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Allied Health Professions

Diabetes toolkit

Art, Music and Drama Therapists


Dietitians
Occupational Therapists
Orthoptists
Paramedics
Physiotherapists
Podiatrists
Prosthetists and Orthotists

How AHPs improve


patient care and save
the NHS money >

Radiographers
Speech and Language Therapists

Click to enter toolkit

Maximising allied health professionals contribution to


the delivery of high quality and cost effective patient care.

A guide for healthcare commissioners

prevention
assessment
treatment
rehabilitation
re-ablement
long-term gain
This toolkit is one of a series of toolkits developed by NHS London
on behalf of the Strategic AHP Leads Group (SAHPLE)

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.
For further information please contact:

The key AHP professions in diabetes include:

This toolkit has been endorsed by:

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.

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

Podiatrists

Lesley.Johnson@london.nhs.uk

Provide expert imaging and interpretation to identify disease


progression / complications (such as arthropathy/ osteomyelitis/renal/
visual complications).

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

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.

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Introduction >

Diabetes toolkit

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).

Click on one of the intervention stages


below to find out more about AHPs input

prevention>
assessment>
treatment>
rehabilitation>
re-ablement>
long-term gain>

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.

Key AHP intervention points in the diabetes pathway


Prevention

Assessment

Treatment

Rehabilitation

Re-ablement

Long-term gain

patient journey
Art, Music and Drama Therapists Dietitians Occupational Therapists Orthoptists Paramedics
Physiotherapists Podiatrists Prosthetists and Orthotists Radiographers Speech and Language Therapists

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Diabetes toolkit

Commissioning principles: which AHPs do you need?


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

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 >

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 >

Peripheral Vascular Disease (PVD)


Ulceration, Suspected Foot
Emergency, Charcot Foot

Outcome
Framework
domain
(download)

Cost saved

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 >

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.

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Diabetes toolkit

Commissioning principles: page 2 of 2

Presenting condition

Health risk

Referral to

Risk mitigated

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

Amputated foot/leg

Mobility and activities of


daily life impacted by limb
loss. Deterioration of comorbidities

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.

Outcome
Framework
domain
(download)
2,4

Cost saved

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 >

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 >

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

Diabetes toolkit

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


AHPs contributions at the prevention stage.
Dietitians

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.

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.

Navigate to:

Orthotists

Podiatrists

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.

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

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

65k
The 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 >

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 >

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

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


Section 4.

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Diabetes toolkit

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


AHPs contribution at the prevention stage.
Dietitians

Physiotherapists

Dietitians provide support and guidance on


lifestyle changes to help patients reduce weight
and improve their health thus reducing risk of
developing diabetes.

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.

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.

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

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Navigate to:

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.

Prevention >

Chartered Society of Physiotherapy, Physical Activity: Evidence


Briefing (2012) See website >

Treatment >

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

Assessment/
diagnosis >

Rehabilitation >
Re-ablement >
Long-term gain >

Navigate to:

Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References

Diabetes toolkit

Benefits of AHP input: assessment / diagnosis stage


AHPs contributions at the assessment/diagnosis stage.

Navigate to:

Podiatrists

Orthoptists

Radiographers

Physiotherapists

Orthotists

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.

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.

Radiographers provide expert


imaging and interpretation to
identify disease progression/
complications (such as arthropathy/
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.

Prevention >

Dietitians

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.

Treatment >

N West Podiatry Services Guidelines for


the Prevention and Management of foot
problems for people with Diabetes 2008,
FDUK See NHS Evidence website >

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.

See pubmed.gov website >

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

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 >

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 >

Assessment/
diagnosis >

Rehabilitation >
Re-ablement >
Long-term gain >

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 >

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 >

Navigate to:

Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References

Diabetes toolkit

Benefits of AHP input: treatment stage


AHPs contributions at the treatment stage.
Orthotists

Podiatrists

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.

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.

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.

