The impact of team based interprofessional comprehensive assessments on the diagnosis and management of diabetic foot ulcers: A retrospective cohort study
The impact of team based interprofessional comprehensive assessments on the diagnosis and management of diabetic foot ulcers: A retrospective cohort study
Ranjani Somayaji 0 1
James A. Elliott 1
Reneeka Persaud 1
Morgan Lim 1 2
Laurie Goodman 1
R. Gary Sibbald 1
0 Department of Medicine, University of Calgary , Calgary , Canada , 2 Toronto Regional Wound Healing Clinic , Mississauga , Canada , 3 Trillium Health Partners, Institute for Better Health , Mississauga , Canada
1 Editor: Shahrad Taheri, Weill Cornell Medical College in Qatar , QATAR
2 Institute of Health Policy , Management and Evaluation , University of Toronto , Toronto , Canada , 5 Humber River Hospital , Toronto , Canada , 6 Trillium Health Partners, Mississauga , Canada , 7 Dalla Lana Faculty of Public Health, University of Toronto , Toronto , Canada , 8 Women's College Hospital, Wound Healing Clinic, Division of Dermatology, Department of Medicine , Toronto , Canada
Funding: The study was funded through an
unrestricted grant (RGS was the grant recipient)
from the Mississauga Halton Local Health
Integration Network (http://www.
mississaugahaltonlhin.on.ca/). The funders had no
Diabetic foot ulcers (DFU) are increasingly prevalent, and associated with significant mor
bidity, mortality, and cost. An interprofessional approach to DFU management is critical
given the etiological complexity involved. This study aimed to assess the impact of an
interprofessional team approach on DFU diagnosis and management for a cohort of patients
receiving treatment in an Ontario Canada home care setting.
A retrospective cohort study of patients attending a large regional Community Care Access
Centre (CCAC) between February 11, 2013-September 30, 2014 was conducted. Following
CCAC referral, patients were assessed by an interprofessional team at the Toronto Re
gional Wound Healing Centre (TRWHC). Those aged > 18 years with a DFU of > 6 weeks
duration were included. The primary outcome was the precision of the initial diagnosis
relating to DFU etiology (i.e. neuropathic, ischemic or mixed etiology). Secondary outcomes
included wound healing, and infection parameters. Analysis was completed with STATA
13.1 (College Stn., TX) of pre-determined outcomes with 2 sided α of 0.05.
A total of 308 patients were screened, and 49 patients (67.3% male) of mean age 64.2
years (SD 13.7) with a diagnosis of DFU > 6 weeks duration were included for analysis. Of
these, 95% were referred with unspecified DFU, and were reclassified to a precise diagnosis
relating to etiology, including neuropathy, ischemia or neuroischemic etiology following
TRWHC assessment (p < 0.001). For secondary outcomes post-assessment, healability
role in study design, data collection and analysis,
decision to publish, or preparation of the
Competing interests: The authors have declared
that no competing interests exist.
assessment was conducted for a greater proportion of patients (100% versus 44%, p <
0.001). Infection was identified in a greater number of patients (p = 0.04), and of the 35
patients, 94.5% had deep and surrounding infection, and 88.0% were initiated on systemic
antibiotics. Vascular insufficiency was diagnosed in an additional 14.3% of the cohort (p =
0.03). Offloading/footwear assessment was conducted in all patients compared with 30.6%
prior to referral (p < 0.001) Dressing change frequency decreased significantly following
TRWHC assessment (pre: 4.31/week; post: 3.54/week; p = 0.03). Pain scores decreased
(2.18 to 1.67) on the numerical rating scale but this was not statistically significant at the
final TRWHC assessment. Notably, 36.7% (18/49) reported improved quality of life by the
second TRWHC encounter.
Interprofessional care teams are associated with improved diagnostic acumen and wound
healing outcomes over conventional community care services. Initiatives including best
practice interprofessional diabetic foot care pathways are recommended with timely
vascular management of ischemia, treatment of deep and surrounding infection as well as the
availability of foot care and footwear.
Diabetes mellitus is a non-communicable chronic disease impacting approximately 415
million individuals worldwide [
]. Global diabetes prevalence continues to rise and in 2014 it was
estimated 9% of all adults had the disease [
]. Further, it is estimated that 50% of persons
with diabetes are unaware of their diagnosis, and that diabetes is directly attributed to more
than 1.5 million deaths annually . Individuals with diabetes have higher rates of health care
utilization, hospitalization, and have a two-fold risk of death at each age group [4±6]. Canada
has > 2.4 million individuals living with diabetes and the province of Ontario has one of the
highest age-standardized prevalences in the country .
