The Crisis in Diabetic Footcare During the Pandemic
John has diabetes. Like many diabetics he developed ulcers on the bottom of his feet that have to be carefully monitored and treated by a professional. Because of the COVID-19 crisis his podiatrist was forced to close his clinic, leaving John without access to treatment. His foot ulcer became infected. He tried to receive treatment at his local hospital's emergency department, but he was turned away because his condition made him vulnerable to infection by the coronavirus. The infection spread and a few days later, John died of the infection.
Except for the fictitious name, this is a true story. It would be shocking enough on its own, but regrettably many of the nearly 30,000 people with diabetes across Ontario who have a foot ulcer are having to deal with exactly the same challenges every day. So far during the COVID-19 pandemic, the offices of the Ontario Podiatric Medical Association have been swamped by calls from diabetic patients whose podiatrist's clinic has had to close because they are deemed "non-essential" and for whom there is no ready alternative. The plight of those patients has prompted me to prepare this opinion piece.
People with diabetes experience compromised sensation and blood flow to their feet and other limbs that in 15-20% of cases leads to ulcers. It also makes them susceptible to infection. Regular evaluation and care by a podiatrist, chiropodist, foot care nurse, or other qualified health care practitioner has been proven to substantially reduce the rate of infection, hospitalisation and lower limb amputation. Because they often lose sensation in their feet, practices that are routine for you and me, such as trimming toenails and debriding calluses is a risky procedure for diabetics because they may unknowingly cut themselves and cause an infection that can quickly lead to severe complications. It may come as a surprise, therefore, that foot care for people with diabetes in Ontario is not considered an "essential" or "emergency" service that can be provided by podiatrists and other allied healthcare practitioners during the pandemic crisis. Since in-person treatment isn't accessible, virtual consultations or telehealth could be an alternative.
A McMaster University study, while noting that more research needs to be done, found tha people with diabetes who use telemedicine for ulcer car may not face a greater risk of health problems than those treated in-person and have the advantage of no travelling Although virtual consultations are allowed by the regulatory College, the Ministry of Health has refused OHIP coverage for virtual visits by podiatrists. By contrast, outpatient podiatry limb preservation clinics in Alberta have been kept open by the government to manage diabetic foot conditions throughout the emergency and returned to full operation on May 4. As a consequence, the number and severity of foot problems in Ontario will inevitably rise significantly during this pandemic. Complications will too often require acute care and Ontario hospitals need to prepare for a tsunami of patients presenting at emergency departments. Limb amputations that could have been avoided by proper and timely treatment and are already at crisis levels in Ontario will inevitably increase. Incidentally, the median life expectancy for an individual who was gone through a lower limb amputation is 3.5 years, which is worse than for many forms of cancer.
In addition to my practice in Windsor, I am also employed as a podiatric physician and surgeon at a hospital in Michigan. That hospital has given the first order of priority to diabetic patients who present with urgent conditions that cary morbid consequences, such as diabetic foot infections and ulcer wound care. Multiple studies have demonstrated the value of a multidisciplinary approach to the treatment of diabetic patients. The ideal diabetic limb preservation model in every part of the world, except Ontario, has a podiatrist leading the multidisciplinary team, along with vascular surgeons, physicians and nurses. Yet, Ontario governments have largely ignored foot care. Even before the pandemic, the Canadian Association of Certified Foot Care Nurses declares the status of foot care, particularly for seniors, as "deplorable". In addition to marginalising diabetic foot care during the pandemic, Ontario has adopted what can only be interpreted as a perverse attitude to the podiatric profession. In 1993, legislation was passed to prohibit the registration of any additional podiatrists in Ontario. The profession is literally dying out; there are only 54 podiatrists in active practice left in Ontario --- the lowest practitioner: public ratio in the developed world. The youngest of those practitioners is 54. Ontario has also been more restrictive than nearly all jurisdictions in North America, including British Columbia and Alberta, as to what podiatrists are allowed to do for their patients. As a consequence, podiatrists in this province are forced to practise at far below the level of competencies they have acquired.
Ontario desperately needs a proper foot care model that includes a strategy to stem the tide of diabetes-related lower limb amputations in the province. That strategy needs to ensure that people with diabetes have access to the treatment they need regardless of the circumstances and the strategy also needs to utilise to the fullest the expertise that each profession can bring.
The COVID-19 emergency has brought the crisis of foot care, particularly diabetic foot care, to the fore. The time to fix the problem is now.
James Hill, Doctor of Podiatric Medicine, FACFAS
President, Ontario Podiatric Medical Association
