Ahp

Art, Music and Drama Therapists

Dietitians

Physiotherapists

Orthoptists

Prosthetists and Orthotists

Occupational Therapists

Podiatrists

Paramedics

Radiographers

Speech and Language Therapists

Allied Health Professions

Diabetes toolkit

Maximising allied health professionals contribution to the delivery of high quality and cost effective patient care.

A guiDe fOR heALThcARe cOMMiSSiOneRS

preventionassessment

treatmentrehabilitation

re-ablementlong-term gain

how AhPs improve patient care and save the nhS money > Click to enter toolkit

This toolkit is one of a series of toolkits developed by NHS London on behalf of the Strategic AHP Leads Group (SAHPLE)

Home Diabetes toolkit 2

Opening narrative

In line with NHS Diabetes stated aim Allied Health Professions (AHPs) are proactively supporting initiatives and service redesign which is evidenced based and addresses the QIPP (Quality, Innovation, Productivity and Prevention) challenge.

The Strategic Health Authority Allied Health Profession Leads (SAHPLE) commissioned a project to identify clinical pathways where AHPs make a significant difference in the clinical outcomes for a group of vulnerable patients including those with diabetes.

AHPs include a number of professions who work both in uniprofessional teams and often show their strengths in diabetes care as part of a Multidisciplinary Team (MDT), for example as part of a coordinated foot protection team as highlighted in the redesign in Salford:

See the success stories on the NHS Diabetes website >

Key outcomes

Amputation rates have fallen by two thirds.

Number of foot ulcers has reduced by 300 over four years.

Estimated savings of over 1m over four years.

This success story is one of a number highlighted by NHS Diabetes.

The key AHP professions in diabetes include:

Dietitians Dietetic treatment aims to optimise glycaemic control, improve HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce hypertension.

Occupational therapists Optimise function and independent living. Provide functional and vocational advice. Facilitate return to employment and leisure activities, and maintain independence improving quality of life.

Orthoptists Provide assessment of vision, visual fields and eye movements. Diagnosis of low vision or visual field loss will aid prevention of falls.

Orthotists Provide orthoses to complement podiatry treatment to enable mobilisation. Orthoses include shoes to accommodate dressings, insoles to reduce plantar pressures and offloading devices to aid wound healing.

Physiotherapists Provide specialist assessment, treatment and advice on improving levels of physical activity, prescription and monitoring of individualised exercise programmes. This helps optimise blood glucose levels in those with diabetes and can help prevent/delay the onset of type 2 diabetes. Physiotherapists also have a role to play in the assessment and rehabilitation of complications and comorbidities associated with diabetes.

Podiatrists By detecting and managing the long-term complications of the diabetic foot the podiatrist reduces the risk of disability and foot complications which can have costly and devastating consequences for people with diabetes.

Radiographers Provide expert imaging and interpretation to identify disease progression / complications (such as arthropathy/ osteomyelitis/renal/ visual complications).

Paramedics Patients often present via the 999 system with acute or emergency problems which involve peripheral neurovascular issues either directly or indirectly. Paramedics are able to recognise such complaints and/or co morbidities early on and refer to the most appropriate pathway, either emergency or through alternative specialist pathways.

Introduction >

For further information please contact:

Lesley Johnson SHA Allied Health Professions Lead NHS London Southside 105 Victoria Street London SW1E 6QT

[email protected]

This toolkit has been endorsed by:

prevention>assessment>

treatment>rehabilitation>

re-ablement>long-term gain>


introduction

What does this toolkit do for you?

This toolkit has been developed by a range of clinicians working in diabetes care. The information has been provided by a national collaboration of clinicians in conjunction with their professional bodies and is based on available research evidence.

The work has been reviewed by a range of specialists including Dr. Rowan Hillson, the National Clinical Lead for Diabetes. The toolkit has been endorsed by the Professional Bodies.

This toolkit provides information on the following:

Which interventions most positively benefit patient care

What range of interventions over time will reap the most benefits during illness and lead to independence

How do the interventions match to the Outcomes Framework

Which interventions are able to save money to the system

How is the functional ability of patients enabled by using Allied Health Professionals (AHPs).

Audience

This information is aimed at those involved in commissioning or developing diabetes care.

The toolkit will provide an interactive method of ensuring that patient care is meeting quality standards and providing essential elements of the QIPP agenda

If you are looking to re-design or provide diabetes services this information will assist you meet the needs of your local population:

Contents

1. List of interventions by Allied Health Profession

2. A pathway graphic highlighting where each profession significantly contributes to value-for-money high quality care

3. QIPP (Quality, Innovation, Productivity and Prevention) key facts

4. Matching interventions to the Outcomes Framework

5. Research evidence

6. Case studies

7. General information

We hope you find it valuable. Art, Music and Drama Therapists Dietitians

Physiotherapists

Orthoptists

Prosthetists and Orthotists

Occupational Therapists

Podiatrists

Paramedics

Radiographers Speech and Language Therapists

Rehabilitation Re-ablement Long-term gainPrevention Assessment Treatment

patient journey

Key AHP InTeRvenTIOn POInTs In THe DIAbeTes PATHWAy

Click on one of the intervention stages below to find out more about AHPs input

Presenting condition Health risk Referral to Risk mitigated Outcome Framework domain

(download)

Cost saved

Obesity Development of Type 2 Diabetes

Dietitians and physiotherapists provide expert support and guidance on lifestyle change to reduce weight and improve health. Occupational therapists also provide lifestyle redesign for obesity.

Prevention of diabetes 1,2 Diabetes UK: obese people are up to 80 times more likely to develop Type 2 diabetes than those who maintain a healthy weight Diabetes UK website >

Patient initially diagnosed with diabetes

Dietary, physical activity and lifestyle information for glycaemia control

Dietitians and physiotherapists aim to optimise glycaemic control, improve HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce hypertension

Escalation to insulin dependency and deterioration in diabetic control (NICE guidelines)

1,2 DAFne study: Diabetes education and self management for ongoing and newly diagnosed (DESMOND) NHS Diabetes website >

Infection and ulceration of feet potentially leading to amputation

Podiatrists and physiotherapists are involved if initial foot assessment reveals evidence of neuropathy, absent pulses or foot deformity

Foot ulceration and potential amputation

2,5 Of the 70 amputations performed per week, 80% potentially preventable Right Care report >

Peripheral Vascular Disease (PVD) Ulceration, Suspected Foot Emergency, Charcot Foot

Infection and ulceration of feet potentially leading to amputation

Podiatrists, radiographers, physiotherapists and orthotists who form part of the Foot Protection Team

Potential amputation, major foot deformity and long tem morbidity

2,5 Comprehensive multi-disciplinary foot care programmes have been shown to increase quality of care and reduce amputation rates by 3686% View details >

For every 1 spent in Orthotics the NHS saves 4 Download Orthotic service in the UK report >

View Diabetes Footcare Activity Profile >

Visual deficits Diabetic eye disease is the most common form of visual loss in the working age population

Orthoptists provide specialist assessment of vision, visual fields and eye movements

Low vision assessment and management (visual rehabilitation) can help the patient remain independent and in some cases remain in the workforce

2,5 Reduce the risk of sight loss amongst people with diabetes through prompt identification and effective treatment NHS Diabetes website >

Risk of falls In the UK each year there are estimated 233,000 fractures primarily due to osteoporosis combined with a fall (fragility fracture)

Orthoptists, occupational therapists, physiotherapists, podiatrists and paramedics provide coordinated falls prevention service. Radiographers undertake DXA scans and monitor bone health.

Visual impairment identified: Home assessment and provision of equipment and techniques to avoid risk of falling

3,5 Falls cause significant morbidity and mortality particularly in older people, and also have marked psychological effects on the individual

Right Care report> Visual loss and falls: a review >


commissioning principles: which AhPs do you need?

Click this link to find out how AHPs save the nHs money, and the evidence and case studies that support claims about the benefit of their interventions.

Commissioners may not presently know how to maximise the use of a range of AHPs to add to patient benefit and the QIPP agenda. This toolkit illustrates the logic and clinical argument around onward referral to multi-disciplinary AHP teams and outlines appropriate use of AHP professions so that patient quality is enhanced and independence wherever possible is gained.

