Telemedicine Follow-up in Primary Health Care for Diabetes-related Foot Ulcers (DiaFOTo)

• healing time for diabetes related foot ulcer [ Time Frame: one year ] [ Designated as safety issue: No ]
  Healing time for diabetes related foot ulcer measured from the time the person is included in the study until the foot ulcer is healed or the study ends (after 12 months).
  
  

• Total number of consultations per person at the Section of Endocrinology [ Time Frame: one year ] [ Designated as safety issue: No ]
  Number of consultations from baseline until the foot ulcer has healed
  
  
• sequela directly related to the foot ulcer [ Time Frame: one year ] [ Designated as safety issue: No ]
  From baseline until the foot ulcer has healed sequelae directly related to the foot ulcer: infection, hospitalization, osteomyelitis and vascular surgery during the study
  
  
• Diabetes-related stress [ Time Frame: one year ] [ Designated as safety issue: No ]
  Diabetes-related stress, measured by using the Problem Areas in Diabetes. Measured at baseline and when the ulcer has healed (or the end of the study)
  
  
• Symptoms of anxiety and depression [ Time Frame: one year ] [ Designated as safety issue: No ]
  symptoms of anxiety and depression, measured by using the Hospital Anxiety and Depression Scale at baseline and the end of the study.
  
  
• Nordic Patient Experiences Questionnaire [ Time Frame: one year ] [ Designated as safety issue: No ]
  Patient satisfaction with health care, measured by using the Nordic Patient Experiences Questionnaire. Measured at baseline and the end of the study.
  
  
• EQ-5D [ Time Frame: one year ] [ Designated as safety issue: No ]
  Health status and cost utility, measured by using the EQ-5D from the EuroQol Group at baseline and the end of the study.
  
  
• Sick leave [ Time Frame: one year ] [ Designated as safety issue: No ]
  Sick leave (number of days with a medical certificate) measured by obtaining data from the Norwegian Sick Leave Registry measured from baseline unntil the ulcer is healed (or at the end of the study)
  
  
• A new foot ulcer appears, the incidence of amputation and survival. [ Time Frame: 2 and 3 years after the end of the study ] [ Designated as safety issue: No ]
  The time elapsing before a new foot ulcer appears, the incidence of amputation and survival.
  
  

The increasing prevalence of diabetes, especially type 2 diabetes, combined with a steadily increasing proportion of older people in the population, will present enormous challenges for health care services in Norway. An epidemiologic study of diabetes-related foot ulcers among community-dwelling adults, including older people, based on data from the Nord-Trøndelag Health Study (HUNT2) showed that a history of foot ulcer was significantly associated with increased mortality and that about 10% of the people with diabetes reported a history of foot ulcer. Studies have shown that a foot ulcer is associated with reduced quality of life, social limitations and pain. Treating foot ulcers costs society considerable money. These results emphasize that diabetes-related foot ulcers represent a challenge for the individual and for health care services. Health care services need to rapidly begin treatment for people with diabetes-related foot ulcers to ensure high-quality treatment.

Telemedicine innovations for health care services have developed considerably in recent decades. The National Health Plan for Norway (2007-2010) emphasizes that the use of information and communication technologies is an important way of achieving health policy aims in establishing more integrated diagnosis, treatment and care pathways across organizational boundaries. Qualitative studies of diabetes-related foot ulcers have shown that using telemedicine equipment enables follow-up care of similar quality to traditional consultations while enabling more flexible organization and greater patient satisfaction. A few minor quantitative studies show positive gains when telemedicine equipment is used in following up diabetes-related foot ulcers, but no randomized controlled studies have been performed in this field. Further, studies focusing on the more long-term effects are lacking.

The project is in accordance with national guidelines and will contribute to increasing the focus on research related to integrated care. We expect this project to provide evidence about alternative care pathways with a holistic approach that could moderate increases in the cost of health care services by delivering a larger proportion of services in municipal primary care. The project will be able to provide new evidence on meeting the challenges of diabetes-related care more systematically and proactively. We expect that the results of this study will contribute to showing the extent to which treatment at the lowest effective service level will be more cost-effective and of good or better quality than traditional clinical follow-up. This study can and will contribute to setting priorities for the users' needs for flexible health services and enabling more patients to be treated near their homes.

If the study finds evidence of positive health gains for the individual people with diabetes and contributes to high quality of care, this new model can be implemented in the entire Stavanger Hospital Trust. This approach will enable the multidisciplinary team in specialist health care to be used more appropriately, and the team will be more accessible for health care personnel in municipal primary health care. This model can be transferred to other hospital trusts and contribute to improving knowledge on diabetes among nurses in municipal primary health care.