Non-traumatic lower extremity amputations are a common complication of diabetes.
Approximately 85% of all amputations are associated with preceding diabetic ulcers of the skin
]. Diabetic foot ulcers (DFU) occur in up to 25% of people with diabetes and it is estimated
that a lower extremity is amputated every 20 seconds due to diabetes [10±12]. DFUs are
commonly of a neuropathic, vascular, or a combined (neuro-ischemic) etiology, and are often
chronic in nature . Furthermore, DFUs and resultant amputations are associated with
significant morbidity, mortality, emotional damage, and financial costs [
11, 14, 15
]. Therefore an
organized approach to DFU screening, prevention, and management is critical for cost savings
to healthcare systems [
It is well established that glycemic control, and preventative foot care in high risk patients
are effective diabetes management interventions [
]. However, once an individual develops
a DFU, the optimal approach and team structure is less well established. DFU prevalence is
estimated at 90, 000 in Ontario resulting in annual costs upwards of 500 million dollars (CAD)
for community care alone [
]. As 10 to 15% of persons with diabetes will develop a DFU
in their lifetime, the DFU prevalence and associated costs will only continue to increase.
Growing evidence demonstrates interprofessional teams defined as a group of individuals from
different health care discriplines that function in a collaborative and integrated structure to be
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the optimal approach for care of complex chronic wounds, including DFUs, and have also
demonstrated reductions in incidence, and subsequent complications including amputations
[19±23]. Further, international initiatives such as the Guyana Diabetes and Foot Care program
were able to demonstrate that an interprofessional approach utilizing assessment of vascular
status, presence of infection, and plantar pressure redistribution (`V.I.P') reduced lower limb
amputations by up to 80% [
Ontario's community based wound care services are administered through a publicly
funded single-payer home care system coordinated by Community Care Access Centres
(CCAC). The CCAC system is structured into 14 geographically discrete areas, and primarily
delivers care via contracts with service provider organizations (SPO) in patient homes and
outpatient clinics. The care is largely nursing based and is provided on the basis of physician
orders from hospital and outpatient care settings. There have been reports of inconsistent
specialist wound team consultations or follow-up [
], leading to lack of standardization, and
coordination of wound care within the system. For DFU management, strategies that have
been studied and validated include the `wound bed preparation' paradigm which utilizes the
`V.I.P.' assessment approach, and includes vascular, infectious, and pressure redistribution
components for determination of etiology, and treatment parameters [
]. Thus, we aimed to
assess the diagnostic and management impact of an interprofessional team approach on DFU
care in Mississauga Halton, a health region in Ontario, Canada.
Setting and population
In Ontario, Mississauga Halton is a large geographic area where community care services are
primarily served currently by a CCAC clinic in the home or outpatient clinic settings. The
Toronto Regional Wound Healing Centre (TRWHC) is an interprofessional outpatient clinic
located in Mississauga Ontario that provides comprehensive assessment and care plan services
for patients with complex wounds. The interprofessional team consists of a physician with
training and extensive experience treating complex wounds, three nurses with advanced
wound care expertise, a chiropodist trained in providing appropriate offloading, and a certified
diabetes educator. Initial comprehensive assessments are approximately two hours long, and
utilize both interview and physical assessment methods as outlined in the Wound Bed
Preparation paradigm [
]. Patients were assessed by the nurse, physician, and diabetes educator as
a minimum, and by the chiropodist if offloading was required (on the basis of wound etiology
and location). Patients are assessed within ten business days following a referral. Follow-up
appointments are scheduled as necessary and guidance is provided for ongoing wound care.
Written consent on standard forms was obtained from participants, and the study protocol was approved by the Trillium Health Partners Research Ethics Board (REB-ID635).