AHPs are not optional but integral to the necessary treatment of patients. There are clinical and financial risks in patients not receiving AHP input.This toolkit aims to show what the appropriate response is to a presenting condition and how a range of AHPs work together to reach the outcomes aspired to in the National Outcomes Framework.


Presenting condition Health risk Referral to Risk mitigated Outcome Framework domain

(download)

Cost saved

Patient asking for strategies to manage long term condition when severe

Deterioration of diabetes control with exacerbation of co-morbidities and loss of independence

Occupational therapists and physiotherapists are able to offer expert assessment of home environment and strategies to achieve rehabilitation and reablement goals

Maintenance of independence and avoidance of depression

2,4 The ultimate goals of patient education are to improve to control of vascular risk factors, and to aid the management of diabetes-associated complications, if and when they develop, to improve quality of life.

NHS Diabetes website >

Amputated foot/leg Mobility and activities of daily life impacted by limb loss. Deterioration of co-morbidities

Prosthetists, physiotherapists, occupational therapists and podiatrists provide a coordinated team alongside medical and nursing colleagues to optimise patient rehabilitation

Injury to contralateral limb and prevention of falls, maintain independence and return to employment. Enhance social inclusion.

1,2,3 Fall in the number of people who were undergoing repeat major amputations caused by diabetes

NHS Diabetes website >

For every 1 spent in Orthotics the NHS saves 4

BACPAR website >

commissioning principles: page 2 of 2

Click on one of the professions above to find out how AHPs save the nHs money, and the evidence and case studies that support claims about the benefit of their interventions.

Home

Benefits of AhP input: prevention stage (1 of 2)

AHPs contributions at the prevention stage.

Dietitians provide individualised diet therapy for those with impaired glucose regulation and metabolic syndrome to reduce risk of progression to diabetes.

Dietitians also provide support and guidance on lifestyle changes to help patients reduce weight and improve their health thus reducing risk of developing diabetes.

Modifying diet and physical activity prevented or delayed type 2 diabetes onset in high risk ethnically diverse population with IGT.

Dietitians play a crucial role in leading the coordination of activities at all levels including individual and family counselling, local initiatives in schools and work places and government policies to support and facilitate healthier choices.

In gestational diabetes dietetic led advice on diet and lifestyle is a high priority following pregnancy to prevent progression to diabetes.

Thomas B. Bishop J (2007) Manual of dietetic Practice Section 4.

Orthotists

Specialist diabetic orthotists provide accommodating footwear and insoles to prevent ulcers and amputation. They also offer regular reviews, where footcare advice is provided, and facilitate re-referral to the high risk foot clinic if necessary.

The prevention and management of foot problems in type 2 diabetes, NICE guideline, page 18. NICE website >

Studies show that high risk patients without prescribed footwear will develop ulcers.

Boulton AJ, Clinical Trials report: Therapeutic footwear in diabetes, CURRENT DIABETES REPORTS. Volume 2, Number 6, 475-476

Key fact In terms of interventions, the cost of targeting high risk groups at population level to prevent or delay raised glucose levels is likely to be lower than the cost of one-to-one interventions to stop people with raised glucose levels progressing to type 2 diabetes.

NICE Guideline Costing statement: Preventing type 2 diabetes: population and community interventions May 2011.

65kThe cost on the NHS to heal one ulcer is 3k to 7.5k. Should this progress to amputation the cost is estimated to escalate to 65k. This is much more than the cost of preventative orthoses.

Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics Consortium: pg 12,13. See website >

International Diabetes Federation, The diabetic foot: amputations are preventable, 2005. See website >

Podiatrists

Podiatrists provide structured diabetes education and deal with all aspects of foot health and lifestyle modifications, such as smoking cessation, footwear education and falls prevention. They also provide foot screening an essential part of the prevention programme for patients with diabetes and foot health advice to all other health professionals and carers

A guide to the benefits of podiatry to patient care. The Society of Chiropodists and Podiatrists. 2010 See report >

The prevention and management of foot problems in type 2 diabetes, NICE guideline, page 18.NICE website >

navigate to:

Dietitians

Diabetes toolkit 6

Prevention >

Assessment/diagnosis >

Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:

Diabetes literature review and analysis

Appendix 1: Improving outcomes, the economic arguments and case studies

References

Home

Benefits of AhP input: prevention stage (2 of 2)

Dietitians

Dietitians provide support and guidance on lifestyle changes to help patients reduce weight and improve their health thus reducing risk of developing diabetes.

Modifying diet and physical activity prevented or delayed type 2 diabetes onset in high risk ethnically diverse population with IGT.

The Diabetes Prevention Programme Research Group (2000) The Diabetes Prevention Programme (DPP): description of the lifestyle intervention. Diabetes Care 25: 2165-2171

The Diabetes Prevention Programme Research Group (2000) Reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin. New Eng J Med 346: 393-403

Wylie-Rosett, J. and Delahanty, L. (2002) an integral role for the dietitian: implications of the diabetes prevention program J. Am. Diet Assoc 102: 1065-1068

Key fact Diabetes UK says obese people are up to 80 times more likely to develop Type 2 diabetes than those who maintain a healthy weight.

AHPs contribution at the prevention stage. navigate to:

Diabetes toolkit 7

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

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References

Physiotherapists

Physiotherapists promote the health and well being of individuals and the general public emphasising the importance of physical activity and exercise. The benefits of exercise in the prevention of type 2 diabetes are well described. Physiotherapists help to optimise blood glucose control with exercise/physical activity to help with prevention/delay of type 2 diabetes.

Physiotherapists utilising their expertise in exercise therapy and physical activity, can provide advice, education and tailored exercise programmes for those individuals identified as being at risk of developing type 2 diabetes.

Deshpande AD et al (2008) Physical Activity and Diabetes: Opportunities for Prevention Through Policy Physical Therapy. 38(11):pp 1425-1435

Peter, R.et al (2011) Effects of Lifestyle Advice in People Newly Diagnosed with Type 2 Diabetes, Diabetes & Primary Care 13(5)pp: 276283.

Physical activity can help prevent and manage over 20 conditions and diseases, promote mental wellbeing and help people to manage their weight. Even relatively small increases in physical activity are associated with some protection against chronic disease and an improved quality of life.

Chief Medical Officers of England S, Wales, and Northern Ireland. Start Active, Stay Active: A report on physical activity from the four home countries Chief Medical Officers. London; 2011. See website >

Stamatakis E, Hamer M, Dunstan DW et al. (2011) Screen based entertainment time, all-cause mortality, and cardiovascular events. Population based study with ongoing mortality and hospital events follow-up. Journal American College Cardiology 57 pp: 292-299

As experts in functional ability and with a thorough knowledge of the pathophysiology of inactivity, physiotherapists have the skills and knowledge to improve physical activity levels across their client demographic.

Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing (2012) See website >

Key fact Physical activity has been shown to improve glycaemic control to levels comparable to pharmaceutical intervention.

Yates, T., Khunti, K., Davies, M., (2011) Physical Activity: Efficacy and Application in the Management of Type 2 Diabetes, Diabetes & Primary Care 13(5)pp: 311-316

Dietitians

Dietitians at Northumbria have implemented a pre insulin assessment process which is now part of the local stepped approach in the glycaemic management of people with type 2 diabetes. A local audit of this dietetically led intervention demonstrated that only half of those referred for insulin therapy actually required this after the pre insulin assessment. And for those who commenced insulin there were lower levels of weight gain than expected.

Oliver L.E (2009) Diabetes UK Annual Professional Conference Poster Presentations. Outcomes for people with Type 2 diabetes on maximum tolerated oral therapy who have pre-insulin assessment with a dietitian.

Home

Benefits of AhP input: assessment / diagnosis stage

AHPs contributions at the assessment/diagnosis stage.

Podiatrists

Podiatrists perform full assessments and evaluation of skin, soft tissue, musculoskeletal, vascular and neurological conditions in the foot and lower limb. They identify risk factors for lower limb amputation and develop care plans to prevent deterioration. National guidelines are in place for the management of the foot in diabetes.

N West Podiatry Services Guidelines for the Prevention and Management of foot problems for people with Diabetes 2008, FDUK See NHS Evidence website >

navigate to:

Orthoptists

Orthoptists provide assessment of vision, visual fields and eye movements. Diagnosis of low vision or visual field loss helps prevent falls while diagnosis of cranial nerve palsy, often linked to microvascular pathology, prompts diabetes detection.