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 >

Home

Navigate to:

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 >

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.

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.

Prevention >

Cade, W.T., (2008) Diabetes Related Microvascular and


Macrovascular Diseases in the Physical Therapy Setting,
Physical Therapy. 38(11):pp 1322 1335

Treatment >

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)

Assessment/
diagnosis >

Rehabilitation >
Re-ablement >
Long-term gain >

Navigate to:

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

Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References

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.
Diabetes toolkit

Benefits of AHP input: rehabilitation stage


AHPs contributions at the rehabilitation stage.

Navigate to:

Orthotists

Podiatrists

Dietitians

Physiotherapists

Golden nugget

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.

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.

Physiotherapists can play a significant role in the


rehabilitation of people with diabetes with associated
complications.

Right
first time
Orthotic input within
the multi-disciplinary
team in the diabetic foot
clinic achieves right first
time quality.
The prevention and management
of foot problems in type 2
diabetes, NICE guideline, page 25
See NICE website >

Orthotists provide
immobilisation and offloading 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.

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.

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 >

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 >

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

Chartered Society of Physiotherapy (2011). Physiotherapy Works:


Cardiac Rehab. See website >

Home

Diabetes toolkit

10

Benefits of AHP input: re-ablement stage


AHPs contributions at the re-ablement stage.

Navigate to:

Podiatrists

Physiotherapists

Dietitians

Occupational therapists

Podiatrists help patients get mobile and remain active,


which reduces risk of further costly ulceration.

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.

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.

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.

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 >

Golden nugget

Reduced risk of disability

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.

The podiatrist reduces the risk of disability and foot


complications which can have costly and devastating
consequences for people with diabetes.

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

A guide to the benefits of podiatry to patient care.


The Society of Chiropodists and Podiatrists. 2010. Read the report >

Clinical guidelines for the pre and post operative physiotherapy


management of adults with lower limb amputation. View the
BACPAR report >

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.

Chartered Society of Physiotherapy (2011). Physiotherapy Works:


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

Golden nugget

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

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.

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

Diabetes toolkit

11

Benefits of AHP input: long-term gain


AHPs contributions to long-term gain.
Podiatrists

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.

Golden nugget

Amputation
preventable
Of the 70 amputations
performed per week,
80% are potentially
preventable.
Nov 2010 The NHS Atlas of
variation in Healthcare. p.29.
See website >

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.

Navigate to:

Dietitians

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 >

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.

Prevention >

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

Re-ablement >

Assessment/
diagnosis >
Treatment >
Rehabilitation >

Long-term gain >

Clinical guidelines for the pre and post operative physiotherapy


management of adults with lower limb amputation.
View the BACPAR report >
Chartered Society of Physiotherapy (2011). Physiotherapy Works:
Cardiac Rehab. See website >

Navigate to:

Chartered Society of Physiotherapy, Physical Activity: Evidence Briefing


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

Diabetes literature
review and analysis
Appendix 1:
Improving outcomes,
the economic
arguments and
case studies
References

Home

Diabetes toolkit

12

Diabetes literature review and analysis


Introduction

Our approach

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:

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.

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.

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

Eye care for patients with type 2 diabetes

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

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
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.

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Diabetes toolkit

13

Diabetes literature review and analysis


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

Dietitian
Physiotherapist

Referral for patients at risk


of developing diabetes

Avoided cost
Development of diabetes
(annual cost 3,000)

Home

Dietitian
Physiotherapist

Supported self-management
for people with diabetes

Avoided cost
Avoidance of
complications

Intervention A

Intervention B

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

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

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.

TABLE 1
Co-morbidity

incidence %

Coronary heart disease

18.4

Cerebrovascular disease

6.4

Nephrology/renal failure

3.6

Continued overleaf >

The First National


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

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)

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.

Diabetes toolkit

14

Diabetes literature review and analysis


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.

