Assessing the Effectiveness of an Integrated Primary and Tertiary Multidisciplinary Diabetic Foot Care Programme: A Historical Control Study

Background: Singapore stands among the countries with the highest rates of diabetes-related lower extremity amputation (LEA) globally. Effective management of diabetic foot ulcer (DFU) is crucial for preserving patients’ limb function and alleviating the healthcare burden. Existing literature has demonstrated the promising impact of DFU care provided by multidisciplinary team (MDT) on lower limb salvage. Since 2020, the Diabetic Foot in Primary and Tertiary (DEFINITE) Care programme, a comprehensive DFU care initiative integrating primary and tertiary care has been implemented. The programme is spearheaded by a MDT comprising more than 50 healthcare professionals, anchored by a core team of primary care physicians, endocrinologists/diabetologists, podiatrists, vascular surgeons, wound care nurses, and diabetic foot coordinators. This programme aims to provide integrated and coordinated to patients with DFU, with the goal of preventing DFU-related amputations and reducing the economic and disease burden associated with DFU within one of Singapore’s three regional health systems. This study seeks to evaluate the effectiveness of the DEFINITE Care programme in preventing minor and major LEA, increasing LEA-free survival, and optimizing inpatient healthcare utilization. Methods: This historical control study compared the outcomes between DFU patients enrolled in the DEFINITE programme (n=2,798) from June 2020 to June 2021 and a historical control group (n=5,462) comprising DFU patients treated in the same regional health system between June 2016 and December 2017. One-to-one propensity score matching (PSM) with replacement was employed to ensure comparability in demographics and clinical factors between the DEFINITE and historical control cohorts. The study estimated the treatment effects of the DEFINITE programme on minor and major LEAs, mortality, LEA-free survival, inpatient admissions, and average length of stay (ALOS) in the subsequent 12 months. Results: Patients in the DEFINITE cohort were, on average, younger (mean age: 65.7 vs. 71.6 years), comprised more males (61.4% vs. 53.8%), and included a higher proportion of non-Chinese individuals(44.2% vs. 34.6%) compared to the patients in the historical control cohort. Following satisfactory 1:1 PSM, the DEFINITE cohort exhibited a 9.3% lower mortality (95% CI] -11.7 – -6.8%), a 5% higher LEA-free survival rate (95% CI: 2.4 – 7.7%), 1.0 fewer inpatient admissions (95% CI: -1.1 - -0.9), and a 5.5-day shorter ALOS (95% CI: -7.4 - -3.6). However, a 5.4% higher minor LEA rate (95% CI: 3.8 – 7.0%) was observed during the first 12 months of enrolment compared to the matched historical control cohort (all p-values<0.001). No significant difference in major LEA rate was observed between the two cohorts. Conclusion: The study findings suggest potential benefits of the integrated and multidisciplinary DFU care programme, including an increased LEA-free survival rate and reduced inpatient care utilisation and mortality. However, results should be interpreted cautiously due to limitations in study design and data availability. The programme will be further expanded to benefit more patients with DFU or with risk of DFU.