See pubmed.gov website >

Radiographers

Radiographers provide expert imaging and interpretation to identify disease progression/complications (such as arthropathy/osteomyelitis/renal/ visual complications).

Management of Diabetes, Scottish Intercollegiate Guidelines Network - SIGN, 2010

Radiographic Advanced Practitioners can also refer patients with suspected Charcots foot for further imaging (such as CT) and orthopaedic opinion.

Paramedics

Paramedics are trained in all aspects of pre-hospital emergency care ranging from acute problems such as cardiac arrest to urgent problems such as minor illness and injury. On arrival at an accident they assess the patients condition, start any necessary treatment and refer as appropriate. They assess diabetes patients and can highlight frequent problems via a range of pathways.

Download report >

Orthotists

During reviews, specialist diabetic orthotists will be able to identify possible new episodes, such as Charcot changes, and re-refer to a specialist clinic or AHP.

In orthotic-only clinics patients are assessed and provided with orthoses to accommodate the changes to the foot shape, thereby preventing further ulcerations caused by excessive plantar pressures and ill fitting footwear.

Key fact For every 1 spent in orthotics the NHS saves 4.

Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics Consortium: pg 1 View document >

Diabetes toolkit 8

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

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References

Physiotherapists

Physiotherapy practitioners using their knowledge of the neurological, musculoskeletal and cardiovascular systems would be able to identify those patients who had developed or are at risk of developing diabetes and those complications associated with it. These could include lower limb peripheral neuropathy, contracted (frozen) shoulder, vascular changes in the lower limb and foot which can potentially lead to lower limb amputation and other cardiac complications such as myocardial infarction. Physiotherapists can also identify those patients who may be at a risk of falls.

Cade, W.T., (2008) Diabetes Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting, Physical Therapy. 38(11):pp 1322 1335

Hanchard N, Goodchild L, Thompson J, OBrien T, Richardson C, Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011) Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.5, standard physiotherapy. Endorsed by the Chartered Society of Physiotherapy. See website >

Key fact 80% of patients referred to musculoskeletal physiotherapy were found to have diabetes or associated risk factors. Identification of these issues during physiotherapy assessment ensures optimum treatment planning and management.

Kirkness, CS, Marcus RL, LaStayo PC, Asche CV, Fritz JM (2008). Diabetes and Associated Risk Factors in Patients Referred for Physical Therapy in a National Primary Care Electronic Medical Record Database. Physical Therapy. 2008; 88:1408-1416. See website >

Podiatrists

Once the level of risk for foot injury or ulceration has been determined by the podiatrist, appropriate management schemes including footwear recommendations and orthotic provision are provided by community podiatry or the specialist and surgical podiatrists.

How can we improve the care of the diabetic foot. Wounds UK 2008. Vol 4. No.4

Direct referral to diabetologists and/or vascular surgeons ensures quality of care in a timely manner which also aids efficient use of NHS resources.

Community podiatrists provide specialist clinical care for patients who are deemed at high risk of a foot/lower leg problem. These interventions help reduce hospital stay and ensure seamless care across primary and secondary care.

Podiatrists with advanced scope of practice within diabetes also provide supplementary prescribing services, e.g. antibiotics, pain relief and referral for diagnostic imaging and surgery.

Putting feet first Commissioning specialist services for the management and prevention of diabetic foot disease in hospital. Diabetes UK. June 2009 Download the report >

Orthotists

Within diabetic foot clinics orthotists provide orthoses to complement podiatry treatment and enable mobilisation. Orthoses include shoes to accommodate dressings, insoles to reduce plantar pressures and offloading devices to aid wound healing.

Munro, The orthotist, the diabetic foot and the future. The diabetic foot journal vol 13, no 3 2010

Orthoptists

Orthoptists treat double vision and visual field loss to enhance adaptation and navigation.

Dietitians

Dietetic treatment aims to optimise glycaemic control, improve HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce hypertension.

It also addressed associated dietary issues such as renal diets, coeliac diets, low residue diets and high kcal diets as required to achieve and maintain appropriate BMI.

The implementation of nutritional advice for people with diabetes. Nutrition Subcommittee of Diabetes Care advisory Committee of Diabetes UK (2003) Diabetic Medicine 20, 786-807.

Home

Benefits of AhP input: treatment stage

navigate to:AHPs contributions at the treatment stage.

Diabetes toolkit 9

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:



References

Physiotherapists

Physiotherapists aim to optimise glycaemic control, improve HbA1c, improve lipid profiles and reduce hypertension. Physical activity and exercise also help to manage other comorbidities and patients fear avoidance behaviours, especially in relation to pain.

Cade, W.T., (2008) Diabetes Related Microvascular and Macrovascular Diseases in the Physical Therapy Setting, Physical Therapy. 38(11):pp 1322 1335

National Institute for Health and Clinical Excellence. Behaviour change at population, community and individual levels. (PH6). London: National Institute for Health and Clinical Excellence; 2007. See website >

Physical activity reduces diabetic related complications by 32% and diabetic related mortality by 42%.

Boule NG, Hadded E, Kenny GP, et al.(2001) Effects of exercise on glycemic control and body mass in type 2 diabetes mellitus: a meta-analysis of controlled clinical trials. Journal of the Americal Medical Association.; 286(1218-27)

Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing (2012) URL: See website >

Chartered Society of Physiotherapy, Facilitating Behaviour Change: Evidence Briefing (2012). See website >

Key fact Exercise significantly improves glycaemic control and reduces visceral adipose tissue and plasma triglycerides in people with type 2 diabetes.

Thomas D, Elliott EJ, Naughton GA (2006) Exercise for type 2 diabetes mellitus. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD002968. DOI: 10.1002/14651858.CD002968.pub2

Key fact A new report published in March 2012 by NHS Diabetes sets out the shocking cost to both patients and the NHS of poor quality diabetic foot care. The report shows that around 650 million (or 1 in every 150 the NHS spends) is spent on foot ulcers or amputations each year. It also highlights the devastating consequences of foot problems in people with diabetes. Around 7% of people with diabetes currently have, or have had, a foot ulcer, which can lead to amputation. 50% of people who have a major amputation die within two years; many of these amputations could be avoided with the right care.

NHS Diabetes is calling on the NHS to set up specialist diabetes foot care teams as a matter of urgency. Foot care multi disciplinary teams (MDTs) can generate savings for the NHS that substantially outweigh the cost of the team. One example shows how a local hospital team costing around 33,000 a year generated savings of almost million a year for the local NHS. Most importantly MDTs have been shown to reduce amputations by up to two thirds. See report >

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Podiatrists

The podiatrist liaises with primary care and diabetes specialist teams in the management of general diabetes care, in particular in advanced practice in preventing limb loss.

The partnership between the diabetologist, vascular surgeon, and podiatrist is a natural one. The complementary skills and knowledge of each professional can improve limb salvage and functional outcomes. Comprehensive multidisciplinary foot care programmes have been shown to increase quality of care and reduce amputation rates by 36% to 86%.

History of the team approach to amputation prevention: pioneers and milestones. Sanders LJ. Robbins JM, Edmonds ME. J Vasc Surg 2010 Sep;5293Suppl);3s-16S. See pubmed.gov website >

Podiatrists help mobilise patients post ulcer care by providing insoles and other orthotics. The podiatrist forms an essential part of the foot protection team whose stated aim is to reduce the rate of limb loss in diabetes by 2013.

Jeffcoate, Putting feet first: halving the number of major amputations by 2013. The diabetic foot journal, vol 13, no.1, 2010.

Orthotists Dietitians

Dietitians support diabetic patients rehabilitation by focusing on their nutritional status, muscle strength and respiratory function. Nutrition also helps maintain tissue viability and patient mobility which supports wound healing and prevents wound breakdown.

Monique et al (2009) Cost Effectiveness of Lifestyle Modification in Diabetic Patients, Diabetes Care Volume 32 No 8 Concludes that: Implementation of lifestyle interventions would probably yield important health benefits at reasonable costs. Some good QALY, prevention CVD incidents and life-years gained data. See American Diabetes Association website >

Benefits of AhP input: rehabilitation stage

navigate to:AHPs contributions at the rehabilitation stage.

