromise the quality of life of proportion of reporting sites that provide services for
people with diabetes [29] and are costly to the health the assessment of moderate-risk patients.
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 9 of 15

Table 4 Assessment of Moderate Risk – Characteristics of Sites

Have a formalized clinic 2014 2019 P-value
Yes No Yes No
Zone N N % Yes N N % Yes
North 11 28 28 5 6 45 0.30
Edmonton 11 12 48 11 7 61 0.53
Central 5 12 29 7 4 64 0.12
Calgary 3 1 75 5 10 33 0.26
South 4 8 33 6 2 75 0.17
Federal or provincial 0 1 0 2 0 100 ND
Total 34 62 35 36 29 55 See Table 2
Non-respondents 8 10
Area of practice (more than 1 answer possible)
Primary or family practice 10 9 53 13 7 65 0.52
Outpatient 4 14 22 7 4 64 0.048
Acute care 5 13 28 3 3 50 0.362
Wound clinic 4 11 27 6 0 100 0.004
Homecare, long-term care 8 28 22 9 10 47 0.07
Community care 6 10 38 3 4 43 1.00
Other 5 2 71 4 3 57 1.00
Type of service (more than 1 answer possible)
HRFT – – 13 –
Hospital/clinic team 25 – 20 –
Home care 5 – 4 –
See referrals 4 – 2 –
Services provided (more than one answer possible)
Skin & nail abnormalities N [%] N [%]
Total number of sites (formalized and unformalized clinics) 96 39
Skin or nail care provided 44 [46] 21 [54] 0.45
Provide list of foot/nail care providers in the community 33 [34] 26 [67] 0.001
Refer to podiatrist or footcare nurse 33 [34] 29 [74] < 0.001
Refer to HRFT – 11 [28] –
None of the above 8 [8] 1 [3] –
Other 2 [2] 3 [8] –
Structural deformities (bunions, hammertoes)
Total number of sites 95 [100] 39
Provide education regarding self-management 47 [49] 30 [77] 0.004
Refer to podiatrist or orthopedics 63 [66] 31 [79] 0.007
Other 13 [14] 3 [8] ND
None of the above 12 [13] 0 ND
Footwear problems
Total number of sites / no answer 96 39
Provide information/education regarding appropriate 76 [79] 35 [90] 0.22
footwear selection
Refer to HRFT – 18 [46] –
Refer for footwear / orthotics through AADL 50 [52] 20 [51] 1.00
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 10 of 15

Table 4 Assessment of Moderate Risk – Characteristics of Sites (Continued)

Have a formalized clinic 2014 2019 P-value
Yes No Yes No
Refer for footwear / orthotics without AADL authorization 26 [27] 14 [36] 0.31
None of the above 7 [7] 1 [3] ND
Other 20 [21] 4 [10] ND
Services provided for vascular problems
Total number of sites 96 [100] 39
Perform vascular (lower limb) assessment 62 [65] 36 [92] 0.001
Refer to HRFT – 19 [49] –
Refer to GP for assessment 36 [38] 23 [59]* 0.035
Refer to vascular lab for assessment 24 [25] 15 [38] 0.14
Other 13 [14] 4 [10] ND
If vascular assessment performed, procedures used Out of 62 Out of 36
ABPI 44 [71] 16 [44] 0.011
PPG (toe pressures) 37 [60] 17 [47] 0.29
ABPI + PPG (gold standard) 32 [52] 14 [39] 0.29
Pedal pulses 38 [61] 34 [94] < 0.001
Other 4 [6] 5 [14] ND
Refer to HRFT – 17 [47] –
Services provided for loss of sensation / neuropathic pain Out of 91 Out of 39
Refer to MD/NP for treatment of neuropathic pain 83 [91] 28 [72]** 0.007
Refer to HRFT – 18 [46] –
Address neuropathic pain in their clinic 6 [7] 5 [13] 0.30
Other 2 [2] 1 [3] ND
None 0 2 [5] ND
Frequency of reassessing patients with moderate risk
1–3 months 15 [16] 8 [21] 0.62
4–6 months 11 [12] 11 [28] 0.039
7–12 months 8 [8] 3 [8] 1.00
No formalized schedule 48 [53] 7 [18] < 0.001
Other 7 [8] 9 [23] ND
Statistical analysis used Fisher’s Exact Test
Abbreviations: ABPI Ankle-brachial pressure index, AADL Alberta Aids to Daily Living, GP General practitioner, HRFT High risk foot team, MD Medical doctor, NP
Nurse practitioner, PPG Photoplethysmography toe pressure, ND Not done

