Referral of patients with diabetic foot ulcers in four European countries: patient follow-up after first GP visit

Objective: This study aimed to analyse the characteristics of patients, including demographics, medical history and treatment, with a diabetic foot ulcer (DFU) during their first follow-up visit to a general practitioner (GP). Methods: A two-part quantitative online questionnaire was distributed among GPs in France, UK, Germany and Spain. Part one entailed a survey of GP's perceptions of referrals for DFU. Part two collected data on recently managed DFU cases. The percentage of responses was compared for each question and across the four countries for significant differences. Results: In part one of the study, 600 questionnaires were collected (150 per country) and 1188 patients managed for a DFU were included in the second part. About 88% of patients had type 2 diabetes, with a significant proportion of suboptimal control (average HbA1c: 10.64mmol/l). A patient complaint led to diagnosis in 60% of the cases. Wounds were found to be more frequently located in the toes and midfoot, and were superficial (according to the Texas Wound Classification system) in 80% of the cases. More than two-thirds of patients developed small wounds (<5cm(2)); more than half of them had infected wounds. Approximately 50% of wounds were ischaemic, which triggered the onset of a DFU. Follow-up wound examinations before and after hospitalisation were performed by nurses, except in Germany where GPs undertook this role, including prescribing offloading devices and in the UK where follow-up was managed by podiatrists. Ischaemia, wound necrosis, suspected osteomyelitis and absence of wound healing were the primary reasons for hospital admission during the first month after diagnosis. Conclusion: Delay in specialised foot care is a recurring topic in the treatment of DFUs, even with different health-care structures across Europe. Knowledge and education on DFUs should be reinforced among GPs and nurses to establish a global DFU care network between primary and specialised care, avoid hospitalisation and adequately manage high-risk patients.