Right first timeOrthotic input within the multi-disciplinary team in the diabetic foot clinic achieves right first time quality.

GOLDen nuGGeT

The prevention and management of foot problems in type 2 diabetes, NICE guideline, page 25

See NICE website >

Orthotists provide immobilisation and off-loading techniques in the care of people with Charcot osteoarthropathy to reduce healing time, prevent further deterioration, maintain tissue viability and prevent the need for hospitalisation.

Diabetes toolkit 10

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:



References

Physiotherapists

Physiotherapists can play a significant role in the rehabilitation of people with diabetes with associated complications.

Utilising their expertise in exercise therapy, physiotherapists can prescribe individual or group exercise programmes focussing on improvements in glycaemic control, the symptoms of pain and reduced activities of daily living associated with intermittent claudication and to assist in weight management.

Physiotherapists also provide tailored rehabilitation programmes for individuals with lower limb peripheral neuropathy. These will focus upon improving balance, walking, functional activity, falls prevention strategies and foot care.

Physiotherapists can also provide advice and education to carers and other members of the multidisciplinary team around the positioning and moving and handling of patients with associated complication of diabetes.

Individuals with diabetes are also at increased risk of developing contracted (frozen) shoulder. Physiotherapists can use a number of treatment modalities to address the symptoms of pain, loss of range of motion, strength and function associated with this condition.

Physiotherapy plays a crucial within the rehabilitation of those patients who have undergone a lower limb amputation as a complication of diabetes both immediately post-operatively and following limb fitting.

Clinical guidelines for the pre and post operative physiotherapy management of adults with lower limb amputation. View the BACPAR report >

Hanchard N, Goodchild L, Thompson J, OBrien T, Richardson C, Davison D, Watson H, Wragg M, Mtopo S, Scott M. (2011) Evidence-based clinical guidelines for the diagnosis, assessment and physiotherapy management of contracted (frozen) shoulder v.1.5, standard physiotherapy. Endorsed by the Chartered Society of Physiotherapy. See website >

Chartered Society of Physiotherapy (2011). Physiotherapy Works: Cardiac Rehab. See website >

Home

Podiatrists

Podiatrists help patients get mobile and remain active, which reduces risk of further costly ulceration.

An integrated care pathway exists for all patients admitted to hospital with suspected foot emergencies

Putting feet first- Commissioning specialist services for the management and prevention of diabetic foot disease in hospital. Diabetes UK. June 2009 See Diabetes UK report >

Physiotherapists

Physiotherapists provide client centred assessments in the community to negotiate longer term measurable goals in collaboration with clients, carers and the multidisciplinary/ interagency team. They can provide support to carers to facilitate sustained participation in community life and return to work, social and life roles.

Individual or group exercise programmes can be used to improve and maintain patients levels of function, focussing upon strength, endurance, range of movement and physical functioning. Physiotherapists can provide advice and guidance on lifestyle management focussing upon physical activity and exercise.

Physiotherapists will play a crucial role with those patients who have undergone lower limb amputation, and in this stage will aim to promote functional independence, participation, inclusion, and enhanced quality of life



Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing (2012) See website >


Benefits of AhP input: re-ablement stage

navigate to:AHPs contributions at the re-ablement stage.

Dietitians

Dietitians provide ongoing review and support for people struggling to maintain glycaemic control or requiring support to adopt healthy eating practices or achieve and maintain a healthy weight.

Reduced risk of disabilityThe podiatrist reduces the risk of disability and foot complications which can have costly and devastating consequences for people with diabetes.

GOLDen nuGGeT

A guide to the benefits of podiatry to patient care. The Society of Chiropodists and Podiatrists. 2010. Read the report >

education is effective54 out of 80 studies demonstrated effectiveness of therapeutic patient education in terms of clinical, psychosocial and educational outcomes.

GOLDen nuGGeT

Albano, M.G., Crozet, C., dIvernois, J.F. (2008). Analysis of the 2004-2007 literature on therapeutic patient education in diabetes: results and trends. Acta Diabetologia, 45, 211-219.

Orthotists

Orthotists ensure patients with diabetes have suitable and appropriate footwear and insoles, which prevent recurrent ulceration and enable safe ambulation. Orthotists also provide regular reviews and ensure the patient can easily re-access the diabetic service.

Occupational therapists

Occupational therapists provide functional and vocational advice that facilitates a return to employment and helps the patient maintain independence and improve their quality of life.

OTs also provide equipment and home adaptations to facilitate independent living and review participation in leisure activities.

COT (2011) Occupational therapy with people who have had lower limb amputations London: College of Occupational Therapists.

Diabetes toolkit 11

Prevention >


Treatment >

Rehabilitation >

Re-ablement >

Long-term gain >

navigate to:



References

Home

Benefits of AhP input: long-term gain

navigate to:AHPs contributions to long-term gain.

Dietitians

Amputation preventableOf the 70 amputations performed per week, 80% are potentially preventable.

Nov 2010 The NHS Atlas of variation in Healthcare. p.29. See website >

GOLDen nuGGeT

Orthotists

Orthotists early intervention can improve quality of life for the patient through the provision of suitable footwear and insoles.

A patient focused strategy and proven implementation plan to improve and expand access to orthotic care services and transform the quality of care delivered.

Download orthotic pathfinder >

Occupational therapists

For people with diabetes who go on to have lower limb amputations, occupational therapy forms a key part of a multi-disciplinary team. The specific focus of occupational therapy is to facilitate independence in activities of daily living, return to work where relevant, and participation in leisure or other meaningful activities.

Key fact Podiatrists help prevent hospital admissions due to foot ulceration by providing regular foot care, particularly for those patients who have existing medical conditions as a result of diabetes, such as renal failure.

Podiatrists

Key fact Two studies have shown that nutrition therapy is cost-effective, judged by savings in drug therapy or reduction in utilisation of medical services.

Albano, M.G., Crozet, C., dIvernois, J.F. (2008). Analysis of the 2004-2007 literature on therapeutic patient education in diabetes: results and trends. Acta Diabetologia, 45, 211-219

Dietitians provide key clinical input in type 1 and type 2 diabetics by supporting behaviour, lifestyle and dietary changes to reduce long term complications and obesity. The multidisciplinary approach encourages improved compliance and reduced risk of complications

How can we improve the care of the diabetic foot. Wounds UK 2008. Vol 4. No.4 Download the report >

Diabetes toolkit 12

Prevention >


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References

Physiotherapists

The role of physiotherapy in Health Promotion emphasises the importance of lifelong participation in programmes of exercise and physical activity. This is particularly important for people with diabetes to assist in glycaemic control, weight management and optimising health and well-being and prevention of associated complications. Physiotherapist can continue to monitor patients and identify if they are at risk of developing further complications associated with their condition.

Regular reviews should be offered to individuals who have received physiotherapy rehabilitation and re-ablement programmes associated with the complications of their diabetes, providing them with clear advice and information on how they can access physiotherapy services



Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing (2012). See website >




The Strategic Allied Health Professionals Leads Group (SAHPLE) commissioned York Health Economics Consortium (YHEC) to carry out economic analysis of the impact of AHP interventions across diabetes care pathways. SAHPLE provided YHEC with a framework which highlighted a series of specific interventions by AHPs classified under six categories:

Prevention Assessment/Diagnosis Treatment Rehabilitation Re-ablement Long-term gain.

Introduction

YHEC reviewed literature around each of the interventions included in each of the five pathways. This has been a considerable undertaking with up to 40 interventions being identified in each pathway. We carried out broad searches for literature using databases including Medline, the Cochrane Database of Systematic Reviews and NHS Evidence. We sought evidence from a range of sources in the following sequence: DH/NHS policy documents; clinical guidelines; case studies; published literature; individual NHS organisations; and expert opinion. We were also provided with a range of literature references from a range of AHP clinicians which we reviewed.

These searches represent an extensive but not exhaustive search of the available literature. With the resources available we were not able to search other sources such as literature held by the Royal Colleges which are available for members only. We contacted the Chartered Society of Physiotherapy, the Royal College of Speech and Language Therapists and the College of Occupational Therapists who provided some clinical

Our approach

guidelines. However, our search is likely to have identified the highest quality evidence. The view from SAHPLE is that there is more extensive literature on interventions by AHPs but that much of this is not published.

