Personalised Assistive Devices Approach for Diabetic Foot Ulcer Prevention

Study Overview
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Brief Summary
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Preventing foot ulcers in people with diabetes can reduce costs and increase quality of life. Despite availability of various interventions to prevent foot ulcers, recurrence rates remain high. We hypothesise that a multimodal approach incorporating a variety of orthotic interventions that matches an individual person's need can reduce ulcer recurrence with beneficial cost-effectiveness and cost-utility.

Official Title
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Cost-utility of an Integrated Personalised Assistive Devices Approach to Reduce Foot Ulcer Recurrence in Diabetes (DIASSIST): a Multicentre Randomised Controlled Trial

Conditions
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Diabetic Foot Ulcer

Intervention / Treatment
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* Device: Custom-made shoes: pressure-optimized
* Device: Custom-made indoor shoes: pressure optimized
* Device: Foot temperature monitoring
* Behavioral: Education


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Diabetes mellitus type 1 or 2 Age 18 years or above Loss of protective sensation based on the presence of peripheral neuropathy A healed plantar foot ulcer or foot amputation in the preceding 4 years until two weeks before study inclusion In possession of custom-made orthopaedic shoes, defined as Orthopaedic shoes type A or Orthopaedic shoes type B , or Orthopaedic Provision in Regular Footwear (OVAC), according to the Dutch healthcare system Ability to provide informed consent Exclusion Criteria: Foot ulcer or open amputation site(s) Active Charcot's neuroarthropathy Foot infection, based on criteria of the PEDIS classification Amputation proximal to the metatarsal bones in both feet Healed ulcer on the apex of digitus 2-5 as the only ulcer location in the past 4 years, as surgical intervention (flexor tenotomy) is a more likely and guideline-recommended treatment for such patients, rather than the multimodal care under investigation Severe illness that would make 12-months survival unlikely, based on the clinical judgment by the physician Concomitant severe physical or mental conditions that limit the ability to follow instructions for the study, based on clinical judgment

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Multimodal care<br>Multimodal personalised treatment | Device: Custom-made shoes: pressure-optimized<br>* Pressure-optimized custom-made shoes: evaluated and optimized using in-shoe pressure analysis, and re-evaluated after 6 months.<br>Device: Custom-made indoor shoes: pressure optimized<br>* Pressure-optimized custom-made indoor shoes: evaluated and optimized using in-shoe pressure analysis, and re-evaluated after 6 months. Specifically designed for indoor use.<br>Device: Foot temperature monitoring<br>* Personalised at-home daily foot temperature monitoring at high-risk regions.<br>Behavioral: Education<br>* Personalised patient education consisting of quantitative feedback on in-shoe pressures, temperature measurements and footwear use and, in addition, motivational interviewing where indicated and needed to improve device use.<br>|
| No Intervention: Usual care<br>Usual care as offered to high-risk patients as offered in the Netherlands | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cost-utility (as the primary economic outcome) | defined as the ratio between costs related to foot care and quality-adjusted life years, based on the health utilities associated with the scoring profiles on the EQ-5D-5L with Dutch reference scores | 12 months (full study period) | 
| Adherence to wearing custom-made footwear (as the primary patient-related outcome) | defined as the percentage of steps taken in prescribed footwear, calculated by combining physical activity and wearing time measurements | 12 months (full study period) | 
| Foot ulcer recurrence during the 12-months follow-up (as the primary clinical outcome) | defined as a break of the skin of the foot that involves as a minimum the epidermis and part of the dermis, in a person who has a history of foot ulceration, irrespective of location and time since the previous foot ulcer, with the first ulcer in the study period recorded as primary outcome and percentage participants with ulcer recurrence on group level as primary outcome | 12 months (full study period) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Cost-effectiveness | defined as the ratio between costs related to foot care and foot ulcer recurrence on any location of the foot | 12 months (full study period) | 
| Plantar foot ulcer recurrence | following the definition of foot ulcer recurrence (outcome 3), but then limited to the plantar side of the foot | 12 months (full study period) | 
| Foot ulcer recurrence at three predefined high-risk locations | following the definition of foot ulcer recurrence (outcome 3), but then limited to a maximum 3 high risk locations per participant, specified at the start of the study, based on barefoot pressures, ulcer history, pre-ulcerative lesions or signs of abundant callus | 12 months (full study period) | 
| Costs related to foot care (from a societal and medical perspective) | Costs will be calculated for each participant as the product sum of resource volume data and their respective unit costs. Resource volume data will be obtained from the completed study specific versions of the institute for Medical Technology Assessment (iMTA) Medical Consumption Questionnaire (iMCQ) and iMTA Productivity Cost Questionnaire (iPCQ), as these contain the volume data on healthcare resource utilization, out-of-pocket expenses and loss of productivity related to foot care. Foot care includes both care for ulcer prevention (e.g. podiatry appointments, rehabilitation physician consultations) and for ulcer treatment (e.g. multidisciplinary treatment, hospitalization, surgery). Reference prices for unit costs will be based on the most recent Dutch manual for costing in healthcare research available at the time of analysis. All costs will be summed during the entire study period. | 12 months (full study period) | 
| Quality-adjusted life years | based on the health utilities associated with the scoring profiles on the EQ-5D-5L with Dutch reference scores. This will be monitored during the entire study period. | 12 months (full study period) | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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diabetes, foot ulcer, prevention, cost-utility