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 2
Costs of fatality
()

Non-fatal costs
year 1 ()

Non-fatal costs
subsequent
years ()

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

Co-morbidity

COMPLICATION

CHD

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
Total cost

720,000
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.

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Diabetes toolkit

15

Diabetes literature review and analysis


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.

Home

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.

Diabetic retinopathy
screening: a systematic
review of the economic
evidence. S Jones and
R Edwards. Diabetic
Medicine. (2010).

NICE guideline CG66


Type 2 diabetes.

Diabetes toolkit

16

Diabetes literature review and analysis


Scenario 3: Foot care for patients with type 2 diabetes

Podiatrist
(52 per session)

Podiatrist, OT
Orthotist, Dietitian

Referral for patients with


established risk factors (25%)

Treatment for patients


with history of previous
ulceration (8%)

Avoided cost
Referral to specialist
(169 per session)

Avoided cost
Avoid progression
to ulcer

OT, Physiotherapist
Orthotist

Progression to ulcer (7,500)

Recovery

Amputation (65,000)

Avoided cost
Avoid progression
to amputation

Intervention descriptions overleaf >

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Diabetes toolkit

17

Diabetes literature review and analysis


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).

Home

Intervention A:

Intervention B:

Intervention C:

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.

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.

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


annual review of all patients with established
risk factors:
550,000 patients x (169-52) = 64m

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

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
.

Diabetes toolkit

18

Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (1 of 4)
Intervention in pathway

Improving outcomes

The economic argument

Dietitians provide individualised diet therapy


for those with impaired glucose regulation and
metabolic syndrome to reduce risk of progression
to diabetes.

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.

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).

(NHS Outcomes Framework: Domains 1 & 2)

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.

Case studies

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.

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.

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 Diabetes Prevention Program: description of the


lifestyle intervention. Diabetes Care 24: 2165-2171.
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 diabetesassociated 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.

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.

Scottish Intercollegiate Guidelines Network, Management


of Diabetes A national clinical guideline, March 2010.

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Diabetes toolkit

19

Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (2 of 4)
Intervention in pathway

Physiotherapists are skilled in assessing and


treating people with complex pathologies and in
developing exercise/physical activity programmes
that are person centred.
(NHS Outcomes Framework: Domain 2)

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.

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

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

Exercise and physical activity are important lifestyle


interventions that can prevent or delay the onset of both
pre diabetes and type 2 diabetes,

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.

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.

Case studies

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 22822303.

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.

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Diabetes toolkit

20

Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (3 of 4)
Intervention in pathway

Improving outcomes

The economic argument

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.

The average cost to the NHS of treating patients with


diabetes at 3,000 per year.

(NHS Outcomes Framework: Domains 1 & 2)

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 oneto-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.

Case studies

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
The First National Bariatric Surgery Registry Report to
incidence of type 2 diabetes in persons who were at
March 2010. Royal College of Surgeons of England.
high risk for diabetes. The intervention consisted of a
In 2002 The NSF for diabetes stated that the average
16-lesson curriculum taught by case managers on a onepersonal cost for people with diabetes was 802 per
to-one basis during the first 24 weeks after enrolment.
person per year plus lost earnings for people without
This was done flexibly and on an individual basis for
any complications. One in twenty people with diabetes
each person. Subsequent individual sessions were held
incurred social services costs of around 2,450, mostly for
monthly and group sessions were also held.
residential and nursing care and home help
Wylie-Rosett J and Delahanty L (2002) An integral role
National Service Framework for Diabetes, Department
for the dietitian: implications of the Diabetes Prevention
of Health, 2002.
Program. Journal of the American Dietetic Association
Two studies have suggested that lifestyle interventions
102: 1065-1068.
for those at risk of diabetes could reduce the occurrence
A Finnish study of a similar approach found a 43 per
of diabetes by 43% and 58% respectively..
cent reduction in the incidence of type 2 diabetes.
Diabetes in the UK 2004, Diabetes UK.
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

An Integrated Career and Competency Framework for


Dietitians and Frontline Staff. Professional Education
Working Group. Diabetes UK. December 2010.

