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Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome

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Abstract

The treatment of patients with diabetic foot ulcers (DFUs) is extremely complex, requiring a comprehensive approach that involves a variety of different healthcare professionals. Several studies have shown that a multidisciplinary team (MDT) approach is useful to achieve good clinical outcomes, reducing major and minor amputation and increasing the chance of healing. Despite this, the multidisciplinary approach is not always a recognized treatment strategy. The aim of this meta-analysis was to assess the effects of an MDT approach on major adverse limb events, healing, time-to-heal, all-cause mortality, and other clinical outcomes in patients with active DFUs. The present meta-analysis was performed for the purpose of developing Italian guidelines for the treatment of diabetic foot with the support of the Italian Society of Diabetology (Società Italiana di Diabetologia, SID) and the Italian Association of Clinical Diabetologists (Associazione Medici Diabetologi, AMD). The study was performed using the Grading of Recommendations Assessment, Development, and Evaluation approach. All randomized clinical trials and observational studies, with a duration of at least 26 weeks, which compared the MDT approach with any other organizational strategy in the management of patients with DFUs were considered. Animal studies were excluded. A search of Medline and Embase databases was performed up until the May 1st, 2023. Patients managed by an MDT were reported to have better outcomes in terms of healing, minor and major amputation, and survival in comparison with those managed using other approaches. No data were found on quality of life, returning-to-walking, and emergency admission. Authors concluded that the MDT may be effective in improving outcomes in patients with DFUs.

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References

  1. Armstrong DG, Boulton AJM, Bus SA (2017) Diabetic foot ulcers and their recurrence. N Engl J Med 376(24):2367–2375. https://doi.org/10.1056/NEJMra1615439. (PMID: 28614678)

    Article  PubMed  Google Scholar 

  2. Wu H, Yang A, Lau ESH et al (2020) Secular trends in rates of hospitalization for lower extremity amputation and 1 year mortality in people with diabetes in Hong Kong, 2001–2016: a retrospective cohort study. Diabetologia 63(12):2689–2698. https://doi.org/10.1007/s00125-020-05278-2

    Article  PubMed  Google Scholar 

  3. Morbach S, Furchert H, Gröblinghoff U et al (2012) Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care 35(10):2021–2027. https://doi.org/10.2337/dc12-0200

    Article  PubMed  PubMed Central  Google Scholar 

  4. Ayada G, Edel Y, Burg A et al (2021) Multidisciplinary team led by internists improves diabetic foot ulceration outcomes a before-after retrospective study. Eur J Intern Med 94:64–68. https://doi.org/10.1016/j.ejim.2021.07.007. (Epub 2021 Jul 27 PMID: 34325949)

    Article  PubMed  Google Scholar 

  5. Rubio JA, Aragón-Sánchez J, Jiménez S et al (2014) Reducing major lower extremity amputations after the introduction of a multidisciplinary team for the diabetic foot. Int J Low Extrem Wounds 13(1):22–26. https://doi.org/10.1177/1534734614521234. (PMID: 24659624)

    Article  PubMed  Google Scholar 

  6. Jiménez S, Rubio JA, Álvarez J, Ruiz-Grande F, Medina C (2017) Trends in the incidence of lower limb amputation after implementation of a multidisciplinary diabetic foot unit. Endocrinol Diabetes Nutr 64(4):188–197. https://doi.org/10.1016/j.endinu.2017.02.009

    Article  PubMed  Google Scholar 

  7. Ventoruzzo G, Mazzitelli G, Ruzzi U, Liistro F, Scatena A, Martelli E (2023) Limb salvage and survival in chronic limb-threatening ischemia: the need for a fast-track team-based approach. J Clin Med 12(18):6081. https://doi.org/10.3390/jcm12186081.PMID:37763021;PMCID:PMC10531516

    Article  PubMed  PubMed Central  Google Scholar 

  8. Buggy A, Moore Z (2017) The impact of the multidisciplinary team in the management of individuals with diabetic foot ulcers: a systematic review. J Wound Care 26(6):324–339. https://doi.org/10.12968/jowc.2017.26.6.324

    Article  CAS  PubMed  Google Scholar 

  9. Blanchette V, Brousseau-Foley M, Cloutier L (2020) Effect of contact with podiatry in a team approach context on diabetic foot ulcer and lower extremity amputation: systematic review and meta-analysis. J Foot Ankle Res 13(1):15. https://doi.org/10.1186/s13047-020-0380-8

