Prioritizing Foot Ulcers During Lockdown Paid Off in Belgium

Belgium’s efforts to prioritize care at its diabetic foot ulcer clinics during the COVID-19 pandemic lockdown minimized both delays in care and adverse outcomes, new data suggest.

The country has had a national diabetic foot care program in place since 2005, with 34 multidisciplinary clinics recognized by the Belgium Ministry of Health for the treatment of diabetic foot ulcers (DFUs). The system has resulted in a decline in lower-limb amputations in the country.

And while all nonurgent medical care in Belgium was postponed during the national COVID-19 lockdown period March 14-May 3, 2020, the clinics followed advice from professional associations to consider all active DFUs as urgent. Thus, nearly all foot clinics remained accessible during lockdown.

“Thanks to the great efforts of diabetic foot clinics, continued availability of diabetic foot ulcer services during lockdown, although in a limited capacity, were really helpful, and may be the reason why we didn’t see late presentation,” said An-Sofie Vanherwegen, PhD, of Health Services Research, Sciensano, in Brussels, Belgium, at the virtual meeting of the European Association for the Study of Diabetes.

The only impact on DFU severity was that wounds tended to be slightly lighter, she said.

“Our findings will hopefully guide diabetic foot clinics in serving their patients using innovative strategies, such as telemedicine, during the current, and eventual future, public health crises,” she added in an EASD statement.

Asked to comment, session moderator Nikolaos Papanas, MD, PhD, told Medscape Medical News: “These results are important inasmuch as they provide information about diabetic foot patients during that critical period. The observation that patients did not delay in presenting to the health system is new and very reassuring, because it implies that they were educated about foot hygiene and that the system was able to cope with foot morbidity despite the new situation. Ulcers were larger but not otherwise more severe, which is probably due to the same reasons.”

Both system restructuring to incorporate telemedicine and patient education were key, said Papanas, who is head of the Diabetes Centre-Diabetic Foot Clinic, Democritus University of Thrace in Xanthi, Greece.

“We have also previously formulated that every healthcare professional must command an absolute minimum of knowledge to detect alarming signs in any new foot lesion. Meticulous foot care and maintenance of multidisciplinary expert management should be available with or without lockdowns.” 

Care Continued at Nearly All of Belgium’s Foot Clinics

It is estimated that around a quarter of all people living with diabetes worldwide will develop a foot ulcer in their lifetime, and these develop as diabetes damages the nerves and blood supply to the feet. Without timely treatment, these ulcers are hard to heal and form the leading cause of lower limb amputations in Western countries.

Data from the US indicate that amputations as a result of diabetic foot ulcers and peripheral arterial disease rose even further during the pandemic, when foot services were not always deemed essential, and the impact on people from communities of color was particularly dramatic.

But in Belgium, it appears the authorities tried to preempt any such effect.

“As the COVID-19 pandemic unfolded, there were concerns about the impact on Belgians with diabetic foot ulcers,” Vanherwegen explained.

Thus, the decision was made to try to keep as many clinics open, or accessible, as possible.

“People need to be seen quickly if an ulcer begins to form. That gives diabetic foot clinics the greatest chance of treating the wound successfully,” she noted.

Of the 22 diabetic foot clinics surveyed in Belgium, just one closed during lockdown while the rest remained open for urgent care. Most (79%) had switched to telemedicine, and 71% were selecting patients based on urgency and ulceration risk. Half (12) of the clinics reduced the frequency of consultations and half also spread the patients out in time and space.

Records were examined for a total of 887 patients with new moderate or severe DFU (Wagner grade 2 or above), of whom 322 first presented pre-lockdown (January 1-March 13), 93 during, and 472 post-lockdown (May 4-September 30).

The mean number of patients per week per clinic was 1.7 pre-lockdown, 0.6 during, and 1.4 post-lockdown. During the comparable periods in 2018, those figures were 1.4, 1.4, and 1.2, respectively.

The decrease during lockdown, of almost 60%, was significant. However, there were no changes in median presentation delay, of approximately 3 weeks pre-lockdown, 2 weeks during, and 3 weeks post-lockdown.  

There were no differences between the time periods in patient demographics, medical history, or comorbidities.

Both during and after lockdown there were more patients presenting with ulcers of 1cm² or larger, but a significantly lower proportion presented with critical ischemia after lockdown (11% vs 18%). There were no differences in ulcer depth, infection rates, or loss of protective sensation.

Vanherwegen speculated that the restriction of movement during lockdown might have had a protective effect in that people would be less likely to injure their feet. On the other hand, “people are less likely to wear adaptive footwear indoors and spending more time at home, so that might contrast with the hypothesis.”

Another factor of Belgium’s health system — the strong link between the diabetic foot clinics and primary care and home nurses — may also have played a role in the outcomes, she noted.

“It has been shown also in our referral data that people are still being referred by healthcare providers in the same proportion as before, indicating that this is a strong system. If people get referred by their healthcare providers in time, the effect on their foot ulcer is limited.”

The study was funded by the Belgian National Institute of Health and Disability Insurance. Vanherwegen and Papanas have disclosed no relevant financial relationships.

European Association for the Study of Diabetes virtual meeting: Abstract 578. Presented September 29, 2021.

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