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Diabetes toolkit

21

Appendix A
Framework of interventions provided by clinicians in a range of settings
Prevention (4 of 4)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

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 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 1998 study by McCabe and colleagues reported


a screening and protection programme conducted
in an English diabetic outpatient clinic setting which
randomised 2001 patients.

(NHS Outcomes Framework: Domain 2)

The prevention and management of foot problems


in type 2 diabetes, NICE guideline CG10 (2004).

A guide to the benefits of podiatry to patient care.


The Society of Chiropodists and Podiatrists. 2010.

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.

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Diabetes toolkit

22

Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (1 of 3)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

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.

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.

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.

(NHS Outcomes Framework: Domains 1 & 2)

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.
(NHS Outcomes Framework: Domains 1 & 2)

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.
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.

Home

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.

Integrated foot care service. NHS Diabetes Case study.


2010.

Systematic screening for diabetic retinopathy is costeffective 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 callout 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.
Diabetes toolkit

23

Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (2 of 3)
Intervention in pathway

Improving outcomes

The economic argument

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.

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.

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.
(NHS Outcomes Framework: Domains 1 & 2)

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 interdisciplinary 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.

Case studies

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.

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.

Home

Diabetes toolkit

24

Appendix A
Framework of interventions provided by clinicians in a range of settings
Assessment/Diagnosis (3 of 3)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

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.

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.

Radiographers provide expert imaging and


interpretation to identify disease progression/
complications (such as arthroplasty/osteomyelitis/
renal/visual complications.
(NHS Outcomes Framework: Domains 1 & 2)

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.
(NHS Outcomes Framework: Domains 1 & 2)

Home

Hutton and Hurry 2009, Orthotic Service in the NHS:


Improving Service Provision. York Health Economics
Consortium.

Hutton and Hurry 2009, Orthotic Service in the NHS:


Improving Service Provision. York Health Economics
Consortium.

Hutton and Hurry 2009, Orthotic Service in the NHS:


Improving Service Provision. York Health Economics
Consortium.

Diabetes toolkit

25

Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (1 of 4)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

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.

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.

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.

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:

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)

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.

Hutton and Hurry 2009, Orthotic Service in the NHS:


Improving Service Provision. York Health Economics
Consortium.
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.

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.

Supplementary prescribing can reduce the number of


appointments in secondary care from weekly to sixweekly as podiatrists are able to prescribe in primary care. Hutton and Hurry 2009, Orthotic Service in the NHS:
Improving Service Provision. York Health Economics
QIPP example - Supplementary prescribing in podiatry:
Consortium.
Hutton and Hurry 2009, Orthotic Service in the NHS:
Provided by: NHS Central Lancashire.
Improving Service Provision. York Health Economics
In Southampton 125k per year for 3 years has been
Consortium.
invested in a Diabetic Foot Protection Team including a
lead podiatrist, specialist nurse, dietitian and specialist
100 people a week have an amputation due to foot
podiatrist. Resulted in reduction in inpatient stay from 50
ulceration. Foot ulceration preceded 85% of amputations
to 18 days, creating 1.2m savings in 3 years.
and foot ulcers occur in 15-20% of people with diabetes.
International Diabetes Federation estimates that 85%
AHP key facts Bulletin 2 October 2010. Allied Health
of amputations could be prevented by early intervention
Professions Federation.
from a diabetic foot team including specialist podiatrists.
AHP key facts Bulletin 2 October 2010. Allied Health
Professions Federation.

Home

Diabetes toolkit

26

Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (2 of 4)
Intervention in pathway

Continued from page 26


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.
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)

Home

Improving outcomes

The economic argument

Case studies

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.

Diabetes toolkit

27

Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (3 of 4)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

Dietetic treatment aims to optimise glycaemic


control, improve HbA1c, reduce hypoglycaemia,
improve lipid profiles and reduce hypertension.

