A national foot screening indicator: an opportunity to address diabetes-related foot disease and improve equity in Aotearoa New Zealand
Michele Garrett
1 2 * , Rinki Murphy 1 2 3 , Timothy Kenealy 4
1
2
3
4
Diabetes-related foot disease (DFD) includes neuropathy, ulceration, infection, gangrene and amputations. It increases the risk of hospitalisation, cardiovascular (CVD) events and premature death.1,2 In 2023, about 323,700 people in Aotearoa New Zealand (NZ) were living with diabetes with the number forecast to rise by up to 90% by 2045.3 Of these perhaps 13% were at high risk of developing or having a diabetic foot ulcer (DFU), and a further 22% were at moderate risk, based on the Scottish Intercollegiate Guidelines Network (SIGN) foot risk catergories.4 More than 700 diabetes-related amputations occur annually in NZ with about one-third being major (above the ankle).5 Māori are two-thirds more likely to undergo a major amputation than non-Māori.6 The NZ estimated major amputation rate of 6.4 per 100,000 total population is double the rate for United Kingdom and approximately 1.7 times the rate for Australia.7
The causal pathway from diabetes-related microvascular and macrovascular complications to DFD overlaps with well-established CVD risks.8,9 Annual foot screening, integrated with CVD risk assessment, is key to identifying risk factors and foot abnormalities.10 Foot screening takes about 1 minute, with checks for sensory, vascular, musculoskeletal, and dermatological changes that enable foot risk categorisation.11 For those at increased risk the results can prompt treatment intensification and referral to preventive services.A Annual foot screening is an established component of diabetes care in NZ. We advocate for consistently capturing foot screening results and strategically using the data to enhance preventative foot care.
Annual foot screening with standardised risk categorisation, data definitions and reporting could serve as an indicator to monitor DFD, helping health care providers, service planners, policymakers, and researchers identify individuals at risk, understand DFD prevalence, commission and monitor relevant foot services, and manage equitable outcomes.12,13 At a patient level, it permits tracking of changes in foot health, enabling timely implementation of appropriate preventative care.10 In the Northern Region of NZ two performance indicators have been introduced aiming to monitor the effectiveness of preventative DFD management. One monitors foot screening coverage, with a 90% target. The other reports the proportion of those people screened who have a recorded foot risk category (low, moderate, high, in-remission or active DFD) with a 100% target.
While the value of standalone foot screening programmes can be debated14 that is not what we are promoting.15–17 Integrating annual foot screening into existing diabetes care pathways is recognised by international guidelines as the foundation for systematic multidisciplinary DFD care.18,19 Prompt referral and early intervention alongside good risk factor management can prevent DFD-caused hospitalisations, amputations, and premature deaths, while preventative foot care services are associated with a decreased incidence of DFU and improved survival.8,15,20,21 Conversely, delayed referral to specialist foot services is associated with increased DFU severity and related infections, more hospitalisations with extended stays, more revascularisations, and increased amputations.22
In NZ, the Quality Standards for Diabetes Care 2020 expect people with diabetes to have annual foot screening with documented results.23 Health care management and coordination of long-term condition care predominately sits with general practice including foot screening and associated referrals.24 However, there have been challenges in achieving consistent annual foot screening,25 with wide variation reported in annual foot screening rates (33% to 80%).26–29
Historically, several initiatives have influenced foot screening practices, including the establishment of the National Diabetes Working Group ‘Get Checked’ programme which ran from 2000 until 2012.30 Although this programme included foot screening, there was no standardised risk stratification tool or algorithm and foot screening results were not reported in the minimum dataset. Establishing the Virtual Diabetes Register (VDR) in 2007 was important for national health service planning; however, foot screening results are not available in the VDR dataset.31
Following calls for the implementation of screening and triage of ‘high-risk’ feet in primary care patient management systems32 alongside funded podiatry services and a standardised national foot risk categorisation tool,33 the National Diabetes Foot Screening and Risk Stratification Tool (NDFSRST) was developed in conjunction with the New Zealand Society for the Study of Diabetes (NZSSD) and refined in consultation with stakeholders.34,35 The NDFSRST was adapted from the SIGN foot risk categories to include Māori ethnicity. Most people will be low risk with foot care recommendations not differing from standard care. However, as foot risk increases risk factor management should intensify and additional foot checks are recommended.
The Northern Region established a Diabetes Foot Advisory Group in 2013 and a podiatry leadership role to address foot screening and foot services inconsistencies.36 Importantly, primary care electronic foot screening forms were aligned to the NDFSRST and standardised data definitions for foot screening terms and risk categorisation implemented for reporting purposes. Collectively stakeholders are establishing a suite of DFD quality indicators, the first being foot screening introduced in 2024. These are linked to patient and practice level data with results reported quarterly as part of the Northern Region Diabetes and CVD clinical indicators. Overall, foot screening coverage is currently at 42% of the enrolled adult population, with 12 practices of 353 reaching the 90% target.
Early interventions to prevent foot ulceration and address CVD risk factors are crucial to reducing excess mortality37,38 with foot screening providing an opportunity to further optimise management of both. Developing a foot screening indicator linked to primary care data, joining the suite of diabetes and CVD indicators, is a promising step towards understanding the connections between DFD prevention initiatives, and the impact on hospitalisations, amputations and premature mortality in NZ. As foot screening tools are refined and screening intervals potentially increasing, understanding the extent of DFD in NZ would provide the basis to revise our foot screening approaches.39,40 The Northern Region initiative achieved consensus on foot screening reporting, providing a roadmap for a nationwide approach.
Data availability
Data sharing is not applicable as no new data were generated or analysed during this study.
References
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