YHEC has used the data obtained to present the evidence in two ways:

n Examples of economic analysis across the pathways where AHPs can make a significant impact on patient care and, potentially, costs. Three scenarios are presented below:

Prevention of diabetes and diabetes-related complications through education and self management

Eye care for patients with type 2 diabetes

Foot care for patients with type 2 diabetes.

n Evidence to support the effectiveness and potential economic benefits for each of the interventions included in the SAHPLE framework. This is provided at Appendix A. We have colour-coded the evidence obtained to provide an indication of the level of robustness of the evidence as follows:

Evidence supported by published study or literature in GREEN

Evidence supported by observational study or case study in AMBER

Evidence supported by clinical opinion or assumption in RED.



scenario 1: Prevention of diabetes and diabetes-related complications through education and self management

DietitianPhysiotherapist

A

DietitianPhysiotherapist

b

Referral for patients at risk of developing diabetes

Supported self-management for people with diabetes

Avoided costDevelopment of diabetes (annual cost 3,000)

Avoided costAvoidance of complications

NICE and SIGN guidelines on diabetes recommend dietary and exercise advice as part of a comprehensive management plan to improve glycaemic control for people at risk of developing diabetes. The cost of providing a programme of education including a dietitian and a physiotherapist would be around 100 per hourly session, less than the cost of attendance at a consultant-led outpatient clinic. The avoided healthcare costs of treating someone who develops diabetes is around 3,000 per year.1

The Diabetes Prevention Programme and a Finnish study into lifestyle intervention found a 58% and 43% reduction in the incidence of diabetes respectively. In a caseload of 50 patients the reduction in diabetes incidence would be 29 and 22 respectively, generating annual savings of 87,000 and 66,000 respectively. If we assume AHP input of 0.5 wte dietitian and 0.5 wte physiotherapist then the cost of the intervention would be around 50,000 so this approach shows potential to generate savings.

Intervention A

50% of people with type 2 diabetes have complications on diagnosis, which could have been prevented if diabetes had been detected earlier.2 A study that examined a cohort of more than 17,000 diabetes patients in Wales reported the incidence of vascular co-morbidities. Excluding eye and foot related complications which are explored in scenarios 2 and 3, the incidence of major complication is given in Table 1.3

Intervention b

1 The First National Bariatric Surgery Registry Report to March 2010. Royal College of Surgeons of England.2 UK Prospective Diabetes Study Group, Intensive Blood Glucose Control with Sulphonylureas or Insulin Compared with Conventional Treatment and Risk of Complications in Patients with Type 2 Diabetes (UKPDS 33). The Lancet 1998; 352:837-53)3 Estimated costs of acute hospital care for people with diabetes in the United Kingdom: a routine record linkage study in a large region. C. Ll. Morgan, J. R. Peters, S. Dixon and C. J. Currie. Diabetic Medicine.

TAbLe 1

CO-mORbIDITy InCIDenCe %

Coronary heart disease 18.4

Cerebrovascular disease 6.4

Nephrology/renal failure 3.6

Continued overleaf >



scenario 1: Prevention of diabetes and diabetes-related complications through education and self management

Table 2 shows the costs of serious complications that can arise from the co-morbidities in table 1 and the costs of treatment.

TAbLe 2

CO-mORbIDITy COmPLICATIOnCosts of fatality

()non-fatal costs

year 1 ()

non-fatal costs subsequent

years ()

CHD Myocardial infarction 1,366 5,199 856

Heart failure 3,007 3,007 1,054

Ischaemic heart disease 2,696 2,696 891

CVD Stroke 4,011 3,180 601

Renal failure Renal failure 30,000 30,000

Assuming a cohort of 200 patients and using the costs and prevalence described in Tables 1 and 2, table 3 shows the costs of complications.

TAbLe 3: COsTs OF TReATIng seRIOus vAsCuLAR COmPLICATIOns OveR A 5-yeAR PeRIOD

COmPLICATIOns FIve-yeAR COsT ()

Myocardial infarction survived 55,288

Heart failure survived 10,230

Ischaemic heart disease survived 71,648

Myocardial infarction died 10,928

Heart failure died 6,014

Ischaemic heart disease died 5,392

Stroke survived 43,820

Stroke died 16,044

Renal failure 720,000

Total cost 939,364

The cost of providing a programme of education including a dietitian and a physiotherapist would be around 100 per hourly session. A structured set of twice yearly education sessions for each patient to support self management would cost around 1,000 per patient over five years or around 200,000 in total.



scenario 2: eye care for patients with type 2 diabetes

The Royal College of Ophthalmologists Preferred Practice Guidance on Diabetic Retinopathy Screening (DRS) and the Ophthalmology Clinic set up in England (2010) details the importance of providing DRS to reduce visual impairment due to diabetic eye disease. The guidance refers to the requirement, under the English National Screening Programme for Diabetic Retinopathy, that all diabetes patients should be sent screening appointments for DRS. Grades 0 and 1 (no diabetic retinopathy and background diabetic retinopathy) of patients should be seen in clinic annually. Patients with higher grades than 1 should be treated in an ophthalmology clinic.

A systematic review of diabetic retinopathy screening has found that systematic screening for diabetic retinopathy is cost effective in terms of sight years preserved compared with no screening.4 NICE puts the cost of blindness at 1,358 in the year of the event with a cost of 575 in subsequent years. 5

The make-up of the staff for DRS eye clinics includes consultant and trainee ophthalmologists and AHPs under supervision, as well as nurses, photographers and technicians. As with diabetic foot clinics, where DRS eye clinics do not exist, the cost of establishing such a team may be considerable and will need to be offset against any savings.

4 Diabetic retinopathy screening: a systematic review of the economic evidence. S Jones and R Edwards. Diabetic Medicine. (2010).5 NICE guideline CG66 Type 2 diabetes.



scenario 3: Foot care for patients with type 2 diabetes

Podiatrist (52 per session)

A

Podiatrist, OTOrthotist, Dietitian

b

OT, PhysiotherapistOrthotist

C

Referral for patients with established risk factors (25%)

Treatment for patients with history of previous

ulceration (8%)

Avoided costReferral to specialist (169 per session)

Avoided costAvoid progression

to ulcer

Progression to ulcer (7,500) Recovery

Avoided costAvoid progression to amputation

Amputation (65,000)

Intervention descriptions overleaf >



scenario 3: Foot care for patients with type 2 diabetes

There are a number of guidelines that refer to the importance of multidisciplinary care, including AHP interventions, in the provision of foot care for patients with type 2 diabetes. These include the NICE Guideline Type 2 diabetes: prevention and management of foot problems (2004) and the Diabetes Competency Framework for prevention, treatment and management of diabetic foot disease (2010). Potential savings are identified at three intervention points but these must be treated with caution as they are reliant on AHPs and multi-disciplinary foot care teams being funded and in place. In areas where there is no multi-disciplinary foot care team, the cost of establishing such a team may be considerable (podiatrist, orthotist, physiotherapist, OT, dietitian, diabetes nurse specialist, clinicians).

Intervention A:

Patients with established risk factors but who have never ulcerated comprise around 25-30% of the adult diabetes population. National guidelines recommend that this group of patients has regular podiatry care, depending on individual need. If this is provided by direct referral to a podiatrist rather than a consultant, then there is a potential cost saving. If podiatry services are not available then this will not be possible.

Potential annual saving in England, based on annual review of all patients with established risk factors:

550,000 patients x (169-52) = 64m

Intervention b:

Patients with a history of previous ulceration or amputation comprise between 8-12% 0f the diabetes population. These patients have between 40-50% risk of re-ulcerating each year. These patients should be treated by appropriately skilled diabetes specialist podiatrists linked to a multi-disciplinary diabetes foot team.

Provision of a specialist diabetes foot team staffed by podiatrists, OTs, orthotists and dietitians may help to prevent re-ulceration.

Potential annual saving in England, based on reduction in levels of ulceration by 5%:

175,000 patients x 5% x 7,500 = 66m

Intervention C:

1-5% of patients have active foot ulcers or foot disease. These should be reviewed frequently in diabetes foot multidisciplinary clinics with a network of community podiatry and nursing teams to continue care in between specialist clinic visits. According to Diabetes UK and the Atlas of Variation in Healthcare there are 70 major amputations per week relating to diabetes, 80% of which are avoidable.