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.

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 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 longterm weight loss maintenance.

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

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.

An Integrated Career and Competency Framework for


Dietitians and Frontline Staff. Professional Education
Working Group. Diabetes UK. December 2010.

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.

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.

Home

Diabetes toolkit

28

Appendix A
Framework of interventions provided by clinicians in a range of settings
Treatment (4 of 4)
Intervention in pathway

Improving outcomes

The economic argument

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.

NICE guidelines state that early recognition of foot


complications, prompt use of preventative measures and
rapid and intensive treatment in multidisciplinary teams
are strategies to minimise foot complications. As part
of this care, patients should be reviewed regularly by
podiatrists and referred to orthotists for special footwear
and other interventions in order to minimise the risk of
trauma and provide early intervention for all foot lesions.
Such a service should reduce prevalence of lower limb
complications therefore offsetting other healthcare costs
such as hospital admissions.

A study in Louisiana estimated that a diabetes foot


programme would save approximately $4,600 per patient
per year, without taking into account the cost of the
service. The service provided

Podiatrists with advanced scope of practice within


diabetes also provide supplementary prescribing
services, eg antibiotics, pain relief and referral for
diagnostic imaging and surgery.
(NHS Outcomes Framework: Domains 2, 3 & 4)

The prevention and management of foot problems in


type 2 diabetes, NICE guideline.
The Diabetes Guide for London describes 4 tiers of care:
1: Primary/Community including specialist diabetes
dietetics and podiatry + psychological support
2: Primary/Community including specialist dietetic +
psychological support

Case studies

Poole Hospital NHS Foundation Trust and Bournemouth


and Poole Community Health Services have worked
together to expand community-based high risk podiatry
clinics and improve access to the multi-disciplinary foot
care team. This has resulted in fewer hospital admissions
staged management foot care consisting of devices to
and attendances with projected savings of 60,000 per
offload pressure, self-care education and, after healing,
custom-fabricated orthoses and footwear, and monitored hospital per year.
A novel multidisciplinary approach to the management
progressive ambulation.
of diabetic foot disease. NHS Diabetes case study. 2010.
Horswell, R. L., Birke, J.A., and Patout, C. A staged
management diabetes foot programme versus standard
care: a 1-year cost and utilization comparison in a state
public hospital system. Archives of Physical Medicine and
Rehabilitation. Volume 84, Issue 12, December 2003,
Pages 1743-1746.

The Podiatry Department undertook a number of


initiatives to improve engagement with patients and
other clinical staff and improve referral processes. This
has resulted in a substantial reduction in inappropriate
referrals to the podiatry service.
West Kent Community Health NHS Trust. Podiatry
Department. Ensuring the appropriate referral of diabetic
patients to the podiatry department.
http://chain.ulcc.ac.uk/chain/subgroup_resources.html

3: Community specialist care including multidisciplinary


clinics and specialist diabetes dietitians and podiatrists
4: Hospital care
Healthcare for London. Diabetes guide for London.

Home

Diabetes toolkit

29

Appendix A
Framework of interventions provided by clinicians in a range of settings
Rehabilitation (1 of 2)
Intervention in pathway

Improving outcomes

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 need for hospitalisation.

NICE guidance recommends that people with suspected


or diagnosed Charcot osteoarthropathy should be
referred immediately to a multidisciplinary foot care team
for immobilisation of the affected joint(s) and for long
term management of off-loading to prevent ulceration.

The prevention and management of foot problems in


type 2 diabetes, NICE guideline.
The podiatrist liaises with primary care and diabetes NICE guidelines recommend potential strategies to
minimise the sequelae of foot complications including:
specialist teams in the management of general

The economic argument

Case studies

The cost to the NHS of an amputation is estimated at


65,000. Comprehensive multidisciplinary foot care
programmes have been shown to increase quality of
care and reduce amputation rates by 36% to 86% so
significant savings can be made.