    Article  PubMed  PubMed Central  Google Scholar 

  10. Musuuza J, Sutherland BL, Kurter S, Balasubramanian P, Bartels CM, Brennan MB (2020) A systematic review of multidisciplinary teams to reduce major amputations for patients with diabetic foot ulcers. J Vasc Surg 71(4):1433-1446.e3. https://doi.org/10.1016/j.jvs.2019.08.244

    Article  PubMed  Google Scholar 

  11. Meza-Torres B, Carinci F, Heiss C, Joy M, de Lusignan S (2021) Health service organisation impact on lower extremity amputations in people with type 2 diabetes with foot ulcers: systematic review and meta-analysis. Acta Diabetol 58(6):735–747. https://doi.org/10.1007/s00592-020-01662-x

    Article  PubMed  PubMed Central  Google Scholar 

  12. Atkins D, Best D, Briss PA et al (2004) Grading quality of evidence and strength of recommendations. BMJ 3287454:1490

    Google Scholar 

  13. Kavanagh BP (2009) The GRADE system for rating clinical guidelines. PLoS Med 69:e1000094

    Article  Google Scholar 

  14. Page MJ, Moher D, Bossuyt PM et al (2021) PRISMA 2020 explanation and elaboration: updated guidance and exemplars for reporting systematic reviews. BMJ 29(372):n160. https://doi.org/10.1136/bmj.n160.PMID:33781993;PMCID:PMC8005925

    Article  Google Scholar 

  15. Brooke BS, Schwartz TA, Pawlik TM (2021) MOOSE reporting guidelines for meta-analyses of observational studies. JAMA Surg 156(8):787–788. https://doi.org/10.1001/jamasurg.2021.0522. (PMID: 33825847)

    Article  PubMed  Google Scholar 

  16. Monami M, Scatena A, Miranda C et al (2023) Panel of the Italian guidelines for the treatment of diabetic foot syndrome and on behalf of SID and AMD. Development of the Italian clinical practice guidelines for the treatment of diabetic foot syndrome: design and methodological aspects. Acta Diabetol. https://doi.org/10.1007/s00592-023-02150-8

    Article  PubMed  PubMed Central  Google Scholar 

  17. Guyatt GH, Oxman AD, Santesso N et al (2013) GRADE guidelines: 12. Preparing summary of findings tables-binary outcomes. J Clin Epidemiol 66(2):158–172. https://doi.org/10.1016/j.jclinepi.2012.01.012

    Article  PubMed  Google Scholar 

  18. Alexandrescu V, Hubermont G, Coessens V et al (2009) Why a multidisciplinary team may represent a key factor for lowering the inferior limb loss rate in diabetic neuro-ischaemic wounds: application in a departmental institution. Acta Chir Belg 109(6):694–700. https://doi.org/10.1080/00015458.2009.11680519

    Article  CAS  PubMed  Google Scholar 

  19. Blanchette V, Hains S, Cloutier L (2019) Establishing a multidisciplinary partnership integrating podiatric care into the Quebec public health-care system to improve diabetic foot outcomes: a retrospective cohort. Foot (Edinb) 38:54–60. https://doi.org/10.1016/j.foot.2018.10.001

    Article  PubMed  Google Scholar 

  20. Driver VR, Goodman RA, Fabbi M, French MA, Andersen CA (2010) The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. J Am Podiatr Med Assoc 100(4):235–241. https://doi.org/10.7547/1000235

    Article  PubMed  Google Scholar 

  21. Gibbons GW, Marcaccio EJ, Burgess AM et al (1993) Improved quality of diabetic foot care, 1984 vs 1990: reduced length of stay and costs, insufficient reimbursement. Arch Surg 128(5):576–581. https://doi.org/10.1001/archsurg.1993.01420170112017

    Article  CAS  PubMed  Google Scholar 

  22. Hsu CR, Chang CC, Chen YT, Lin WN, Chen MY (2015) Organization of wound healing services: The impact on lowering the diabetes foot amputation rate in a ten-year review and the importance of early debridement. Diabetes Res Clin Practice 109(1):77–84. https://doi.org/10.1016/j.diabres.2015.04.026

    Article  Google Scholar 

  23. Huizing E, Schreve MA, Kortmann W, Bakker JP, de Vries J, Ünlü Ç (2019) The effect of a multidisciplinary outpatient team approach on outcomes in diabetic foot care: a single center study. J Cardiovasc Surg (Torino) 60(6):662–671. https://doi.org/10.23736/s0021-9509.19.11091-9