Potential annual saving in England, based on reducing the avoidable amputation rate by 50%:

70 amputations x 52 weeks x 40% x 65,000 = 95m

.


Appendix A

Framework of interventions provided by clinicians in a range of settingsPrevention (1 of 4)

InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes THe eCOnOmIC ARgumenT CAse sTuDIes

Dietitians provide individualised diet therapy for those with impaired glucose regulation and metabolic syndrome to reduce risk of progression to diabetes.

(NHS Outcomes Framework: Domains 1 & 2)

NICE guidance states that the major consensus-based recommendations from the UK and USA emphasise sensible practical implementation of nutritional advice for people with Type 2 diabetes. It recommends individualised and ongoing nutritional advice from a healthcare professional with specific expertise and competencies in nutrition and the integration of dietary advice with a personalised diabetes management plan, including other aspects of lifestyle modification, such as increasing physical activity and losing weight.

National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline for management in primary and secondary care (update). London: Royal College of Physicians, 2008.

The Diabetes Prevention Program has drawn up a lifestyle protocol, which includes weight loss and activity goals; individual case managers; intensive ongoing intervention; individualisation through a toolbox of adherence strategies; materials and strategies that address the needs of an ethnically diverse population.

The Diabetes Prevention Program: description of the lifestyle intervention. Diabetes Care 24: 2165-2171.

The Dose Adjustment for Normal Eating (DAFNE) educational programme is associated with a net cost saving over 10 years of 2,679 per patient and a higher number of quality adjusted life years (QALYs).

NICE guidance on the use of patient education models for diabetes. Technology Appraisal 60. 2003.

Avoiding progression to diabetes can save the NHS a considerable amount for each case prevented: The First National Bariatric Surgery Registry Report estimates the average cost of treating patients with diabetes at 3,000 per year.

The First National Bariatric Surgery Registry Report to March 2010. Royal College of Surgeons of England.

Specialist diabetic orthotists provide accommodating footwear and insoles to prevent ulcers and amputation. They also offer regular reviews, where foot care advice is provided, and facilitate re-referral to the high risk foot clinic if necessary.

Studies show that high risk patients without prescribed footwear will develop ulcers.

(NHS Outcomes Framework: Domain 2)

The SIGN guideline on diabetes states that programmes which include education with podiatry show a positive effect on minor foot problems at relatively short follow up. Access to a podiatrist reduces the number and size of foot calluses and improves self care. More recent studies assessing the effectiveness of structured education programmes for patients at high risk of diabetes-associated foot disease found an improvement in overall knowledge and foot care behaviours but no change in the incidence of foot ulceration or in amputation rates. Foot care education is recommended as part of a multidisciplinary approach (including a podiatrist and an orthotist) in all patients with diabetes.

Scottish Intercollegiate Guidelines Network, Management of Diabetes A national clinical guideline, March 2010.

The cost to the NHS to heal one ulcer is between 3,000 and 7,500. Should this progress to amputation the cost is estimated to escalate to 65,000. This is much higher than the cost of preventative orthoses.

Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics Consortium: pg 12-13.


Appendix A


InTeRvenTIOn In PATHWAy ImPROvIng OuTCOmes ReFeRenCes CAse sTuDIes

Physiotherapists are skilled in assessing and treating people with complex pathologies and in developing exercise/physical activity programmes that are person centred.


Physiotherapists help to optimise blood glucose control with exercise/physical activity to help with prevention/delay of type 2 diabetes. Physiotherapists are able to use their expertise in exercise therapy and physical activity to provide advice, education and tailored exercise programmes for those individuals identified as being at risk of developing type 2 diabetes.

The increasing worldwide prevalence of obesity and a sedentary lifestyle are directly linked to the rising rate of metabolic syndrome and type 2 diabetes

Exercise and physical activity are important lifestyle interventions that can prevent or delay the onset of both pre diabetes and type 2 diabetes,

People with IGT and type 2 diabetes often present with complex biopsychosocial issues.

It is acknowledged that there are already many exercise facilities available for the general public to access, however there appears to still be a population who have increased barriers to exercise. Physiotherapists can empower people to make gradual, positive changes in their ability to become more active and enable participation in exercise and to address the barriers which may make change difficult.

The ultimate achievement will be sustainable lifestyle changes which incorporate increased exercise/physical activity and which individual participants feel have a positive affect on their own physical and emotional well being.

1 Ferguson, B. and Kingdom, A. (2006) Diabetes Key Facts. York: Yorkshire and Humber Public Health Observatory.

2 Alberti, K.G.M.M., Zimmet, P., Shaw, J., (2006) Metabolic Syndrome - a new world wide definition. A Consensus Statement from the International Diabetes Federation. Diabetes Medicine 23:pp 469-480.

3 American College of Sports Medicine (ACSM) and American Diabetes Association Joint Position Statement.(2010) Exercise and Type 2 Diabetes. Medicine and Science in Sports and Exercise vol 42 No.12, pp 2282-2303.

Home

Appendix A



Dietitians provide support and guidance on lifestyle changes to help patients reduce weight and improve their health thus reducing risk of developing diabetes.


Risk factors for Type II diabetes and Coronary Heart Disease (CHD) are influenced by lifestyle factors such as poor diet, lack of exercise and smoking. These are potentially reversible factors and research has shown that lifestyle interventions in the form of individualised therapy, provided by dietitians, may prevent the onset of diabetes in individuals with impaired glucose regulation and metabolic syndrome.

Forms of individualised therapy may include the prescription of a healthy low-calorie, low fat diet, engagement in a physical activity regime of moderate intensity for at least 150 minutes per week and a one-to-one educational programme providing information on diet, exercise and smoking cessation.

The Diabetes Prevention Programme Research Group (2000) Reduction in incidence of Type 2 diabetes with lifestyle intervention or metformin. New Eng J Med 346: 393-403.

Nutritional advice and information is essential for the prevention of diabetes in those at risk of Type 2 diabetes and for the effective management of the condition for those with Type 1 and Type 2 diabetes. This advice and information enables people with diabetes to make appropriate choices on the type and quantity of the food which they eat. The advice must take account of the individuals personal and cultural preferences, beliefs and lifestyle, and must respect their wishes and willingness to change. It must be adapted to the specific needs of the individual, which may change with time and circumstance; for example, age, pregnancy, hospital admission, nephropathy, intercurrent illness and other illnesses. The beneficial effects of physical activity in the prevention and management of diabetes and the relationship between activity, energy balance and body weight, are an integral part of nutritional counselling.

An Integrated Career and Competency Framework for Dietitians and Frontline Staff. Professional Education Working Group. Diabetes UK. December 2010.

The average cost to the NHS of treating patients with diabetes at 3,000 per year.

The First National Bariatric Surgery Registry Report to March 2010. Royal College of Surgeons of England.

In 2002 The NSF for diabetes stated that the average personal cost for people with diabetes was 802 per person per year plus lost earnings for people without any complications. One in twenty people with diabetes incurred social services costs of around 2,450, mostly for residential and nursing care and home help

National Service Framework for Diabetes, Department of Health, 2002.

Two studies have suggested that lifestyle interventions for those at risk of diabetes could reduce the occurrence of diabetes by 43% and 58% respectively..

Diabetes in the UK 2004, Diabetes UK.

A study by the Diabetes Prevention Program Research Group found that lifestyle intervention in 1,079 participants resulted in a 58 per cent reduction in the incidence of type 2 diabetes in persons who were at high risk for diabetes. The intervention consisted of a 16-lesson curriculum taught by case managers on a one-to-one basis during the first 24 weeks after enrolment. This was done flexibly and on an individual basis for each person. Subsequent individual sessions were held monthly and group sessions were also held.

Wylie-Rosett J and Delahanty L (2002) An integral role for the dietitian: implications of the Diabetes Prevention Program. Journal of the American Dietetic Association 102: 1065-1068.