South Devon Healthcare NHS Foundation Trust has


changed its diabetic foot service to a multi-disciplinary
foot care team working across community and secondary
care, accepting patient as well as professional referrals.
This has resulted in a reduction in the major amputation
rate from 31.47 to 10.15 per 10,000 people with
diabetes. It has also resulted in 2 to 3 fewer beds being
occupied year on year.

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

diabetes care, in particular in advanced practices in Early recognition of the at risk foot
Prompt use if preventative measures
preventing limb loss.
The partnership between the diabetologist,
vascular surgeon, 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%.

Rapid and intensive treatment of foot complications


in multidisciplinary foot care services.

Hutton and Hurry 2009, Orthotic Service in the NHS:


Improving Service Provision. York Health Economics
This leads to reduced prevalence of lower limb
Consortium.
complications in people with diabetes, including fewer
amputations and a reduced need for hospital admissions. Sanders et al. History of the team approach to
amputation prevention: Pioneers and milestones. J Vasc
The prevention and management of foot problems in
Surg. 2010.
type 2 diabetes, NICE guideline.

Open referral outpatient to multidisciplinary foot care


team. NHS Diabetes case study. 2010.

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

Home

Diabetes toolkit

30

Appendix A
Framework of interventions provided by clinicians in a range of settings
Rehabilitation (2 of 2)
Intervention in pathway

Improving outcomes

The economic argument

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.

A Dutch study identified interventions for diabetic


patients in which lifestyle issues were addressed. The
long-term outcomes for these interventions were
simulated with a computer-based model. Seven trials
met predefined criteria. All interventions improved
cardiovascular risk factors at around one year follow-up
and were projected to reduce cardiovascular morbidity
over lifetime.

The Dutch study found that the interventions resulted in


an average gain of 0.010.14 quality-adjusted life-years
(QALYs) per participant. Health benefits were generally
achieved at reasonable costs (50,000/QALY). A selfmanagement education program (X-PERT) and physical
activity counselling achieved the best results with 0.10
QALYs gained and 99% probability to be very costeffective (20,000/QALY).

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

Case studies

Monique et al. Cost-Effectiveness of Lifestyle Modification The study concluded that implementation of lifestyle
in Diabetic Patients. Diabetes Care. 2009 August; 32(8):
interventions would probably yield important health
14531458.
benefits at reasonable costs. However, essential evidence
for long-term maintenance of health benefits was limited.

Podiatrists help mobilise patients post ulcer care by


providing insoles and other orthotics. The podiatrist
forms and essential part of the foot protection
team whose stated aim is to reduce the rate of
limb loss in diabetes by 2013.
(NHS Outcomes Framework: Domains 2, 3 & 4)

Home

Monique et al. Cost-Effectiveness of Lifestyle Modification


in Diabetic Patients. Diabetes Care. 2009 August; 32(8):
14531458.
The cost to the NHS of an amputation is estimated
at 65,000. The putting feet first policy of reducing
amputations can reduce costs significantly.
Hutton and Hurry 2009, Orthotic Service in the NHS:
Improving Service Provision. York Health Economics
Consortium.
Jeffcoate et al. Putting feet first: halving number of major
amputations by 2013. The Diabetic Foot Journal. Vol 13.
2010.

Diabetes toolkit

31

Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (1 of 3)
Intervention in pathway

Improving outcomes

The economic argument

Case studies

Podiatrists help patients get mobile and remain


active, which reduces risk of further costly
ulceration.

Diabetic foot problems have a significant impact on


patients quality of life; for example, reduced mobility
that may lead to loss of employment, depression and
damage to or loss of limbs.

The CIPD annual survey absence report 2009 found


that the average level of employee absence was 7.4
days per employee and the average cost per employee
per year was 692. The cost included elements such
as occupational and statutory sick pay, the cost of
replacement labour, overtime costs and the cost of
reduced performance. That equates to an average cost
of absence per day per employee of 94 and an overall
cost to UK employers of around 875 million.

