Diabetic foot in primary and tertiary (DEFINITE) care: An efficacious, synergistic and cost-effective multidisciplinary team model for diabetic foot care in Singapore

Abstract

Diabetic foot ulcers (DFUs) and lower extremity amputations (LEAs) threaten survival and quality of life (QoL) of patients, contributing to healthcare and economic burden. Guidelines advocate for a multidisciplinary team (MDT) approach, but limited literature exists on cost-effectiveness and collaboration with primary care. We present the outcomes of the Diabetic Foot in Primary and Tertiary (DEFINITE) Care program, an MDT initiative in Singapore across primary and tertiary care. Patients with DFU from June 2020 to 2022 were enrolled. Clinical outcomes encompassed one-year minor and major LEAs, mortality and LEA-free survival rates. Healthcare utilization outcomes included number of admissions, length of stay, and primary care and hospital visits. QoL and Patient Reported Outcome Measures (PROMs) were respectively assessed using the EuroQol Five-Dimensional Questionnaire and Diabetic Foot Ulcer Scale-Short Form. Results from DEFINITE were propensity-score matched against a retrospective cohort. Cost-effectiveness analysis was performed using Markov simulation. Subgroup analyses focused on at-risk populations, including patients without access to MDT clinics or podiatry, appointment defaulters, octogenarians, patients with end-stage renal failure and different primary care locations. Total of 2,798 patients, with a mean age of 65.7 years and majority males (61.4%), were included for analysis. DEFINITE Care patients had higher minor LEA and improved LEA-free survival rates, fewer and shorter hospital admissions, and enhanced QoL and PROMs. DEFINITE Care demonstrated greater cost-effectiveness when compared to traditional care. Outcomes varied among subgroups. DEFINITE Care is an efficacious and cost-effective MDT model which fosters collaboration between primary and tertiary care for diabetic limb salvage.