A Finnish study of a similar approach found a 43 per cent reduction in the incidence of type 2 diabetes. The participants in that programme had face-to-face consultation sessions (30 min 1 hour) with the study nutritionist at weeks 0, 1-2 and 5-6 and at 3, 4, 6 and 9, ie, seven sessions in the first year and every three months thereafter. In addition, there were voluntary group sessions, expert lectures, low-fat cooking lessons, visits to local supermarkets, and between-visit phone calls and letters.

Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study (Lindstrom et al, 2006) The Lancet, Vol368, Issue 9548: 1673-1679



Appendix A



Podiatrists provide structured diabetes education and deal with all aspects of foot health and lifestyle modifications, such as smoking cessation, footwear education and falls prevention. They also provide foot screening an essential part of the prevention programme for patients with diabetes and foot health advice to all other health professionals and carers.


NICE guidelines recommend that as part of an annual review, podiatrists should examine patients feet to detect risk factors for ulceration and discuss a management plan which includes foot care education, encourages self-care and minimises inadvertent self-harm. Foot screening and education helps to avoid ulceration as well as subsequent treatments or potential amputations.

The prevention and management of foot problems in type 2 diabetes, NICE guideline CG10 (2004).

The Society of Chiropodists and Podiatrists reported that between 15-20 per cent of patients with diabetes will develop a foot ulcer during their lifetime and that foot ulceration precedes 85 per cent of amputations. Eighty five per cent of amputations could be avoided by early detection of foot complications, timely intervention, involvement of a diabetic foot care team, good diabetes control and patient education. The report found that investing in foot clinics and podiatrists could reduce waiting times and amputation rates, improve patient outcomes and lower the need for consultant time due to podiatry autonomy.

A guide to the benefits of podiatry to patient care. The Society of Chiropodists and Podiatrists. 2010.

A 1998 study by McCabe and colleagues reported a screening and protection programme conducted in an English diabetic outpatient clinic setting which randomised 2001 patients.

Patients in the intervention group (n=1001) were screened and patients at raised risk (n=259) were recalled. Following a second assessment, 192 (19.2%) patients were entered into a foot protection programme. When compared to the control group, the intervention group demonstrated non-significant trends in reduced ulceration and minor amputations, and statistically significant reductions in overall and major amputation. Of those presenting with ulcers significantly fewer progressed to amputation in the intervention group suggesting that ulcers were spotted sooner and treated more effectively. The cost per patient was around 100, significantly less than treatment for ulceration or amputation.

McCabe CJ, Stevenson RC, Dolan AM (1998) Evaluation of a diabetic foot screening and protection programme. Diabetic Medicine 15: 8084.

Home Diabetes toolkit 23Home

Appendix A

Framework of interventions provided by clinicians in a range of settingsAssessment/Diagnosis (1 of 3)


Podiatrists perform full assessments and evaluation of skin, soft tissue, musculoskeletal, vascular and neurological conditions in the foot and lower limb. They identify risk factors for lower limb amputation and develop care plans to prevent deterioration. National guidelines are in place for the management of the foot in diabetes.


Guidelines for the prevention and management of foot problems for people with diabetes provide guidance on risk identification and assessment; management of low/increased /high risk feet; management of ulcerated feet.

The guidelines assist NHS podiatrists and managers to review, plan and provide specific best care for people with diabetes, from both a clinical and cost effectiveness perspective, creating equity of care across the region, including minimum standards.

Guidelines for the prevention and management of foot problems for people with diabetes. North West Podiatry Services, Diabetes Clinical Effectiveness Group.

A study in Wales found that the mean hospital length of stay for people with vascular-related diabetic foot problems was 15 days. The current cost for a general medicine bed day is around 123 so an average inpatient stay would cost 1,845. If risk factors are managed better through podiatrist assessments any reduction in bed days for these complications would provide cost efficiency savings.

Estimated costs of acute hospital care for people with diabetes in the UK: a routine record linkage study in a large region. C Morgan et al. Diabetic Medicine 2010.

Salford Community Health has reorganised its care pathway for people with diabetes to ensure seamless care across community and acute services and reorganising the case load of podiatry services. This has included annual foot screening and risk stratification and preventative and specialist foot care services. This has resulted in a reduction in the number of foot ulcers by 300 over 4 years. At a cost of 3,500 per ulcer this represents a saving of over 1m over 4 years.

Integrated foot care service. NHS Diabetes Case study. 2010.



Retinopathy can be treated by laser which is very successful if the condition is caught early. There is little evidence relating to the effects of diabetic retinopathy and falls. Because retinopathy affects an individuals visual field, this in itself may increase the risk of falling but other diabetic factors also need to be taken into account such as lower limb neuropathy which could also affect balance.

P Turpin. RNIB Care Homes Falls Prevention Project: A review of the literature. 2011.

PCTs are responsible for implementing the English National Screening Programme for Diabetic Retinopathy (ENSPDR). ENSPDR recommends that patients are seen in diabetic eye clinics including AHPs under supervision.

The Royal College of Ophthalmologists. Preferred Practice Guidance. Diabetic Retinopathy Screening (DRS) and the Ophthalmology Clinic set up in England. September 2010.

Systematic screening for diabetic retinopathy is cost-effective in terms of sight years preserved compared with no screening. Variation in compliance rates, age of onset of diabetes, glycaemic control and screening sensitivities influence the cost-effectiveness of screening programmes and are important sources of uncertainty in relation to the issue of optimal screening intervals. There is controversy in relation to the economic evidence on optimal screening intervals.

Diabetic retinopathy screening: a systematic review of the economic evidence. Jones & Edwards. Diabetic Medicine 2010.

Falls cost the NHS and social care an estimated 6m per day or 2.3bn per year in hip fractures alone. This figure does not take into account other costs associated with falls that do not result in hip fracture but that may still require treatment or care. There are also other costs involved, for example, falls cost 115 per ambulance call-out There is growing evidence to show that investing in falls prevention services is cost-effective. The Department of Health currently estimates that if every strategic health authority in England invested 2m in falls and bone health early intervention services they could each save 5m (net 3m) each year through reduced NHS costs, such as 400 fewer hip fractures.

Age UK. Stop Falling: Start Saving Lives and Money. 2010.


Appendix A



Continued from page 23



Patients with clinically isolated single cranial nerve palsies associated with diabetes or hypertension are likely to recover spontaneously within 5 months and initially require observation only. However, patients with unexplained binocular diplopia and those who progress or fail to recover should be investigated to establish the underlying aetiology and managed as appropriate.

Causes and outcomes for patients presenting with diplopia to an eye casualty department. Comer et al. Eye (2007).

For falls various interventions, such as programmed inter-disciplinary involvement, have shown promise, however these need further confirmation of their efficacy and cost effectiveness. An added confounder may be that an intervention (eg, cataract extraction) paradoxically affects an individuals future activity level and behaviour, thereby increasing the risk of falling. With an ageing population the importance of this topic is likely to increase, as will the potential benefits of optimising our assessment and management of these patients.

Visual loss and falls a review. Dhital et al. Eye (2010).

NICE guidance recommends eye screening at, or around, the time of diagnosis of diabetes and that arrangements should be made for a repeat of structured eye surveillance annually.

National Collaborating Centre for Chronic Conditions. Type 2 diabetes: national clinical guideline for management in primary and secondary care (update). London: Royal College of Physicians, 2008.

For diabetic retinopathy (DR), RNIB estimate that in 2010, 748,000 have background DR with 85,484 having more advanced DR. By 2020 will be 938,000 and 107,218. 40,982 in 2010 will be partially sighted and 24,976 blind. By 2020 will be 46,473 and 29,957 respectively.

The cost of is estimated at: 680m in 2010 for detection, treatment and provision of state and family social care for all diabetics at risk of eye disease. In 10 years to 2020 cumulative cost will be 6.4bn (1.6bn health costs, 3.4 bn personal and social care costs and 1.03bn lost productivity).

Future sight loss UK (2) An epidemiological and economic model for sight loss in the decade 2010-2020. RNIB (2009).

Retinopathy screening can prove very cost effective for all type 2 diabetes with an incremental cost effectiveness ratio as low as 1,400 per QALY.

Yorkshire & Humber Public Health Observatory. Diabetes: key facts. 2006.


Appendix A



Radiographers provide expert imaging and interpretation to identify disease progression/complications (such as arthroplasty/osteomyelitis/renal/visual complications.