The Ipswich Hospital NHS Trust has developed a multidisciplinary foot care team which has been running since
1997. Key outcomes have been a 70% reduction in
amputation rates over 11 years, a reduction in the length
of stay and bed days, and annual savings of around
0.5m to offset 120,000 annual expenditure.

An integrated care pathway exists for all patients


admitted to hospital with suspected foot
emergencies.
(NHS Outcomes Framework: Domains 2, 3 & 4)

NICE has recommended in its clinical guidelines that:


Each hospital should have a care pathway for patients
with diabetic foot problems
The multidisciplinary foot care team should normally
include a diabetologist, a relevant surgeon, a diabetes
nurse specialist, a podiatrist and a tissue viability nurse;
The multidisciplinary foot care team should:

A multi-disciplinary footcare team. NHS Diabetes case


study. 2010.

Chartered Institute of Personnel and Development.


Absence management annual survey report 2009.

Assess and treat the patients diabetes, which should


include interventions to minimise the patients risk of
cardiovascular events, and any interventions for preexisting chronic kidney disease or anaemia
Assess, review and evaluate the patients response to
initial medical, surgical and diabetes management
Assess the foot, and determine the need for specialist
wound care, debridement, pressure off-loading and/or
other surgical interventions
Assess the patients pain and determine the need for
treatment and access to specialist pain services.
Diabetic foot problems: inpatient management of
diabetic foot problems. NICE guideline draft (January
2011).

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Diabetes toolkit

32

Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (2 of 3)
Intervention in pathway

Improving outcomes

The economic argument

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.

Fifty four out of eighty studies demonstrated


effectiveness of therapeutic patient education in terms of
clinical, psychosocial and educational outcomes.

Twelve studies showed that therapeutic patient education


(TPE) may have interesting effects on health economy.
Positive cost-effectiveness results may originate from
the fact that the educated patient takes less diabetes
medications and knows better how to appropriately
use the health care system, thus lowering the admission
rate at the emergency department. Moreover, as a
consequence of TPE programs, a reduction in the number
of days of hospitalisation and a decrease in the long-term
complications of diabetes were observed.

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

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

Albano et al. Analysis of the 2004-2007 literature on


therapeutic patient education in diabetes: results and
trends. Acta Diabetologia 14. 211-219. 2008.

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.

Case studies

Albano et al. Analysis of the 2004-2007 literature on


therapeutic patient education in diabetes: results and
trends. Acta Diabetologia 14. 211-219. 2008.
The CIPD annual survey absence report 2009 found
that the average level of employee absence was 7.4
days per employee and the average cost per employee
per year was 692. The cost included elements such
as occupational and statutory sick pay, the cost of
replacement labour, overtime costs and the cost of
reduced performance. That equates to an average cost of
absence per day per employee of 94 and an overall cost
to UK employers of around 875 million.
Chartered Institute of Personnel and Development.
Absence management annual survey report 2009.

Orthotics services can assist in the achievement of major


policy objectives of the NHS, including reducing referral
to treatment times; developing stroke care services;
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.
Hutton and Hurry 2009, Orthotic Service in the NHS:
Improving Service Provision. York Health Economics
Consortium.

Home

Diabetes toolkit

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Appendix A
Framework of interventions provided by clinicians in a range of settings
Re-ablement (3 of 3)
Intervention in pathway

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

Improving outcomes

The economic argument

Case studies

The CIPD annual survey absence report 2009 found


that the average level of employee absence was 7.4
days per employee and the average cost per employee
per year was 692. The cost included elements such
as occupational and statutory sick pay, the cost of
replacement labour, overtime costs and the cost of
reduced performance. That equates to an average cost of
absence per day per employee of 94 and an overall cost
to UK employers of around 875 million.
Chartered Institute of Personnel and Development.
Absence management annual survey report 2009.

