Pandemic leads to changes in delivery of care for diabetic foot infections
The COVID-19 pandemic led to early disruptions in diabetic foot care during lockdowns, and cases of diabetes-associated foot infections increased after lockdowns were lifted, according to a speaker.
Brian Schmidt, DPM, an assistant professor of internal medicine in the division of metabolism, endocrinology and diabetes at the University of Michigan School of Medicine, said during a virtual presentation at the American Diabetes Association Scientific Sessions that poor messaging at the start of the COVID-19 pandemic may have kept many patients with diabetic foot conditions from contacting providers about complications, leading to increases in infections after stay-at-home orders were lifted.
However, telemedicine can be an effective tool in preventing poor outcomes in diabetes foot care if proper procedures are in place, he said.
“The biggest lesson we can learn from this is there were a lot of protocols and procedures that were developed during the pandemic to maintain contact with patients, but our messaging wasn’t clear enough to say, ‘If you need help, we are here, please contact us. We can get you in the clinic, we can still give you high level care in spite of the pandemic,’” Schmidt told Healio.
Foot care trends shift during pandemic
Health care systems across the U.S. and internationally saw similar trends in diabetic foot care at the start of the pandemic, with practices experiencing a large drop in outpatient visits. When stay-at-home orders were instituted in March 2020, Schmidt’s practice at the University of Michigan implemented a triage system in which patients with low-risk diabetic foot care issues would engage in telemedicine visits, and those who were high risk would have face-to-face outpatient visits. In the first 2 months of the pandemic, the University of Michigan experienced an 81.9% drop in outpatient care and a 62.8% reduction in inpatient care compared with the same period from the year before. There were 220 virtual visits conducted in the 2-month period compared with none in 2019.
The monthly average of diabetic foot infections plummeted at the start of the pandemic. After stay-at-home orders ended, the number of telemedicine visits for diabetic foot care greatly decreased, with most people opting for in-person visits again. In addition, the number of diabetic foot infections spiked after stay-at-home orders were lifted before returning to normal levels.
Similar trends were observed with the rise and fall of COVID-19 cases. When COVID-19 cases increased late in 2020 and early in 2021, the number of diabetic foot infections at the University of Michigan dropped. When COVID-19 cases fell again, diabetic foot infections increased.
“When patients see the COVID-19 numbers on the news, they are waiting to see us, maybe in spite of how bad their foot is,” Schmidt said during the presentation. “When we do see them, we see them much later in the course of their care. This is an alarming trend that we certainly need to be aware of moving forward.”
The future of diabetic foot care
Data from hospitals across the globe similarly showed that poor outcomes for diabetic foot ulcers increased during the pandemic. Schmidt said this could have an impact on providers in the immediate future.
“In the near term, we’re going to see worse outcomes with these patients — worse than what we are used to — because we are now seeing an unprecedented surge of patients who require our care,” Schmidt told Healio. “The standard care that was delivered pre-pandemic was never built for this volume of patients. It’s going to be a somewhat arduous road back to pre-pandemic care outcome levels.”
Despite the increase in poor outcomes, Schmidt said, telemedicine could become an important tool moving forward for diabetic foot care. A study published in PLOS ONE this year analyzed outcomes for 549 people with diabetic foot complications who were treated via telemedicine. Of the study cohort, 227 had diabetic foot ulcers at the start of the lockdown. Of the remaining 322 participants, only 32 developed new-onset ulcers during the lockdown.
“Don’t give up on the virtual care implementations, because you can be very effective with your time with virtual care,” Schmidt told Healio. “If you have to see a patient but they are running late, have them do a virtual visit. There’s no reason why they shouldn’t still get care. Continue to implement these strategies, and over time, that will make you more efficient in your care for these individuals.”
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Those with diabetic foot lesions during the pandemic were appropriately fearful of coming to hospital clinics for treatment: Such patients have multiple risk factors that could result in poor outcomes were they to contract COVID-19 infections. Most of these individuals have “lost the gift of pain” due to neuropathy, and they may not heed other warning signs of foot infections. As expected, there was a decrease in attendances during lockdowns which increased as restrictions were reduced. We reported that moving clinics to health centers in the community increased attendance rates during lockdowns (Shin L, et al. Diabetes Care. 2020;doi:10.2337/dc20-1176). Similarly, as in Michigan, we predict that the use of telemedicine and smart technologies will improve diabetic foot care in the future. There have been increasing reports of the effectiveness of such advanced technologies in monitoring not only foot skin temperatures, but also in shoe pressures. Whereas the future of diabetic foot care looks promising with these new technologies, I fear that we will witness a tsunami of serious diabetic foot disease in the next year as we gradually emerge from the global pandemic.
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Schmidt B. 1-AC-MS01. Presented at: American Diabetes Association Scientific Sessions; June 25-29, 2021 (virtual meeting).