Patient selection and study design
A retrospective cohort study of patients referred to the TRWHC from a local CCAC between
February 11, 2013 and September 30, 2014 was conducted. Patients who were aged 18 years
with history of diabetes mellitus, and a referral diagnosis of DFU, and who were seen at least
once at the TRWHC were included in the analysis. The diagnosis of diabetes mellitus was
confirmed through review of chart records of glycemic testing, including hemoglobin A1c
(HbA1c) values and/or previously recorded diagnosis. As patients may have multiple ulcers,
the primary ulcer was designated by the CCAC staff of chief concern based on standardized
wound parameters including size, depth, location, and complications (i.e. infection, vascular
compromise). Demographic and clinical data were collected through chart review of CCAC
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referral forms, laboratory investigations, and TRWHC medical records using a case report
form. The case report form was tested using ten randomly selected patient charts and reviewed
for changes by three investigators separately prior to finalizing the form (JE, RP, RGS).
Collected data included: demographics (age, sex), co-morbidities, smoking status, referral details,
vascular status (including Doppler testing), presence of infection, wound parameters
(duration, size, location, treatment to date, healability classification), diabetes history and
complications, footwear or offloading details, functional ability, and TRWHC diagnosis and treatment
ordered. When discrepant information was noted between CCAC and TRWHC records, the
TRWHC chart data was utilized.
Continuous variables were described using means and standard deviations (SD), and discrete or
non-normally distributed variables were described with medians and interquartile ranges
(IQR). Comparisons were conducted with Student t-tests and Chi-squared tests for continuous
and categorical variables respectively. For the primary outcome of the precision of DFU
diagnosis, Chi-squared testing, and inter-rater reliability with Cohen's kappa was used to compare the
CCAC and TRWHC diagnoses. Precision of DFU diagnosis was coded as a binary variable at
the time of TRWHC assessment. A precise diagnosis was defined as one which included etiology
in the terminology, such as neuropathic, infectious, or vascular aspects relating to an otherwise
unspecified ulcer, or unspecified DFU diagnosis. Chi-squared analysis was utilized to analyse
the secondary outcomes of assessment of healability (defined as healable, maintenance,
nonhealable), vascular compromise (yes/no), identification of infection (deep and surrounding or
superficial infection; bacterial damage present yes/no), assessment of pain (yes/no), footwear/
offloading assessment (yes/no + qualitative assessment of devices) and wound closure events
(yes/no). Infection was defined as critical colonization if superficial, or deep and surrounding
wound infection based on previously validated NERDS and STONEES criteria [
ttest with unequal variance was utilized to analyse mean weekly dressing change frequency.
Inter-rater reliability with Cohen's kappa was also used to compare healability classification. All outcomes were determined prior to data collection and hypotheses were two sided with an alpha significance of 0.05. Analyses were conducted with STATA 13.1 (College Stn., Texas).
A total of 318 patients referred to the TRWHC were screened, and 49 patients (67.3% male)
with diabetes mellitus referred with DFU were included for analysis (Table 1). Baseline
demographics of age (p = 0.09) and sex (p = 0.08) were not significantly different from the screening
cohort. The patients had an overall mean age of 64.2 years (SD 13.7), with a median wound
duration of 26.0 weeks (IQR 10±52), and a median of 3.5 (IQR 3±7) clinical encounters per
week through the CCAC at the time of TRWHC referral. Referrals to the TRWHC were most
commonly initiated by Enterostomal therapists/wound care specialists (28/49, 57.1%), and
were requested on a priority or urgent basis defined as < 7 days duration (30/49, 61.2%); all
patients were seen within ten business days following referral. Following TRWHC assessment,
patients were followed for a median of 12.0 weeks (IQR 5±25) and attended a median of 3.0
nursing homecare treatment visits (IQR 2±5) per week. Of the cohort, only 18% (7) had a BMI
value in the normal adult range (18.5±24.9), with the majority being obese. Most common
other co-morbidities were hypertension (67.4%), dyslipidemia (55.1%), current or historical
tobacco use (38.8%), peripheral vascular disease (34.7%), and heart disease (24.5%).
Approximately 30% of the cohort had a history of prior DFU associated surgical interventions for
either the presenting ulcer, or a past ulcer. Notably, less than one-third of the cohort had
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received adequate foot screening, foot care (including improper footwear devices without
modifications), or diabetes related testing (i.e. HbA1c) at the time of referral. Additionally, less
than 5% of patients had vascular assessment or need for vascular testing documented when
they were referred.
Of 49 patients, only 3 patients had a precise DFU diagnosis relating to etiology at the time of
referral compared with 42 patients following initial TRWHC assessment (p < 0.001). Cohen's
kappa to assess inter-rater agreement using a two unique rater model was poor with a kappa
statistic of 0.02 (p = 0.24). The most common CCAC referral diagnosis was ªunspecified
diabetic foot ulcerº (77.6%). Following the TRWHC assessment, the diagnoses were further
refined into ischemic, neuropathic, and mixed DFU etiologies.
