Care of Patients with Diabetic Foot Disease in Oman

Diabetes mellitus is a major public health challenge and causes substantial morbidity and mortality worldwide. Diabetic foot disease is one of the most debilitating and costly complications of diabetes. While simple preventative foot care measures can reduce the risk of lower limb ulcerations and subsequent amputations by up to 85%, they are not always implemented. In Oman, foot care for patients with diabetes is mainly provided in primary and secondary care settings. Among all lower limb amputations performed in public hospitals in Oman between 2002–2013, 47.3% were performed on patients with diabetes. The quality of foot care among patients with diabetes in Oman has not been evaluated and unidentified gaps in care may exist. This article highlights challenges in the provision of adequate foot care to Omani patients with diabetes. It concludes with suggested strategies for an integrated national diabetic foot care programme in Oman.


D
iabetes mellitus is a chronic disease of worldwide significance. 1On a global scale, the prevalence of diabetes has continued to increase steadily, reaching 8.8% among adults aged 20-79 years old in 2015. 2 Diabetes is associated with long-term microvascular and macrovascular complications, including diabetic foot disease (DFD) -a group of heterogeneous foot conditions in which peripheral neuropathy and vascular disease, sometimes complicated by infection, may result in foot ulceration and lower limb amputation. 3,4Due to its substantial morbidity and mortality, DFD is regarded as a global public health challenge and is considered to be one of the most debilitating complications of diabetes, with severe personal, societal and economic costs. 1,3Nevertheless, DFD continues to be inadequately managed by healthcare services in many countries. 1lobally, the prevalence of diabetic foot ulcers ranges from 1-12%, with national rates generally higher among Arab countries, from 5% in Jordan to 12% in Algeria. 5,6Approximately half of all lower limb amputations are due to diabetes, and of these lower limb amputations, active foot ulceration has been found to be a precursor in more than 85% of cases. 3,7n 2015, the reported age-adjusted prevalence of diabetes in Oman was 14.8%. 2 In response to the rise in diabetes prevalence over the past two decades, diabetes care is currently a priority in the national health programme coordinated by the Omani Ministry of Health (MOH).8,9 While advances have been made in the delivery of diabetes care, the prevalence of long-term complications of diabetes, including foot ulceration and lower limb amputation, is expected to rise.9,10 A structured well-resourced national programme is therefore vital to prevent and effectively manage DFD in Oman.11 The aim of this article was to review diabetesrelated amputations and describe the current status of foot care services among patients with diabetes in Ibrahim S. Al-Busaidi, Nadia N. Abdulhadi and Kirsten J. Coppell

Review | e271
Oman.Challenges in the provision of adequate foot care to Omani patients with diabetes are discussed and recommendations drawn from international guidelines are presented in order to improve diabetic foot care in primary and secondary care settings in Oman.Both relevant published and grey literature was reviewed.

Diabetic Foot Disease Management
It is widely acknowledged that the implementation of evidence-based preventative and therapeutic foot care strategies can reduce lower limb ulceration rates and subsequent amputations by 45-85% in patients with diabetes. 5,25,27,28Such strategies include optimised glycaemic control, regular foot selfcare, screening/identification of at-risk feet, risk reduction through podiatry, appropriate footwear/ orthotic devices, patient/staff education and multidisciplinary management of DFD cases. 5,11,32Surgical interventions-including both prophylactic and revascularisation surgeries-play a role in preventing foot ulceration, improving wound healing and reducing the incidence and site of lower limb amputations. 32successful foot care programme requires a coordinated healthcare system with a multidisciplinary approach. 11,32International guidelines recommend that all countries adopt a three-level model of foot care management which should be resourced to provide appropriate foot care services for patients with different levels of risk [Table 1]. 11In 1990, the National Diabetes Prevention and Control Programme was established in Oman to tackle the growing burden of diabetes as well as to reduce the rate of long-term diabetes-related complications. 9In 2006, the National Programme for Screening of Non-Communicable Diseases was implemented to provide screening services for five chronic conditions (diabetes, hypertension, obesity, hypercholesterolaemia and chronic renal impairment) to all Omanis aged ≥40 years old attending primary health care centres (PHCCs). 33However, this latter programme does not screen for diabetes-related complications and there is currently no specific national goal to reduce the burden of DFD in Oman.