Both clinical and cost-effectiveness are essential to sus- services were implemented in a hospital in Ireland they
taining innovations in healthcare delivery. Interventions were proven to reduce DFU and be cost-effective [36].
targeting healthcare organizations to improve secondary Likewise, a Scottish analysis found a 0.3% reduction in
prevention of DFU are effective in reducing ulcer recur- lower limb amputation after introducing a national strat-
rence and lower limb amputations [21, 33]. Moreover, egy for screening and risk stratification [32].
timely access to wound care specialists results in less se- From our survey, which components of the clinical
vere presentation and faster healing than when access to pathway, resource toolkit and training were found most
specialists is delayed [8, 34]. Preliminary exploration of valuable in facilitating organizational change could not
lower limb amputation rates in Alberta after 1-year easily be identified. However, a separate survey con-
follow-up indicated a small reduction of 0.5% and a sig- ducted by the DON SCN™ only in primary care settings
nificant net monetary benefit of $3000 per patient-year, (for program evaluation purposes) found that the most
consisting of $3500 health utilization cost avoidance ver- used resources were the foot screening tool, followed by
sus $500 intervention cost [35]. When foot protection the Diabetes Foot Risk Assessment Triage Referral form
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 11 of 15

Fig. 2 Provision of service to patients with moderate risk feet. a – Nail and skin care services provided. b – Services for structural deformities
provided. c – Services for specialty footwear provided. d – Performance of vascular assessment and related referrals for peripheral artery disease.
Comparing 2014 to 2019, *p < 0.05, **p < 0.01, *** p < 0.001 by Fisher’s exact test. Data were analysed using raw counts and transformed to %
respondents for presentation

and its associated process guidelines, and the patient re- screening rates on individual patients in primary health
source. These materials were used by more than 30% of care and HC/LTC are not easily tracked. However, based
the respondents. E-learning modules and the Provider’s on the data presented here, we predict that individuals
Guide for the pathway were used by less than 25% of re- self-reporting an annual foot screen would increase from
spondents (K. Dmytruk and M. Mainville, personal com- the 40% recorded in a cohort prior to implementation of
munication). Annual screening is recommended in the diabetes foot care pathway [16]. To further increase
Canada and internationally [26, 37]. A review of the util- uptake of diabetes foot screening into clinical practice,
ity of screening in primary care of all people with dia- embedding the screening tool into the electronic medical
betes yielded only weak evidence for benefit [38] but in records would allow for automated reminders and track-
the context of a comprehensive care plan, is the first ing of foot screens performed.
step to identifying risk and ensuring that people with An online patient education resource and handouts
diabetes can access specialized care expeditiously [26]. for each risk level were developed by the DON SCN™.
Our survey found an overall increase in screening from Patient education is recommended [26] even though evi-
57 to 74% of respondents predominantly in primary dence for effectiveness is conflicting [40, 41]. In particu-
health care and HC/LTC sites, which is important, lar, a single education session focused only on increasing
because foot problems identified early increases the po- knowledge is unlikely to provide lasting behaviour
tential to avoid overt ulceration [39]. Uptake of the AHS change [41]. Individuals with diabetic foot disease ex-
foot screening tool was strong in 2019, likely due to the press complex emotional and behavioral responses to
training provided in its use. Unfortunately, actual their condition and may feel they lack control over their
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 12 of 15