Of the cohort, healability was assessed at the CCAC in 44.9% of patients, and increased to 100.0% by the first TRWHC assessment (p < 0.001) (Table 2). The inter-rater reliability of
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TRWHC (Interprofessional team)
Legend: No±number; SD±standard deviation; CCAC±community care access centre; TRWHC±Toronto Regional Wound Healing Clinic
*Number of wounds closed refers to the final visit at TRWHC where the denominator representing the total number of patients from the initial cohort has
healability assessment between the CCAC and TRWHC was poor, with a kappa-value of 0.06.
As all patients seen at the TRWHC underwent vascular assessment (Ankle-Brachial Index
and/or Doppler studies), a greater proportion were identified to have vascular compromise as
compared with the time of referral (p = 0.03). Similarly, assessment for bacterial
damage/infection (p = 0.04), and wound associated pain (p < 0.001) was completed for a greater proportion
following TRWHC assessment. Of the 35 patients identified with bacterial damage, 94.5%
(n = 33) were diagnosed with deep and surrounding infection, and 88.0% were initiated on
systemic antibiotics. Offloading assessments were conducted for all patients at the TRWHC as
part of their comprehensive evaluation (p < 0.001). No validated pain scale score was
documented at time of CCAC referral. Mean pain score on a validated visual analog scale (0±10) at
time of TRWHC assessment was 2.18 (SD 3.21). Mean pain scores decreased over the
followup period at the TRWHC, though the reduction was not significant.
Significant improvement in wound closure rates were demonstrated following TRWHC
assessment and care (p = 0.001). Once a patient achieved wound closure of their primary
wound, they were no longer accounted for in the denominator as they were no longer followed
by the TRWHC. Weekly dressing change frequency decreased significantly following TRWHC
assessment and follow-up (4.32/week to 3.54/week, p = 0.035). When stratified by CCAC
service setting (i.e. in-home, outpatient clinic, or patient self-management), a decreasing trend in
weekly dressing change frequency was noted, although it did not achieve statistical
significance. Quality of life measures were not assessed on a validated scale at time of CCAC referral
and thus could not be directly compared. Notably however, 36.7% (18/49) of the cohort
reported improved quality of life scores at their second TRWHC clinic encounter.
As a small proportion of patients had prior history of diabetes education, glycemic control
measurements, or footwear assessments at time of CCAC referral (Table 1), these treatment
elements were addressed at TRWHC. Diabetes education was planned or provided, including
referral to diabetes education programs, and HbA1c tests were ordered for an additional 33%
of the cohort at initial assessment. Doppler studies conducted in all patients at the TRWHC
demonstrated a triphasic or `normal' waveform in only 22.5% (11/49) of the cohort. Although
advanced wound care therapies were requested in a number of patients on referral,
implementation of negative wound pressure therapy was recommended in less than 5.0% of the cohort,
and only 6.1% of patients were referred for consideration of hyperbaric oxygen therapy after
TRWHC assessment (data not shown).
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When DFU diagnostic and management measures were assessed between a standard
community care model and an interprofessional wound care team model, significant improvements
were noted in multiple domains. Specifically, the study demonstrated more precise diagnoses,
increased healability classifications, increased vascular and footwear/offloading assessment,
enhanced identification of deep and surrounding infection, and improved healing times
following interprofessional comprehensive would team assessment. Pain and quality of life scores
also trended towards improvement, although they did not reach statistical significance.
Wound closure was more readily achieved despite a significantly lower mean follow-up time.
Few advanced wound care modalities were deemed required. Our findings are consistent with the results of randomized controlled trials of interprofessional wound teams completed in other jurisdictions that have demonstrated significant improvements in healing rates, pain scores, treatment frequency, and trends to wound closure [25,27].
The TRWHC foot assessments and redistribution results may have been improved further
if the primary footwear were dispensed following interprofessional assessment as patients at
times had inappropriately dispensed footwear without modifications at time of this
assessment. Based on previous data from the Guyana foot care project [
] as well as the primary
care reform project in Ontario, integration and coordination of footwear and orthotic
dispensing by expert foot care clinicians can improve foot-related outcomes.