    Article  PubMed  Google Scholar 

  24. Kim CH, Moon JS, Chung SM et al (2018) The changes of trends in the diagnosis and treatment of diabetic foot ulcer over a 10-year period: single center study. Diabetes Metab J 42(4):308–319. https://doi.org/10.4093/dmj.2017.0076

    Article  PubMed  PubMed Central  Google Scholar 

  25. Laakso M, Honkasalo M, Kiiski J et al (2017) Re-organizing inpatient care saves legs in patients with diabetic foot infections. Diabetes Res Clin Practice 125:39–46. https://doi.org/10.1016/j.diabres.2017.01.007

    Article  Google Scholar 

  26. Lo ZJ, Chandrasekar S, Yong E et al (2022) Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: a case-control study. Int Wound J 19(4):765–773. https://doi.org/10.1111/iwj.13672

    Article  PubMed  Google Scholar 

  27. Martínez-Gómez DA, Moreno-Carrillo MA, Campillo-Soto A, Carrillo-García A, Aguayo-Albasini JL (2014) Reduction in diabetic amputations over 15 years in a defined Spain population. Benefits of a critical pathway approach and multidisciplinary team work. Rev Esp Quimioter 27(3):170–179

    PubMed  Google Scholar 

  28. Meltzer DD, Pels S, Payne WG et al (2002) Decreasing amputation rates in patients with diabetes mellitus. An outcome study. J Am Podiatr Med Assoc 92(8):425–428. https://doi.org/10.7547/87507315-92-8-425

    Article  PubMed  Google Scholar 

  29. Nason GJ, Strapp H, Kiernan C et al (2013) The cost utility of a multi-disciplinary foot protection clinic (MDFPC) in an Irish hospital setting. Ir J Med Sci 182(1):41–45. https://doi.org/10.1007/s11845-012-0823-8

    Article  CAS  PubMed  Google Scholar 

  30. Nather A, Siok Bee C, Keng Lin W et al (2010) Value of team approach combined with clinical pathway for diabetic foot problems: a clinical evaluation. Diabet Foot Ankle. https://doi.org/10.3402/dfa.v1i0.5731

    Article  PubMed  PubMed Central  Google Scholar 

  31. Plusch D, Penkala S, Dickson HG, Malone M (2015) Primary care referral to multidisciplinary high risk foot services - too few, too late. J Foot Ankle Res 8:62. https://doi.org/10.1186/s13047-015-0120-7

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Riaz M, Miyan Z, Waris N et al (2019) Impact of multidisciplinary foot care team on outcome of diabetic foot ulcer in term of lower extremity amputation at a tertiary care unit in Karachi Pakistan. Int Wound J 16(3):768–772. https://doi.org/10.1111/iwj.13095

    Article  PubMed  PubMed Central  Google Scholar 

  33. Yesil S, Akinci B, Bayraktar F, et al. Reduction of major amputations after starting a multidisciplinary diabetic foot care team: single centre experience from Turkey. Exp Clin Endocrinol Diabetes 2009;117(7):345–9. (In eng). DOI: https://doi.org/10.1055/s-0028-1112149.

  34. Bus SA, van Netten JJ, Monteiro-Soares M, Lipsky BA, Schaper NC (2020) Diabetic foot disease: “the times they are a changin.” Diabetes Metab Res Rev. https://doi.org/10.1002/dmrr.3249

    Article  PubMed  PubMed Central  Google Scholar 

  35. Carinci F, Uccioli L, Massi Benedetti M, Klazinga NS (2020) An in-depth assessment of diabetes-related lower extremity amputation rates 2000–2013 delivered by twenty-one countries for the data collection 2015 of the organization for economic cooperation and development (OECD). Acta Diabetol 57(3):347–357. https://doi.org/10.1007/s00592-019-01423-5. (Epub 2019 Oct 11 PMID: 31605210)

    Article  PubMed  Google Scholar 

  36. Lazzarini PA, Raspovic KM, Meloni M, van Netten JJ (2023) A new declaration for feet’s sake: Halving the global diabetic foot disease burden from 2% to 1% with next generation care. Diabetes Metab Res Rev. https://doi.org/10.1002/dmrr.3747

    Article  PubMed  Google Scholar 

  37. Lombardo FL, Maggini M, De Bellis A, Seghieri G, Anichini R (2014) Lower extremity amputations in persons with and without diabetes in Italy: 2001–2010. PLoS ONE 9(1):e86405. https://doi.org/10.1371/journal.pone.0086405.PMID:24489723;PMCID:PMC3904875

