Declining offloading rates in Belgian Recognized Diabetic Foot Clinics (RDFC): results from an audit-feedback quality improvement initiative.

<p><strong>Aim:</strong> To evaluate how DFU (Diabetic Foot Ulcer) are offloaded in RDFC and the evolution over time. RDFC receive their results after each audit for benchmarking (IQED-Foot project).</p> <p><strong>Method:</strong> Comparison of offloading methods used in 2 audits (2011 and 2013/14). Audits characteristics are described in table 1. In each audit, RDFC registered the first 52 diabetic patients over a 1-year period with a “new” foot problem: DFU of Wagner grade 2 or more and/or active Charcot foot (table 2). Off-loading was categorized as follows: 1. <strong>knee-high device</strong>, removable or not (TCC, Diabetic walkers...), 2 ankle-high <strong>shoe</strong> or cast shoe, 3. <strong>other</strong> off-loading techniques around the ulcer (felt, orthoses). 4. <strong>No off-loading</strong>. In case of multiple means of off-loading, the most elaborate one was selected.</p> <p><strong>Results /Discussion:</strong> Population characteristics in 2013/14 are described in table 3. For plantar ulcers, the overall offloading rate diminished significantly between 2011 and 2013/14, from 84.6% to 76.3% (P=0.01). A non-significant decrease was observed in the use of shoes (42.3 and 34.7% in 2011 and 2013/14 respectively, P>0.05), and no decrease in knee-high off-loading (14.8 and 14.7%) and other off-loading techniques (24.8 and 23.4%). For dorsal ulcers,  the overall off-loading rates were lower and the decline between 2011 and 2013/14 more pronounced (73.1 and 53.7%, P<0.001), affecting both ankle-high off-loading (31.1 and 21.9%, P=0.02) and other off-loading techniques (30.4 and 19.9%, P=0.02), but not knee-high off-loading (7.0 and 8.1%).</p> <p><strong>Conclusion:</strong> Periodical audits in Belgian Recognized Diabetic Foot Clinics have shown a decline in offloading rates. The percentage of patients without any offloading device is increasing. Audit and feedback including non-public anonymous benchmarking has not been able to prevent this decline. Knowing that offloading is the cornerstone of DFU treatment these results are worrying, although overall off-loading rates were comparable to those reported in Eurodiale. Efforts are needed to understand and tackle the barriers towards a correct application of gold standard offloading techniques.</p>