p r i m a r y c a r e
In Oman, routine foot care is provided mainly in primary care settings at PHCCs as part of overall diabetes care.The diabetes care team consists of a primary care physician or family physician, a diabetes practice nurse and a dietitian. 34Local diabetes guidelines mandate primary care professionals perform at least one annual foot examination on all patients with diabetes, including an assessment of skin abnormalities, structural deformities, protective sensation, circulation and footwear. 9,12Patients with foot ulcers are frequently managed by nurses, most of whom are not trained in diabetic foot care. 35To date, no detailed national guidelines for the prevention and management of DFD have been published or implemented.However, the MOH launched several nurse-led clinics in selected catchment areas throughout Oman in 2004 so that patients with diabetic foot ulcers could be initially managed by nurses trained in wound and diabetic foot care. 35Situated in PHCCs, the clinics are equipped with basic wound care materials including scalpels, forceps and cotton gauze for basic wound dressing.By December 2013, 25 nurse-led diabetic foot clinics had been established in Oman; however, more are required. 35e c o n d a r y c a r e Patients with more severe or complicated cases of DFD are referred from PHCCs to secondary care facilities known as polyclinics.34 Within these polyclinics, highrisk diabetes clinics and foot care clinics are situated next to each other and operate simultaneously on specific days of the week.In most cases, a multidisciplinary team manages DFD cases, including a diabetologist, dietitian and nurse with training in diabetes and sometimes a podiatrist or wound care nurse in certain cases.Foot care clinics are equipped with some of the equipment and materials required for the diagnosis and management of peripheral vascular disease, peripheral neuropathy and foot ulcers (e.g.Semmes-Weinstein monofilament, 128 Hertz tuning forks, hand-held 5-10 megahertz Doppler probes and advanced wound care products such as charcoal, hydrogels and calcium alginate dressings).However, it is important to note that secondary care diabetic foot care clinics are not available in all areas of Oman due to a lack of local resources, staffing and infrastructure. Futhermore, there is a shortage of other diagnostic and therapeutic resources, such as vibration perception threshold devices, insoles, orthotic and off-loading devices, casting techniques and radiological studies.

Podiatric services
The role and value of podiatrists in the primary and secondary prevention of DFD is recognised internationally. 36Regular access to podiatry services can decrease the prevalence and size of foot callosities, improve foot care knowledge and self-care and significantly reduce the risk of foot ulceration recurrence in patients with diabetes. 36,37In Oman, podiatrists mainly work as part of multidisciplinary teams in secondary care settings.Unfortunately, there is a severe shortage in the podiatry workforce of Oman; this is common for many countries worldwide, particularly developing countries. 24,38Currently, there are 16 podiatrists in the public health system in Oman, of which 13 are based in the capital city of Muscat and the other three are located in the Ad Dakhilyah, Ash Sharqiyah North and Al-Batinah North governorates. 35his equates to approximately one podiatrist per 5,000 patients with diabetes in Oman. 24Due to this workforce shortage, diabetes podiatry services are essentially limited to the care and management of high-risk patients.Fortunately, the existing shortage of podiatrists in Oman has been recognised by decision-makers-in coordination with the Ministry of Higher Education, the MOH currently provides scholarships for students to complete their podiatry studies at overseas universities.As of December 2015, there were 10 students (eight undergraduate and two postgraduate) from Oman undergoing podiatry training abroad. 35e r t i a r y c a r e Patients who require more specialised diabetic foot management are referred to regional or national centres in Oman where tertiary care is provided.In addition to advanced non-surgical services, tertiary care centres provide surgical interventions for the management of DFD, including wound debridement, revascularisation surgeries and lower limb amputations. 35Further details and discussion of the surgical management of DFD cases in Oman is outside the scope of this review.

Diabetic Foot Care Education
Patient and carer education about DFD risk factors and foot self-care is instrumental in preventing foot ulcers and subsequent amputations. 11,32During routine follow-up consultations, diabetes care providers are mandated by local guidelines to provide foot care education. 9Although PHCCs in Oman are staffed with qualified professionals, opportunities for patient education are somewhat limited.Currently, no established programmes focus on the delivery of diabetic foot care education.A recent pilot study evaluated the provision of foot care education to 310 Omani diabetic patients attending PHCCs and found that less than 50% of patients reported receiving education on recommended foot self-care practices and protective footwear. 39A number of factors could contribute to suboptimal diabetic foot care education in Oman.First, healthcare professionals are faced with a number of organisational and system-related barriers to effective diabetes care education.These include heavy workloads, language/communication barriers, a perceived lack of teamwork and a shortage in the number of diabetes service providers. 40Second, a large proportion of Omani patients with diabetes, especially patients over the age of 50 years, have minimal or no formal education, as access to education was limited prior to the 1970s. 41Finally, health literacy is poor among people with diabetes in Oman, which is a factor associated with poor diabetes outcomes. 42

