A national foot screening indicator: an opportunity to address diabetes-related foot disease and improve equity in Aotearoa New Zealand

Diabetes-related foot disease (DFD) includes neuropathy, ulceration, infection, gangrene and amputations.It increases the risk of hospitalisation, cardiovascular (CVD) events and premature death. 1,2In 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. 4More than 700 diabetes-related amputations occur annually in NZ with about one-third being major (above the ankle). 5Mori are two-thirds more likely to undergo a major amputation than non-Mori. 6The 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. 7he causal pathway from diabetes-related microvascular and macrovascular complications to DFD overlaps with well-established CVD risks. 8,9Annual foot screening, integrated with CVD risk assessment, is key to identifying risk factors and foot abnormalities. 10Foot screening takes about 1 minute, with checks for sensory, vascular, musculoskeletal, and dermatological changes that enable foot risk categorisation. 11For 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. 12,13At a patient level, it permits tracking of changes in foot health, enabling timely implementation of appropriate preventative care. 10In 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 debated 14 that is not what we are promoting. [15][16]6][17] Integrating annual foot screening into existing diabetes care pathways is recognised by international guidelines as the foundation for systematic multidisciplinary DFD care. 18,19Prompt 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. 8,15,20,21Conversely, 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. 22n NZ, the Quality Standards for Diabetes Care 2020 expect people with diabetes to have annual foot screening with documented results. 23Health care management and