I. Introduction
Diabetes mellitus is a chronic disease affecting millions worldwide, and its complications, such as diabetic foot ulcers (DFUs), pose significant healthcare challenges. Effective management of DFUs requires timely and coordinated interventions, ideally within primary care settings. However, primary care physicians (PCPs) often face challenges in managing these complex conditions due to limited access to specialized resources and standardized protocols. This article explores the development and validation of a novel decision support tool designed to assist primary care physicians in the diagnosis and management of DFUs, ultimately aiming to improve patient outcomes and streamline the referral process to specialist care. This tool is not intended for initial risk screening, as validated tools for that purpose already exist. Instead, it focuses on providing practical, step-by-step guidance for PCPs once a DFU is identified.
II. The Need for Decision Support in Primary DFU Care
Research consistently demonstrates that a multidisciplinary approach to DFU management, involving specialized wound care teams, leads to improved healing rates, reduced amputation risks, and lower healthcare costs. Despite these benefits, access to such specialized teams is often limited, particularly in primary care settings and outside of major urban centers. This disparity highlights the critical need for tools that can empower primary care professionals to deliver high-quality DFU care within their existing practice frameworks. A decision support tool in this context can bridge the gap between ideal multidisciplinary care and the realities of resource constraints in primary care. By providing structured guidance and readily accessible information, these tools can enhance the confidence and competence of PCPs in managing DFUs.
III. Development and Validation of a DFU Decision Support Tool
To address this gap, a comprehensive decision support tool was developed and rigorously validated through a Delphi protocol. This involved an expert panel of healthcare professionals representing the ideal composition of an interdisciplinary wound care team. The Delphi method, a structured communication technique, facilitated consensus-building among experts on the essential components of DFU assessment and management in primary care. The tool’s development was informed by a thorough review of existing guidelines and best practices, ensuring its alignment with current evidence-based recommendations. The iterative nature of the Delphi process allowed for refinement of the tool based on expert feedback, enhancing its practical applicability and clinical relevance for primary care settings.
IV. Key Features and Intended Use of the Tool
The decision support tool is specifically designed for primary care professionals, including PCPs and registered nurses (RNs). It serves as a practical care pathway and checklist, guiding users through the necessary steps for managing patients with DFUs. The tool aims to promote coordinated care within primary care settings and improve communication and referral pathways to specialist services when needed. It is important to emphasize that this tool is intended to support, not replace, the clinical judgment of healthcare professionals. It functions as a guide to ensure comprehensive assessment and management, facilitating informed decision-making in complex DFU cases. The tool’s focus on primary care is crucial as it aims to reduce the need for emergency department visits and hospital admissions, which are associated with higher costs and increased patient morbidity. By enhancing primary care management of DFUs, the tool contributes to a more efficient and patient-centered healthcare system.
V. Addressing Resource Limitations in DFU Care
During the development process, the expert panel identified significant resource limitations in primary care settings that impact DFU management. These challenges include:
- Limited Access to Equipment: Lack of readily available equipment, such as portable Doppler devices for vascular assessment, hinders timely and accurate diagnosis.
- Poor Access to Specialist Services: Delays in accessing hospital-based technical platforms and specialist consultations, particularly vascular evaluations, can negatively affect the quality of DFU care.
- Insufficient Resources for Health Promotion: Limited resources for essential health promotion interventions, such as nutritional evaluations and diabetes education, impede patient empowerment and self-management.
- Financial Barriers to Offloading: The high out-of-pocket costs for effective offloading modalities present a significant financial burden for many patients, hindering DFU healing.
The decision support tool acknowledges these limitations and, where possible, provides guidance within these constraints. For example, recognizing the challenges in accessing advanced vascular assessments in primary care, the tool emphasizes when referral to a vascular surgeon is necessary based on clinical indicators. Furthermore, the tool implicitly highlights the importance of advocating for improved resource allocation within primary care to better support DFU management and preventative care.
VI. Telemedicine and Improved Referral Pathways
The tool also recognizes the potential of telemedicine to enhance DFU care, particularly in regions with limited access to specialist services. Telemedicine can facilitate communication and collaboration between PCPs and specialists in tertiary centers, improving the timeliness and appropriateness of referrals. Standardized referral criteria embedded within the decision support tool can help PCPs determine when specialist consultation is necessary, ensuring patients receive timely access to advanced care when indicated. By streamlining referral pathways and promoting telemedicine solutions, the tool contributes to a more integrated and accessible healthcare system for individuals with DFUs.
VII. Conclusion: Enhancing Primary Care DFU Management
This newly developed and validated decision support tool represents a significant step forward in empowering primary care physicians to effectively manage diabetic foot ulcers. By providing a structured, evidence-based framework for assessment and management, the tool has the potential to improve patient outcomes, reduce healthcare costs, and streamline the interface between primary and specialist care. While acknowledging existing resource limitations within primary care, the tool offers practical guidance to optimize DFU management within these constraints. Future research should focus on implementing and evaluating the impact of this tool in diverse primary care settings, as well as exploring its potential to be adapted into a knowledge translation resource for both healthcare professionals and patients, further enhancing diabetes primary care.