During reviews, specialist diabetic orthotists will be able to identify possible new episodes, such as Charcot changes, and re-refer to a specialist clinic or AHP.

In orthotic-only clinics patients are assessed and provided with orthoses to accommodate the changes to the foot shape, thereby preventing further ulcerations caused by excessive plantar pressures and ill fitting footwear.


It is well documented within the EU that between 30-44% of high risk patients will have further foot pathologies (mainly ulceration and amputation). Studies show, that high risk patients without prescribed footwear will develop ulcers and the cost of healing one ulcer is 3000-7500 as published by the International Diabetic Foot 2005. Should this progress to an amputation the cost is estimated to be around 65,000.

Hutton and Hurry 2009, Orthotic Service in the NHS: Improving Service Provision. York Health Economics Consortium.

The average cost per patient for this type of care was estimated to be 501 in a sample of 103 patients over a two year period. This is less than 300 per year, a fraction of the cost of an amputation, and far less than the cost of treating a single foot ulcer.


The orthotic service has a dramatic impact on patients lives: I know the complications diabetic patients can have with their feet. Since I have been wearing diabetic footwear I have the confidence to be more active. I do a lot of walking and have lost a considerable amount of weight (4 stones). Generally my health has improved.


Home Diabetes toolkit 26Home

Appendix A

Framework of interventions provided by clinicians in a range of settingsTreatment (1 of 4)



Once the level of risk for foot injury or ulceration has been determined by the podiatrist appropriate management schemes, including footwear recommendations and orthotic provision, are provided by community podiatry or the specialist and surgical podiatrists.

(NHS Outcomes Framework: Domains 2, 3 & 4)

To individual patients the correct supply and fitting of orthotic devices can be a major factor in the management of their condition or the prevention of future problems. The technology of orthoses can appear deceptively simple, such as foot insoles or orthoses made for back problems but the selection and fitting of the most appropriate device requires detailed knowledge of the functioning of the musculo-skeletal system. Many orthotic devices have to be fitted specifically for the individual patient. Delivery of a service of this kind can only be carried out by those with a proper professional training in orthotics and a broad experience of the range of products available.

Orthotics services can assist in the achievement of major policy objectives of the NHS, including reducing referral to treatment times; facilitating choice for people with long term conditions; and providing seamless health care with service provision by those best placed to meet patient needs. Orthotic services can play an important role in meeting the NHS objective of keeping people mobile and independent and therefore reducing the need for acute treatment or social care services.


100 people a week have an amputation due to foot ulceration. Foot ulceration preceded 85% of amputations and foot ulcers occur in 15-20% of people with diabetes. International Diabetes Federation estimates that 85% of amputations could be prevented by early intervention from a diabetic foot team including specialist podiatrists.

AHP key facts Bulletin 2 October 2010. Allied Health Professions Federation.

A survey of 6 trusts involved in the 2004 Pathfinder project which highlighted that for every 1 spent on orthotic services the NHS saves 4. With current expenditure on orthotic service provision estimated at 100 million this represents a saving of 400 million to the NHS.


In the UK adult population the incidence of foot ulcers is 55,211, and the prevalence is 154,592.

Costing statement: Diabetic foot problems: inpatient management of diabetic foot problems NICE clinical guideline Draft, November 2011.

The annual cost of ulceration, infection and amputation associated with diabetic foot is 251.5m.

Gordols et al, 2003.

Supplementary prescribing can reduce the number of appointments in secondary care from weekly to six-weekly as podiatrists are able to prescribe in primary care.

QIPP example - Supplementary prescribing in podiatry: Provided by: NHS Central Lancashire.

The West Midlands Regional Orthotic Project in 2007 was designed to develop orthotic services in one region of the English NHS, along the lines proposed in the Pathfinder report. The key recommendations were aimed at commissioners, orthotic service managers and contracted service providers in order to improve service delivery. The report also recommended collaboration between commissioners and senior management in providing trusts. Similarly, there was a need for more coordination between management levels within providing trusts, from the orthotic service manager upwards. Six key factors central to the achievement of change were identified:

Clear service specifications Valuing health care professionals Companies acting responsibly A clinical evidence base Cost savings from appropriate provision to fund further developments Whole system change to gain maximum benefit from orthotic services.


In Southampton 125k per year for 3 years has been invested in a Diabetic Foot Protection Team including a lead podiatrist, specialist nurse, dietitian and specialist podiatrist. Resulted in reduction in inpatient stay from 50 to 18 days, creating 1.2m savings in 3 years.

AHP key facts Bulletin 2 October 2010. Allied Health Professions Federation.


Appendix A



Continued from page 26


Once the level of risk for foot injury or ulceration has been determined by the podiatrist appropriate management schemes, including footwear recommendations and orthotic provision, are provided by community podiatry or the specialist and surgical podiatrists.


Between January 2002 and June 2003(18 months), 128 diabetic patients with lower limb ischaemia were seen. Thirty-four (26.6%) patients received medical treatment alone, and 18 (14.1%) were deemed palliative due to their significant co-morbidities. The remaining 76 (59.4%) patients underwent either angioplasty (n = 56), surgical reconstruction (n = 18), primary major amputation (n = 2) or secondary amputation after surgical revascularisation (n = 1). Minor toe amputations were required in 35 patients. The mortality in the intervention group was 14% (11/76). This integrated multidisciplinary approach offers a consistent and equitable service to diabetic patients with critically ischaemic feet and appears to have a beneficial major/minor amputation ratio.

An integrated care pathway to save the critically ischaemic diabetic foot. K El Sakka et al. Int J Clin Pract, June 2006, 60, 6, 667669.


Appendix A



Dietetic treatment aims to optimise glycaemic control, improve HbA1c, reduce hypoglycaemia, improve lipid profiles and reduce hypertension.

It also addresses associated dietary issues such as renal diets, celiac diets, low residue diets and high kcal diets as required to achieve and maintain appropriate BMI.


Overweight and obesity are major contributors to both type 2 diabetes and cardiovascular disease (CVD). Individuals with type 2 diabetes who are overweight or obese are at particularly high risk for CVD morbidity and mortality. Although short-term weight loss has been shown to ameliorate obesity-related metabolic abnormalities and CVD risk factors, the long-term consequences of intentional weight loss in overweight or obese individuals with type 2 diabetes have not been adequately examined.

Look AHEAD Research Group (2003). Look AHEAD (Action for health in diabetes): design and methods for a clinical trial of weight loss for the prevention of cardiovascular disease in type 2 diabetes. Controlled Clinical Trials 24, 610-628.

Another study in New Zealand found that intensive dietary advice has the potential to appreciably improve glycaemic control and anthropometric measures in patients with type 2 diabetes and unsatisfactory HbA1c despite optimised hypoglycaemic drug treatment.

Nutritional intervention in patients with type 2 diabetes who are hyperglycaemic despite optimised drug treatmentLifestyle Over and Above Drugs in Diabetes (LOADD) study: randomised controlled trial. Coppell K et al. BMJ 2010; 341:c3337.

Medical nutrition therapy is an integral component of diabetes management and of diabetes self-management education. Yet many misconceptions exist concerning nutrition and diabetes. Moreover, in clinical practice, nutrition recommendations that have little or no supporting evidence have been, and are still being, given to persons with diabetes. This career and competency framework will ensure that dietitians and supporting staff have the competences in place to deliver sound and evidence-based therapy to support the person with diabetes in self-managing their condition.

An Integrated Career and Competency Framework for Dietitians and Frontline Staff. Professional Education Working Group. Diabetes UK. December 2010.

An American study found that a multidisciplinary weight loss program consisting of diet, exercise, and behaviour modification provides good value for money, but more research is required to confirm the impacts of such programmes on quality of life and the likelihood of long-term weight loss maintenance.

For overweight and obese women, a three-component intervention of diet, exercise, and behaviour modification cost $12,600 per quality-adjusted life year gained compared with routine care. All other strategies were either less effective and more costly or less effective and less cost-effective compared with the next best alternative.

Economic Evaluation of Weight Loss Interventions in Overweight and Obese Women. L Roux et al. Obesity Research (2006) 14, 10931106.


Appendix A



Community podiatrists provide specialist clinical care for patients who are deemed at high risk of a foot/lower leg problem. These interventions help reduce hospital stay and ensur

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