Table 5 Comparison between sites utilizing HRFT vs other care models for assessing moderate risk patients
All HRFT Clinic/ hospital team P-value
N unique sites 36 13 20
PHC 10 5 5 0.574
Outpatient 6 3 3
Acute care 1 0 1
Wound clinic 4 2 2
HC/LTC 9 5 4
Community care 1 0 1
Private/independent 2 0 2
Multiple areas of practice 6 1 5
N for geographical location: 0.015
Metro & Urban 21 11 8
Rural 10 2 7
Remote 2 0 2
First Nations 3 0 3
Services provided N (%) N (%)
Skin and nail care Provide skin & nail care 5 (38) 15 (75) 0.067
Provide a list of community resources 11 (85) 13 (65) 0.264
Refer to podiatrist 9 (69) 18 (90) 0.184
Assess structural deformities Provide education 11 (85) 17 (85) 1.00
Refer podiatrist or orthopedic specialist 11 (85) 18 (90)
Other 0 2 (10) –
Address footwear problems Provide education 13 (100) 19 (95) 0.501
Refer to AADL 9 (69) 7 (35) 0.0799
Refer without AADL authorization 8 (62) 8 (40) 0.296
Other 5 (38) 5 (25)
Assess vascular problems Perform vascular assessment 13 (100) 20 (100) 1.00
Refer to GP 5 (38) 16 (80) 0.0265
Refer to vascular lab 10 (77) 10 (50) 0.1595
Vascular assessment methodology ABPI 7 (54) 8 (40) 0.4928
PPG 9 (69) 8 (40) 0.151
ABPI + PPG 7 (54) 7 (35) 0.472
Pedal pulses 12 (92) 12 (60) 0.0560
Perform all 3 tests 7 (54) 7 (35) 0.472
Other 1 (8) 1 (5)
Assess loss of protective sensation Refer to physician 10 (77) 18 (90)
Treat neuropathic pain 3 (23) 2 (10)
Statistical analysis using Fisher’s Exact Test. For discussion purposes, p < 0.1 was considered significant given the small number of sites available for comparison
Abbreviations: AADL Alberta Aids to Daily Living, ABPI Ankle-brachial pressure index, GP General practitioner, HC/LTC Homecare/long-term care, PHC Primary health
care, PPG Photoplethysmography toe pressure
Metro, urban, rural and remote were defined according to Alberta Health Services and Alberta Health criteria [28]. N = 3 sites responded “other” (one referred to
home care, two were themselves referral sites)

ability to prevent re-ulceration [42], thus the provision the AHS-developed screening tool and the pathway rec-
of simple leaflets may be insufficient support. ommends footcare education and referral to a footcare
When screened patients present with skin, nail, ana- nurse or podiatrist by the family physician or HRFT
tomical or sensory abnormalities but not skin break- [23]. In 2019, about half of respondents referred such
down or ulceration, they are defined as moderate-risk in patients to family physicians, the other half to HRFT
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 13 of 15