Diabetic Foot Care Training
Diabetic foot education and wound care training directed at diabetes healthcare providers is equally vital in the prevention and management of DFD. 11,32n Oman, few educational facilities provide on-going diabetic foot care training.However, the establishment of the National Diabetic Foot Training Centre in 2012 was the first step in providing nursing staff with the necessary training to manage patients with diabetic foot ulcers.The centre is based in the diabetic foot clinic in Bausher Specialized Polyclinic in Muscat and is staffed with a podiatrist, a wound care nurse specialist and wound management nurses.
In addition to being a referral centre for patients with DFD, it provides nurses from all over the country with short training courses in foot examination, basic and advanced wound management and diabetic foot care.However, advances in training healthcare professionals are limited as the centre accommodates only 2-3 trainees per month.As of February 2016, 100 nurses had received training in diabetic foot care, of which 61 work in Muscat. 35

Recommendations to Improve Diabetic Foot Care in Oman
Given that diabetes-related foot amputations are largely preventable, there is room for improvement in the delivery of diabetic foot care in Oman. 3,5,11,32The increasing national prevalence of diabetes highlights the importance of providing sufficient high-quality health services for those with the condition.The following recommendations are suggested to improve diabetic foot care services in Oman.Alongside current programmes to manage and prevent diabetes, a national diabetic foot care programme needs to be designed and implemented to address system-wide changes required for the prevention and management of DFD. 9,344][45] The primary goal of this programme should be to reduce diabetes-related lower limb amputations.The Save the Diabetic Foot Project in Brazil is a commendable example of how the implementation of simple and low-cost preventative measures can result in a large reduction in amputation rates among patients with diabetes (77.8% over nine years). 45Taking into account shortages in diabetic foot care services and human resources in Oman, the establishment of a national diabetic foot care programme should occur in phases and be based on time-limited, attainable targets. 11oordination between diabetes care providers and health policymakers is pivotal to facilitate the implementation of such a programme. 46In addition, the impact of foot care improvement strategies as part of the programme should be evaluated continuously through a set of process and outcome indicators, such as the completion and outcomes of foot examinations and amputation rates.This type of monitoring will enhance understanding of the epidemiology and burden of DFD in Oman.
pat i e n t e d u c at i o n Education programmes for patients with diabetes and their families should be provided to enhance community awareness of DFD and emphasise the importance of optimal diabetes control to prevent complications in general and regular foot self-care practices to prevent foot ulcers in particular.This education needs to be tailored to Oman, as a number of sociocultural factors may put patients with diabetes in Oman at particularly high risk for DFD-for example, many individuals may find it uncomfortable to wear closed shoes and socks due to the characteristically hot and dry weather in Oman; patients with diabetes therefore often continue to wear traditional sandals, which do not offer protection from external trauma. 7iven the limited literacy and education among many individuals with diabetes in Oman, the mode of delivery and the content of educational initiatives needs to be simple, repetitive, clearly presented and targeted for education/literacy level and sociocultural practices. 41,42Ideally, foot care education, as part of self-management education for patients with diabetes, should be delivered by health educators, nurses or doctors to patients in groups rather than individuals; furthermore, attractive written materials with pictorial diagrams should be used.Given the shortage of human resources and health infrastructure in Oman, the set-up of multidisciplinary diabetic foot care teams in primary and secondary care should be done in stages, with various specialist team members introduced gradually.

Figure
Figure 1A & B: Trends in (A) overall diabetes-and non-diabetes-related lower limb amputations and (B) diabetes-related lower-limb amputations by gender performed in Ministry of Health institutions in Oman between 2002-2013. 13-24 i m p l e m e n tat i o n o f a n at i o n a l p r o g r a m m e d i a b e t i c f o o t c a r e r e s o u r c e s a n d fa c i l i t i e s

r e s e a r c h
Diabetic foot care and DFD research in Oman is still in its infancy which undoubtedly leaves knowledge gaps in understanding the national burden of DFD.Future research should focus primarily on understanding the burden and extent of DFD.Population-based studies are urgently needed to better describe and understand the epidemiology of diabetic foot ulcers and lower limb amputations in Oman.The contribution and effectiveness of current diabetic foot services should also be evaluated regularly.

Table 1 :
Levels of foot care required at the national level in the management of diabetic foot disease An alternative would be to hold annual workshops on foot examination, identification of at-risk feet and management of foot ulcers for hospital-based and primary care health professionals involved in diabetes care.Moreover, the training should be supported by the development and regular updating of diabetes foot care guidelines.
11,24In PHCCs, healthcare teams should consist of a primary care physician, diabetes nurse, health educator and podiatrist.Secondary care-based teams should include a diabetologist, surgeon, podiatrist, diabetes nurse and orthotist.Continuous coordination between policymakers at the MOH and Ministry of Higher Education in Oman is necessary to increase the numbers of skilled professionals in the labour pool.Moreover, diabetic foot care clinics should be set up throughout the country and equipped with the necessary resources for the management of diabetic foot ulcers, including diagnostic devices, customised footwear and orthotics, offloading devices, casting techniques and imaging studies.