    Article  PubMed  PubMed Central  Google Scholar 

  38. Monge L, Gnavi R, Carnà P, Broglio F, Boffano GM, Giorda CB (2020) Incidence of hospitalization and mortality in patients with diabetic foot regardless of amputation: a population study. Acta Diabetol 57(2):221–228. https://doi.org/10.1007/s00592-019-01412-8. (Epub 2019 Aug 29 PMID: 31468200)

    Article  PubMed  Google Scholar 

  39. Meloni M, Andreadi A, Bellizzi E et al (2023) A multidisciplinary team reduces in-hospital clinical complications and mortality in patients with diabetic foot ulcers. Diabetes Metab Res Rev 9:e3690. https://doi.org/10.1002/dmrr.3690

    Article  Google Scholar 

  40. Anichini R, Brocco E, Caravaggi CM et al (2020) SID/AMD diabetic foot study group. Physician experts in diabetes are natural team leaders for managing diabetic patients with foot complications. A position statement from the Italian diabetic foot study group. Nutr Metab Cardiovasc Dis 30(2):167–178. https://doi.org/10.1016/j.numecd.2019.11.009

    Article  CAS  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Systems of Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy

    Marco Meloni & Luigi Uccioli

  2. Department of Endocrinology and Diabetology, CTO Hospital, 00145, Rome, Italy

    Laura Giurato & Luigi Uccioli

  3. AMD-Italian Association of Clinical Diabetologists, Milan, Italy

    Luca Monge

  4. Pordenone Hospital, Pordenone, Italy

    Cesare Miranda

  5. Ospedale San Donato, Arezzo, Italy

    Alessia Scatena, Matteo Apicella & Michele Mantuano

  6. Azienda Ospedaliero Universitaria Careggi, Largo Brambilla 3, 50141, Florence, Italy

    Benedetta Ragghianti, Giovanni Antonio Silverii & Matteo Monami

  7. Azienda Ospedaliera Santa Maria Della Misericordia, Ospedale Di Perugia, Perugia, Italy

    Cristiana Vermigli, Giuseppe Murdolo, Eleonora Bianchini & Francesco Gaggia

  8. University Hospital of Padua, Padua, Italy

    Alessandro De Cassai

  9. Policlinico Abano Terme, Padua, Italy

    Antonio Volpe

  10. Asl Roma 4, Civitavecchia, Italy

    Rodolfo Tramonta

  11. SIMG- Italian Society of General Medicine, Florence, Italy

    Gerardo Medea

  12. Università Cattolica del Sacro Cuore, Rome, Italy

    Corrado Bordieri

  13. Cisanello Hospital and University of Pisa, Pisa, Italy

    Marco Falcone

  14. Azienda Sanitaria Friuli Occidentale, Pordenone, Italy

    Laura Stefanon

  15. Sapienza University, Rome, Italy

    Andrea Bernetti

  16. Associazione Di Volontariato Piede Diabetico Umbria ODV, Perugia, Italy

    Cristina Cappella

  17. University of Bologna, Policlinico Sant’Orsola-Malpighi, Bologna, Italy

    Mauro Gargiulo

  18. Scuola Superiore Sant’Anna, Pisa, Italy

    Valentina Lorenzoni

  19. Ospedale Sandro Pertini, Rome, Italy

    Germano Scevola

  20. Azienda Ospedaliera Regionale “San Carlo”, Potenza, Italy

    Eugenio Stabile

  21. Azienda Sanitaria Universitaria Giuliana Isontina, Monfalcone, Italy

    Roberto Da Ros

  22. ASL Città Di Torino, Turin, Italy

    Carlotta Gauna

  23. ASL TO5, Chieri, Turin, Italy

    Francesco Romeo

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  1. Marco Meloni
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  2. Laura Giurato
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For the Panel of the Italian Guidelines for the Treatment of Diabetic Foot Syndrome and on behalf of SID and AMD

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Meloni, M., Giurato, L., Monge, L. et al. Effect of a multidisciplinary team approach in patients with diabetic foot ulcers on major adverse limb events (MALEs): systematic review and meta-analysis for the development of the Italian guidelines for the treatment of diabetic foot syndrome. Acta Diabetol 61, 543–553 (2024). https://doi.org/10.1007/s00592-024-02246-9

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