(with some overlap). Improvement in practices for unable to be fully documented because of the untargeted
moderate-risk patients in 2019 included more sites recruitment, particularly in 2014. Also, sites receiving
following the recommended [23] 4–6 months follow-up multiple invitations to participate may have designated
increasing 1.7-fold and an increased proportion of sites the most knowledgeable member of the team to respond
performing vascular assessment, which requires per- to the survey to avoid duplication of effort. Nurses may
forming specific diagnostic tests by 1.3-fold compared have been over-represented (about 40% of respondents),
with 2014. Training and video modules of assessment however, nurses play an important role in foot screening
were provided to facilitate uptake. Patients with periph- and foot care and thus may be the most knowledgeable
eral artery disease have 2-fold higher risk of major lower of their site’s practices. Although we were unable to
limb amputation [43] so the increased proportion of sites directly compare sites’ responses in 2019 versus 2014,
performing vascular assessment is encouraging because a we could document trends in improved diabetic foot
systematic review found that timely referral of patients care practices in Alberta. Ability to assess the benefits of
with peripheral artery disease can reduce morbidity and HRFT was limited by the small number of respondents
mortality [44]. Access to HRFT following community- and differences in geography between HRFT and the
level screening is important, in particular forming net- comparator group of hospital/clinic teams. Finally, this
works with a HRFT hub [32]. It was facilitated in the analysis provides an overview of the uptake of the
clinical care pathway by the Triage Referral Form pro- comprehensive diabetes foot care clinical pathway and
vided to those in primary care performing screening. resource toolkit but further work should include valid-
We identified differences in clinical practices between ation of the foot screening tool and evaluation of the
clinic/hospital teams and HRFT, which received specific effectiveness of the patient education resources to im-
training in the pathway and resource toolkit use. Specif- prove self-care.
ically, clinic/hospital teams were more likely to provide In conclusion, this study supports that a multi-faceted,
skin and nail care than HRFT, which was associated with concerted approach to improve diabetic foot care im-
their service to mainly remote and First Nations com- proves awareness of healthcare providers and uptake of
munities. This might reflect lack of community services appropriate screening in primary care and HC/LTC set-
(e.g., podiatry) for such care. Indeed, inspection of the tings in Alberta, Canada. Provincial outreach and training
sites providing skin/nail care by the clinic/hospitals re- provided by the DON SCN™ facilitated uptake of the clin-
vealed that 12 out of 12 rural/remote/First Nations sites ical pathway. Preliminary data are consistent with cost
provided this service versus only 3 out of 8 urban sites. avoidance and reduction in foot-related complications in
Provision of such services in rural settings is important, persons with diabetes and are consistent with reports from
perhaps even more so in First Nations communities be- other jurisdictions. HRFT provide increased expertise for
cause the prevalence of neuropathy is high and patients assessment and procedures for patients with moderate risk
tend to be younger than in non-First Nations popula- of ulceration so that individuals screened in primary
tions [45, 46]. Referral of patients to family doctors healthcare, homecare or other settings can be referred.
versus a specialized vascular laboratory was noted for This comprehensive model has the potential to reduce
the clinic/hospital teams, possibly also related to access progression of foot problems and overall health services
variation imposed by geography. Referral practices for utilization.
therapeutic footwear did not change but this may be
more related to restrictions on prescribing and insurance
coverage than lack of attention to pathway recommenda- Supplementary information
Supplementary information accompanies this paper at https://doi.org/10.
tions. Because properly-fitted footwear is important for 1186/s13047-020-00393-0.
preventing ulcers [47], development of policies and clear
criteria for more universal provision of therapeutic or cus- Additional file 1.
tom footwear and offloading inserts would be beneficial.
The strengths of this study include attempts to reach a
broad base of respondents from all settings where dia- Abbreviations
ABPI: Ankle-brachial pressure index; AADL: Alberta Aids to Daily Living;
betic foot care is performed, and ability to compare with AHS: Alberta Health Services; DFU: Diabetic foot ulcer; DON SCN™: Diabetes,
data collected prior to implementation of the diabetic Obesity and Nutrition Strategic Clinical Network™; GP: General practitioner;
foot care pathway. However, we acknowledge some HC/LTC: Homecare/long-term care; HRFT: High risk foot team; MD: Medical
doctor; NP: Nurse practitioner; PPG: Photoplesthysmography toe pressure;
weaknesses. The customized survey was not validated RNAO: Registered Nurses Association of Ontario
and selection bias is probable because sites with a strong
interest or expertise in diabetic foot care were more
Acknowledgments
likely to respond than those with less investment in that The assistance of Christine Goertzen is greatly appreciated. Respondents are
area. Moreover, the professions of non-respondents were thanked for their participation.
Chan et al. Journal of Foot and Ankle Research (2020) 13:26 Page 14 of 15

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