Vascular Surgery Service, Department of Surgery, Woodlands Health, Singapore, Singapore.
Centre for Population Health Sciences. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore.
Int Wound J. 2023 May;20(5):1609-1621. doi: 10.1111/iwj.14016. Epub 2022 Nov 13.
Diabetic Foot in Primary and Tertiary (DEFINITE) Care is an inter-institutional and multi-disciplinary team (MDT) health systems innovation programme at a healthcare cluster in Singapore. We aim to achieve coordinated MDT care across primary and tertiary care for patients with diabetic foot ulcers (DFU), within our public healthcare cluster - an integrated network of seven primary care polyclinics and two acute care tertiary hospitals (1700-bed and 800-bed) with a total catchment population of 2.2 million residents. Results from prospective DEFINITE Care is referenced against a retrospective 2013-2017 cohort, which was previously published. Cardiovascular profile of the study population is compared against the same population's profile in the preceding 12 months. Between June 2020 and December 2021, there were 3475 unique patients with DFU with mean age at 65.9 years, 61.2% male, mean baseline HbA1c at 8.3% with mean diabetes duration at 13.3 years, mean diabetes complication severity index (DCSI) at 5.6 and mean Charlson Comorbidity Index (CCI) at 6.8. In the 12-months preceding enrolment to DEFINITE Care, 35.5% had surgical foot debridement, 21.2% had minor lower extremity amputation (LEA), 7.5% had major LEA whilst 16.8% had revascularisation procedures. At 18-months after the implementation of DEFINITE Care programme, the absolute minor and major amputation rates were 8.7% (n = 302) and 5.1% (n = 176), respectively, equating to a minor and major LEA per 100000 population at 13.7 and 8.0, respectively. This represents an 80% reduction in minor amputation rates (P < .001) and a 35% reduction in major amputation rates (P = .005) when referenced against a retrospective 2013-2017 cohort, which had minor and major LEA per 100000 population at 68.9 and 12.4, respectively. As compared to the preceding 12 months, there was also a significant improvement in cardiovascular profile (glycemic and lipid control) within the DEFINITE population, with improved mean HbAc1 (7.9% from 8.4%, P < .001), low-density lipoprotein (LDL) levels (2.1 mmol/L from 2.2, P < .001), total cholesterol (3.9 mmol/L from 4.1, P < .001) and triglycerides levels (1.6 mmol/L from 1.8, P = .002). Multivariate analysis revealed a history of minor amputation in the preceding 12 months to be an independent predictor for major and minor amputation within the study period of 18 months (Hazard Ratio 3.4 and 1.8, respectively, P < .001). In conclusion, within DEFINITE care, 18-month data showed a significant reduction of minor and major LEA rates, with improved medical optimisation and cardiovascular profile within the study population.
糖尿病足的初级和三级（明确）护理是新加坡一个医疗保健集群中的机构间和多学科团队（MDT）卫生系统创新项目。我们的目标是在我们的公共医疗保健集群内实现跨初级和三级护理的协调 MDT 护理，为糖尿病足溃疡（DFU）患者提供服务 - 这是一个由七个初级保健诊所和两个急性护理三级医院组成的综合网络（1700 张床位和 800 张床位），共有 220 万居民。前瞻性明确护理的结果是根据之前发表的 2013-2017 年回顾性队列进行参考的。研究人群的心血管特征与前 12 个月中同一人群的特征进行了比较。在 2020 年 6 月至 2021 年 12 月期间，有 3475 名独特的 DFU 患者，平均年龄为 65.9 岁，男性占 61.2%，平均基线糖化血红蛋白（HbA1c）为 8.3%，平均糖尿病病程为 13.3 年，平均糖尿病并发症严重指数（DCSI）为 5.6，平均 Charlson 合并症指数（CCI）为 6.8。在纳入明确护理前的 12 个月中，35.5%的患者接受了足部清创手术，21.2%的患者接受了小下肢截肢术（LEA），7.5%的患者接受了大 LEA，16.8%的患者接受了血运重建手术。在明确护理计划实施后的 18 个月，小和大截肢的绝对发生率分别为 8.7%（n=302）和 5.1%（n=176），相当于每 10 万人中分别有 13.7 和 8.0 的小和大 LEA。这表示小截肢率降低了 80%（P<0.001），大截肢率降低了 35%（P=0.005），与之前的 2013-2017 年回顾性队列相比，该队列每 10 万人中的小和大 LEA 分别为 68.9 和 12.4。与前 12 个月相比，明确护理人群的心血管状况（血糖和血脂控制）也有显著改善，平均 HbAc1 改善（从 8.4%降至 7.9%，P<0.001），低密度脂蛋白（LDL）水平（从 2.2mmol/L降至 2.1mmol/L，P<0.001），总胆固醇（从 4.1mmol/L降至 3.9mmol/L，P<0.001）和甘油三酯水平（从 1.8mmol/L降至 1.6mmol/L，P=0.002）。多变量分析显示，在研究期间的 18 个月内，前 12 个月有小截肢史是大截肢和小截肢的独立预测因素（危险比分别为 3.4 和 1.8，P<0.001）。总之，在明确护理中，18 个月的数据显示小和大 LEA 率显著降低，研究人群的医疗优化和心血管状况得到改善。
