Sailer Monica, Wergeland Hilde, Randsborg Per-Henrik
Department of Orthopaedic Surgery, Akershus University Hospital, Lørenskog, Norway.
Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
J Foot Ankle Res. 2025 Mar;18(1):e70024. doi: 10.1002/jfa2.70024.
Diabetes-related foot ulcer (DFU) is the leading cause for lower extremity amputations (LEAs) in western countries, and may cause social isolation, depression, and death. However, people with DFU are not offered the same prioritized care as cancer patients, despite comparable mortality rates. We therefore decided to create a clinical pathway for patients with DFU. The purpose of this study is to evaluate the efficacy of implementing a new clinical pathway on rates of LEA, length of hospital stays, and cost reduction.
On January 1, 2019, a new clinical pathway ensured that all patients with a DFU were evaluated in a designated clinic run by a foot and ankle orthopedic surgeon in collaboration with the vascular surgeons, supported by a specialized wound nurse and a certified prosthetist/orthotist (CPO). We designed an algorithm for the first consultation to identify patients in need for further investigation by other specialties such as endocrinology, infectious diseases, cardiology, or vascular surgery. All patients underwent a surgical wound debridement of DFU. Negative pressure wound therapy (NPWT) was not applied. After surgery, the dressings were changed daily on the ward, until the wound was deemed viable and clean. The patients were followed for two years and compared to a historic cohort of patients with DFU admitted to the institution in 2017.
The number of major amputations was reduced from 65% (13/20) to 7.4% (2/27) (p < 0.001) after the introduction of the clinical pathway. Both the mean number of surgical revisions (5.5 vs. 1.2) and the median length of stay (46 vs. 9 days) were statistically significantly reduced. The median cost per patient was reduced by 76% (from €538 000 to €129 000, p < 0.001).
The clinical pathway for managing DFUs resulted in a reduction in major amputations and shorter hospital stays. Discontinuing NPWT after surgical debridement did not adversely affect clinical outcomes. The new pathway also contributed to lower healthcare costs.
糖尿病相关足部溃疡（DFU）是西方国家下肢截肢（LEA）的主要原因，可能导致社交隔离、抑郁和死亡。然而，尽管DFU患者的死亡率与癌症患者相当，但他们并未得到与癌症患者相同的优先治疗。因此，我们决定为DFU患者创建一条临床路径。本研究的目的是评估实施新的临床路径对LEA发生率、住院时间和成本降低的效果。
2019年1月1日，一条新的临床路径确保所有DFU患者在由足踝整形外科医生与血管外科医生合作运营的指定诊所接受评估，由一名专业伤口护士和一名认证假肢矫形师（CPO）提供支持。我们设计了首诊算法，以识别需要内分泌学、传染病学、心脏病学或血管外科等其他专科进一步检查的患者。所有患者均接受了DFU手术清创。未应用负压伤口治疗（NPWT）。术后，在病房每天更换敷料，直到伤口被认为可行且清洁。对患者进行了两年的随访，并与2017年入住该机构的DFU历史队列患者进行了比较。
引入临床路径后，大截肢数量从65%（13/20）降至7.4%（2/27）（p < 0.001）。手术翻修的平均次数（5.5次对1.2次）和中位住院时间（46天对9天）均有统计学显著降低。每位患者的中位成本降低了76%（从53.8万欧元降至12.9万欧元，p < 0.001）。
DFU管理的临床路径导致大截肢数量减少和住院时间缩短。手术清创后停用NPWT对临床结果没有不利影响。新路径还降低了医疗成本。
