Successful network

“What happens to people with diabetic foot syndrome depends on the efficiency of local structures,” says Dr. Peter Mauckner. Patients in the Cologne/Leverkusen metropolitan area are lucky in this regard, as Mauckner, a diabetes specialist , and several of his colleagues have established an extremely successful network in the region.

A missed target and a somewhat shocking study – those were the two driving forces that accelerated the establishment of the Netzwerk Diabetischer Fuß Köln und Umgebung e.V. (www.fussnetz-koeln.de). The St. Vincent Declaration of 1989 had called for a 50-percent reduction in the number of diabetes-related amputations in Europe within five years. “When the Leverkusen Amputation Reduction Study1 was released in 2000, it became disturbingly clear to us that we were extremely far from achieving the target in Germany,” says Dr. Peter Mauckner, Chief Senior Physician for Diabetology at St. Remigius Hospital in the Opladen district of Leverkusen. “At the same time, no one realized that the relevant figures for Germany, which when extrapolated would amount to 30,000 amputations per year, were actually pretty good.”2 Still , Germany as a whole was suddenly taking a closer look at the “bad situation” in Leverkusen. “And we in Leverkusen couldn’t stand idly by, of course,” Mauckner explains. That’s because the specialists in Cologne/Leverkusen had already been looking for ways to improve the treatment of diabetic foot ulcers for quite some time.

Binding structural quality

“It was clear that without intensive interdisciplinary cooperation, we would not be able to get diabetes-related secondary diseases under control ,” says Mauckner. Together with a group of medical colleagues, he therefore launched a painstaking and groundbreaking initiative for creating structural and process-related quality standards for everyone involved in the treatment of diabetics. This was no easy task, particularly because the concept also meant incorporating professionals from many different sectors and disciplines into the project. “A key player in this respect was and remains the family physician, as it’s important to get general practitioners to find diabetes patients and direct them to the network,” Mauckner explains. “However, we managed to do this very successfully with the help of training sessions and periodic quality workshops. We also developed our own control component in the form of coordinating physicians. In other words, we have doctors for both the inpatient and outpatient side of things who assume overall responsibility for the treatment of individual diabetes patients and coordinate all the associated steps. For example, the coordinating physician at our hospital , St. Remigius, is the internist.” With this kind of setup, hospitalized patients are not sent from one department to another; instead, each member of the network visits patients directly at their beds, while the coordinating physician is responsible for all the documentation. “Documentation is very important to us,” says Mauckner. “For example, we all agreed to implement a clear and understandable system of mandatory documentation of all results. This was not just important for us and the patients; it also gave us leverage during the tough but ultimately successful negotiations we conducted to obtain initial funding for the network from the health insurance providers.” The provider companies wanted to make sure that the network would generate cost-saving potential. “Thanks to our extensive documentation, we were able to demonstrate that the amputation rate in our Netzwerk Diabetischer Fuß was 72 percent lower than the general rate,” says Mauckner. Moreover, the rate of major amputations (above the ankle) declined to approximately two percent. By comparison, the average for Germany as a whole is eight percent.

Applying expertise in a targeted manner

Network members include diabetologists, surgeons, angiologists, podologists, and orthotists. The key aspect of a network arrangement is that everyone does what they reasonably can (but no more) when called upon, and then enlists the help of the respective specialist. “Everyone in the network has an equal standing,” Mauckner explains. “Consider the case of a surgeon who performs highly specialized operations such as bypasses or flap transplantations. As soon as the patient is ‘let loose,’ the most important individual is now the podologist , whose job is to determine whether calluses have formed on the patient’s foot. If this is the case, the patient is then quickly sent to the family physician or the coordinating physician in order to get a foot orthosis prescribed that will ease the pressure.” And speaking of foot orthoses: “One of the main cost issues when treating diabetes patients involves the extensive use of custom-made orthopedic shoes, which isn’t always helpful. Because the family physicians and podologists in our network are aware of this issue, we can now get to patients at a very early stage and prescribe a soft cushioning foot orthosis to relieve the pressure. We’ve also moved away from the full-layer hard foot orthoses common in the Chantelau era, although these represented a very innovative and pioneering approach at the time. Today, we prefer more extensive pressure distribution and offer treatment based on PG 31.03.07 – making use of the transverse and lengthways arches of the foot and combining this approach with possibilities for local pressure relief.” Still , regardless of whether it’s custom or ready-made shoes with sole reinforcement and a suitable foot orthosis, the important thing is to check both the foot and the medical aid on a regular basis in order to identify changes and respond to them before they become problematic.

Second opinions prior to amputations

In order to further reduce the amputation rate for diabetic feet , the network also launched a major media campaign on second opinions several years ago. Even today, the network offers non-network hospitals the possibility to obtain an independent opinion within two days on whether a planned amputation is actually necessary or if other options are feasible. “The hospitals frequently take advantage of this service because our process quality is now justiciable,” Mauckner explains. “Unfortunately, one problem remains – namely the fact that you can still make a lot of money with amputations.”

1 Trautner C, Haastert B, Spraul M, et al. Unchanged incidence of lower-limb amputations in a German City, 1990-1998. Diabetes Care. 2001 May; 24(5):855-9.
2 In February 2016, the German Diabetes Association (DDG) cited a figure of approximately 50,000 diabetes-related foot amputations that were being performed each year.

Pictures: istockphoto.com/portishead1, Stefan Durstewitz, Bauerfeind