Home

Diabetes toolkit

34

Appendix A
Framework of interventions provided by clinicians in a range of settings
Long-term gain (1 of 1)
Intervention in pathway

Improving outcomes

The economic argument

Dietitians provide group education which has


demonstrated improved glycaemic control and
clinical, lifestyle and psychosocial outcomes.

The Diabetes Control and Complications Trial (DCCT) was


a major clinical study conducted from 1983 to 1993 and
funded by the National Institute of Diabetes and Digestive
and Kidney Diseases. The study showed that keeping
blood glucose levels as close to normal as possible slows
the onset and progression of the eye, kidney, and nerve
damage caused by diabetes. In fact, it demonstrated
that any sustained lowering of blood glucose, also called
blood sugar, helps, even if the person has a history of
poor control.

The DCCT found that to prevent one case of diabetes


during a period of three years, 6.9 persons would have
to participate in the lifestyle-intervention programme.
This means that in a cohort of 100 patients the lifestyle
intervention programme would prevent around 14 cases
of diabetes. At approximately 3,000 per patient per
year, this would save around 42,000 per year.

This helps prevent long-term complications


including cardiovascular, renal, diabetic foot
disease, visual impairment and complications
around diabetes in pregnancy, reducing hospital
admissions and costs.
(NHS Outcomes Framework: Domains 2, 3 & 4)

In the DCCT trial the average HbA1c was significantly


lower in patients adhering to diet-related behaviours.

Orthotists early intervention can improve quality


of life for the patient through the provision of
suitable footwear and insoles.
(NHS Outcomes Framework: Domains 2, 3 & 4)

Diabetes Prevention Program Research Group.


Reduction in the incidence of Type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med 2002;
346:393-403.
Patients with diabetes who receive orthotic therapy
have reported improvements in their health status, both
physically and mentally, compared to those who did not
receive therapy.
Davies S et al (2000). The health status of diabetic
patients receiving orthotic therapy. Quality of Life
Research 9 233-240.

Case studies

Diabetes Prevention Program Research Group.


Reduction in the incidence of Type 2 diabetes with
lifestyle intervention or metformin. N Engl J Med 2002;
346:393-403.

A study modelled the economic effects of poor care


provision, assessing the costs and benefits of introducing
improved orthotic Care. It demonstrates that the benefits
of providing good care far outweigh the costs needed to
deliver it. However, this is only so if the costs and benefits
to social care are considered in addition to those of the
NHS.
The model shows how low initial costs for starting the
change achieve break even within three

In a sample of 280 type 1 and type 2 diabetes patients,


the study group comprised four groups of patients;
those receiving orthotic therapy for pedal complications
as a result of their diabetes; those with diabetes mellitus
without complications of the disease affecting their foot;
those with unilateral lower limb amputation and those
with active ulceration who had not been prescribed
footwear. The specialised orthotic intervention resulted in
statistically significant improvements in health status both
physically and mentally, for patients with at risk feet and
should become an integral part of the treatment regime
for diabetics with at risk feet.

years, but the benefits really begin to escalate after ten


years. The corollary of not making the improvements is
that in a typical catchment area, public bodies (NHS trusts
Davies S et al (2000). The health status of diabetic
and social care) will continue to suffer an unnecessary
patients receiving orthotic therapy. Quality of Life
increased cost of 882,000 because they are providing
Research 9 233-240.
poor health care and compromising the quality of life
of their older citizens, preventing 1,200 mainly elderly
people from receiving care who need it.
RL Steeper. A patient focused strategy and proven
implementation plan to improve and expand access to
orthotic care services and transform the quality of care
delivered. Orthotic Pathfinder Report. 2004.

Home

Diabetes toolkit

35

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Quality of Life Research 9
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Department of Health
Gateway Reference 17269
Diabetes toolkit

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