Although chronic wounds associated with diabetes mellitus are common, significant
variation in diagnostic and management practices exist [
]. Notably, before their
interprofessional comprehensive assessment a large proportion of patients had no documented history of
diabetes education, foot screening, or footwear/offloading device assessment, reflecting a lack
of evidence based care in DFU care delivery. The lack of standardization and adherence to best
practices may contribute to suboptimal outcomes. Socioeconomic factors have been
demonstrated to have a negative impact on diabetes related complications and outcomes [
Individuals with diabetes have a 15% lifetime risk of developing a DFUs, with recurrence rates
of 70% or higher without effective interventions [
9, 32, 33
Not uniquely in Canada, wound care in the province of Ontario has highly varied referral
and care pathways. A survey study to characterize the interprofessional service models for
wound care in Ontario identified 49 separate teams across the province's 14 CCACs. The
findings identified the numbers of wound care teams, disciplines of team members, locations,
clinical experience, volume and diversity of patients assessed, available resources, and access to
key services vastly differed between the teams [
]. A study of the burden of chronic wounds
in Ontario estimated that 25% of 22,000 long-stay clients (> 60 days) were persons with
diabetes that received care annually through CCAC services [
]. Wound care was provided for a
mean duration of 27 months with no noted improvement, and potential worsening, in at least
60% of clients in this time period [
]. Total costs of DFU management based on 2009
estimates are approximately $511,000,000 or $5,678 CAD per DFU with provision of standard
community care [
This study's primary strengths were the detailed nature of the review, and the comparison
of two contrasting models of DFU management. Weaknesses included the relatively small
sample size, limited follow-up time of approximately 3±4 months, and use of two models of
wound care which hampered our ability to examine short and long-term outcomes of wound
recurrence, and mortality. Although individuals with DFU are prone to rapid changes in
clinical status and thus may have had changes in their wound between referral and assessment, this
was minimized as they were all seen within ten days of referral. Other limitations included
drawbacks inherent to retrospective study designs e.g. vulnerability to information bias (i.e.
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missing data, misclassification of DFU), selection bias based on the heterogeneity of
populations, and confounding factors not accounted for in the data analysis. Although there were
significant differences in the components of diabetes wound assessments that were completed in
the two models of care (i.e. healing potential, vascular assessment), due to the study design and
our limited power, larger prospective studies are needed to further validate the findings.
This is one of the first studies to examine and highlight the differences in care between usu
ally wound care in the community and interprofessional care models for DFU management.
The population studied were clients with long-term ulcers not meeting the benchmarks for
care and therefore costly to the system. Moving forward, a coordinated approach with
evidence based paradigms to diabetic ulcer management at the health system level is critical.
Given the geographical size of Ontario, a highly specialized team may be needed in each Local
Health Integrated Network. Accessibility can be improved by connecting regional
interprofessional wound care teams to expert team hubs via pre-defined and well established referral
pathways. (e.g. in Ontario the community health link teams would be connected to the
interprofessional team within the local integrated health network). Furthermore, larger prospective
studies examining the impact of interprofessional teams on DFU management would assist in
optimizing team characteristics including team composition and referral pathways, thereby
improving patient outcomes, and decreasing DFU attributed health care costs.
Our study demonstrates a coordinated community-based interprofessional team approach to
DFU management is associated with more accurate and precise diagnoses in comparison to
current community based care centres. Successful implementation of DFU management
strategies may also benefit from optimizing technological and telehealth strategies for education
and provision of care. Moving forward, it will be important for healthcare systems, politicians,
policymakers, providers, and payers who inhabit them, to coordinate and integrate care with
health care professionals. This integrated care approach with interprofessional teams will
improve patient-centred outcomes with enhanced value to the healthcare dollar.
Conceptualization: James A. Elliott, Laurie Goodman, R. Gary Sibbald.
Data curation: James A. Elliott, Reneeka Persaud, R. Gary Sibbald.
Formal analysis: Ranjani Somayaji.
Funding acquisition: R. Gary Sibbald.
Investigation: Reneeka Persaud.
Methodology: Ranjani Somayaji, James A. Elliott, Reneeka Persaud, Morgan Lim, R. Gary
Project administration: James A. Elliott.
Supervision: Laurie Goodman, R. Gary Sibbald.
Validation: James A. Elliott, Reneeka Persaud.
Writing ± original draft: Ranjani Somayaji.
Writing ± review & editing: James A. Elliott, Reneeka Persaud, Morgan Lim, Laurie Goodman, R. Gary Sibbald.
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