Diabetic Foot in Qatar: A Primary Care Perspective
Authors: Mohamed Hashim 
Published: July 2019

Diabetic Foot in Qatar

A primary care Perspective Introduction Diabetes represents a major public health burden in developing countries, especially the Arabian Gulf region, which is going through a rapid socioeconomic transition. Diabetic foot is becoming an escalating problem in Qatar due to the high prevalence of diabetes which is around 16%. Currently, diabetic footcare is disintegrated within the health system resulting in increased medical costs, reduced quality of life, decreased productivity, increased hospitalization and unnecessary amputations. Primary care intervention in this regard is paramount in order to tilt the balance in favoring patient-centered integrated diabetic foot care strategies. As a result we have conducted a retrospective cohort study assessing the feasibility and efficacy of such an intervention. The morbidity and mortality associated with diabetic foot lesions remain extremely high, and management needs to be optimized to ensure the best outcome. Although it is accepted that the institution of rapid access to expert multidisciplinary service is an essential component of care, there are remarkably few data to justify particular approaches to the treatment of different types of foot ulcers. Evidence of the efficacy of specific interventions depends on the completion of robust clinical trials, whereas evidence of the overall effectiveness of a management strategy requires some form of systematic audit, using methods that allow comparison between different units. If such a comparative audit is controlled for case mix, it would provide an invaluable benchmark against which other units may compare their performance. For this to be done, it is necessary to establish clinically meaningful outcome measures. Outcome measures are of two broad types: those that relate primarily to the ulcer and those that relate more to the patient. Ulcer-related outcome measures are commonly used in clinical trials and are appropriate for studies designed to assess either the efficacy or the effectiveness of interventions directed to improving wound healing. Such ulcer-related outcome measures include healing, a change in ulcer area, and resolution of the ulcer by amputation. However, ulcer-related measures are not necessarily appropriate markers of the overall quality of clinical care and may not be the best measures of the effectiveness of practice in different specialist units. Thus, an index ulcer may heal, whereas the patient remains incapacitated by the presence of another (persistent or newly occurring) ulcer, by the effects of the treatment (e.g., amputation) of the original problem, or by comorbidity. It is for these reasons that patient-centered measures must also be considered, and these include survival, all amputations, ulcer-free status, duration of ulcer-free survival, well-being, and disability. Implicit in the choice of any outcome measure of the effectiveness of care, however, is the need for the process to be simple enough to be undertaken on a routine basis in all presenting patients and atone or more fixed intervals after presentation. We have therefore sought to determine the outcome of management in a consecutive series of patients presenting to a single primary health care center over a 5-year period.

Background

Chronic Diabetic foot ulcers (CDFU) is associated with increased morbidity, mortality and represents a huge burden especially in developing countries where diabetes has reached epidemic proportions.

Objective

To assess the efficacy, safety and acceptability of natural honey in the management of (CDFU) at primary care level & identify criteria predictive of failure.

Methods

We conducted a 5-year retrospective cohort study with prospective long-term follow-up of all diabetic patients with (CDFU) presented to Umgwalinah Primary Health Care Centre diabetic foot clinic, Doha, Qatar. The average follow-up after discharge was 1 year. Failure of Natural honey based treatment was the main outcome measure. Independent predictor variables were selected by logistic regression analysis.

Results

A total of 126 patients with diabetes were assessed and treated for various foot lesions; including neuropathic, neuro ischemic ulcers, charcot foot, second degree burns and trauma. Five patients (4%) of a total of 126 underwent immediate amputation. Natural honey treatment was successful for 91 (92.86%) of the 98 neuropathic ulcers, 3 (30%) of 10 neuro ischemic ulcer, 2 (66%) of 3 Charcot foot ulceration, 4 (100%) of 4 patients with second degree burns & 6 (100%) of 6 traumatic foot ulceration or (P < .001, chi2 for trend). Independent factors predictive of failure to heal were presence of osteomyelitis (odds ratio [OR] = 1.6, 95% confidence interval [CI], 1.0–1.3), increased Hemoglobin A1C level (OR = 1.002; 95% CI, 1.2–1.3), severe peripheral vascular disease (OR = 1.0, 95% CI, 1.0–1.03), prior hospitalization for (CDFU) (OR = 1.4; 95% CI, 1.2–1.6) & gangrenous lesion (OR = 1.7; 95% CI, 1.3–2.1). During the study period no side effects were reported and there was a high level of satisfaction by both patients and healthcare workers alike.

Conclusions

Primary care based management of (CDFU) using natural honey is efficacious, safe and acceptable. We propose a multi-disciplinary approach utilizing primary care diabetic foot coordinator (PCDFC). The (PC DFC) will work with patients and their caretakers in order to: Coordinate the care pathways, reduce waiting time, increase patient satisfaction, stratify the patients appropriately into: Low, Intermediate and High risk and finally, reduce cost and improve outcome. The (PCDFC) will propose and disseminate clinical guidelines for managing diabetic foot, offer continuous medical and nursing programs, including conferences and symposiums, propose hand on clinical courses for healthcare professionals interested in diabetic foot care and carry out prospective studies regarding the efficacy, process and outcomes of integrated diabetic foot care in Qatar. The objectives of the (PCDFC) are: Propose a multi-disciplinary integrated diabetic foot care program Introduce the concept of patient-centered diabetic foot care model Reduce the rate of diabetes related amputations in Qatar Reduce the cost and suffering of patients Empower primary care physicians in taking an active role in preventing diabetic foot complications.