A scoping review protocol to identify strategies to implement evidence-based diabetic foot disease guidelines for healthcare professionals in primary care

Introduction

The prevalence of diabetes mellitus and its’ associated complications is increasing globally^1,2. All people with diabetes mellitus are at risk of developing diabetic foot disease (DFD), with a lifetime incidence of between 19 and 34%³. The presence of one or more risk factors of DFD can put the person at risk of ulceration and possible amputation⁴. The key risk factors are loss of protective sensation, peripheral arterial disease, foot deformity, a history of foot ulceration and previous lower extremity amputation⁵. Diabetic foot ulcers (DFU) have a significant impact on morbidity, mortality and quality of life^6–10. The five year mortality rates following major amputation have been found to be comparable to cancer mortality rates, being as high as 56%¹¹. It has also been established that there is a significant impact on the quality of life of people living with diabetes mellitus who suffer from DFD, with increased risk of foot ulceration and amputation⁹. DFD has been recognized as a significant financial burden to health care systems^10,12. It is the treatment associated with the complication of DFD that constitutes the majority of the spending⁹. An Australian study examined the proportion of funding spent in the health system on the four major complications of diabetes mellitus including; cardiovascular disease, renal disease, ocular disease and DFD¹³. They found that DFD had the second highest burden on health services, but had the least funding associated with this complication¹³.

Research has highlighted that when resources are invested into the prevention and treatment of DFD it can have significant benefits for people at risk^14–20. The International Working Group on the Diabetic Foot (IWGDF), has identified screening and early identification of the “at risk” foot as being an important part of any health service strategy to prevent complications³. To successfully manage DFD, a multi-disciplinary approach is advocated internationally^21–25. The provision of screening and care for the “at risk” foot and treatment of active DFD is more efficient when provided in primary care with an integrated pathway for referral to tertiary services^21,26,27. In a study examining the priorities of primary care professionals when assessing people with diabetes mellitus, it was reported that foot care was a low priority²⁸. They found that unless the person presented with either a break in the skin of their foot or complained of tingling in the foot there was a low chance of foot care being a priority²⁸. Some of the barriers identified to providing foot care for people with diabetes mellitus by health professionals include lack of education and training for health professionals, lack of guidelines and referral pathways, lack of access to appropriate professionals and lack of time in the clinical areas^29–33. While there is a dearth of information on enablers to implementing evidence-based practice for DFD, education and training, foot specialist teams and standardized assessment tools being available to health professionals were identified to improve diabetic foot care^29,34.

The Joanna Briggs Institute (JBI) suggest that evidence implementation is a purposeful and enabling set of activities designed to engage key stakeholders with research evidence to inform decision-making and generate sustained improvement in the quality of healthcare delivery³⁵. Implementation of evidence-based practice can enhance healthcare safety and improve patient outcomes. However, implementing evidence-based practice can be challenging, particularly in the primary healthcare setting, with very little consensus in the literature as to the best way to proceed^36–38. This scoping review aims to map the evidence on strategies that have been used to support primary care health professionals in the implementation of evidence-based guidelines as it relates to DFD^39,40.

Protocol

Discussion

This scoping review will provide an overview of the evidence available to healthcare professionals in primary care to allow strategies to be devised for the implementation of the evidence-based guidance in relation to DFD. Any barriers or facilitators identified will also be presented to allow practitioners and organizations learn from these. The ability of practitioners and organizations to be able to anticipate barriers and facilitators prior to implementation of a strategy can lead to a greater uptake in the intervention by the population it is aimed at. This scoping review will provide the research base to allow all health care services in primary care diabetic foot care to be aware of the barriers and facilitators that they may encounter while devising an implementation strategy for diabetic foot care.

Promoting the foot care of people with diabetes in the primary care setting can make a significant impact on overall outcomes for the patient and their carers. There is also significant benefit to the health service in terms of cost and efficient use of resources. Improving the service for prevention and treatment of DFD in primary care will have a positive effect on the tertiary services, in terms of decreasing bed days and amputations. Evaluating the different elements of the implementation of a strategy is important. This paper will provide an overview of how different strategies are used to implement evidence-based guidelines. It will also identify how these strategies are evaluated in primary care and the outcome measure used internationally. The transition of evidence-based guidelines into practice can be difficult to assess, the evidence from this scoping review will provide a synthesis of outcomes that can be used by health service providers to assess their implementation strategies for diabetic foot care. This will be valuable for health service providers to ensure that resources put into diabetic foot care can be assessed in terms of outcomes for people with diabetes. This study will gather evidence that can assist health systems to transfer evidence-based practice for patients with diabetes at risk of DFD to primary health care professionals.