While substantial research has demonstrated the potential for preventing the adverse outcomes of type 2 diabetes [
The estimated adult prevalence of diabetes in Guyana was 15.5% in 2011 [
The Phase 1 goal was to create health system changes in evaluation and management to improve foot care in PWD and reduce diabetes-related LEA at GPHC, while Phase 2 expanded this to 6 administrative regions, comprising 90% of the population, and added training in the management of diabetes and hypertension.
Clinical activities resided within the Guyanese public health system and staff and resource costs were paid by Ministry of Health (MoH). Multilevel knowledge to action (K2A) cycles was utilized to identify the challenges facing the Guyanese health care system and develop the intervention. Both process and clinical outcomes were monitored. Participants were all persons with type 2 diabetes presenting to the GPHC or to regional facilities with personnel trained in the project, and the care provided to them was based on the decision of these personnel and patient wishes. Patient data was entered into a ministry approved database and identifiable personal information, apart from sex and age, was withheld from the authors. Since this was a quality improvement (QI) project, run under the auspices of the Ministry of Health of Guyana in public health facilities, approval of an ethics committee was not required. Project oversight and coordination was provided by steering committees, meeting regularly, with both Canadian and Guyanese members, including Ministry of Health officials.
The key interventions are detailed elsewhere [
Given the limited local resources, it was important to allocate the available resources effectively, and this was facilitated by using clinical screening tools to recognize loss of protective sensation, and identification of the patient at high risk of ulceration or amputation. The simplified 60-second screening tool was developed [
Targeted process outcomes were the establishment of a National Centre of Excellence in foot care at GPHC and 7 regional foot care centers, project tools accepted and used by the MoH, measurement of HbA1c and blood pressure for people with diabetes, identification of the high risk foot using the simplified 60-second screening tool, and appropriate referral to regional or national DFCs. Targeted clinical outcomes included reduction in major LEA at GPHC and measurement of the proportion of PWD with HbA1c <9% (75 mmol/mol) and BP
Continuous variables were summarized using means (SD) and median (IQR) and tested using two sample
Time series analysis of diabetes-related major amputations at Georgetown Public Hospital Corporation 2005–2012.
Key opinion leader (KOL) team: A total of 16 trainees (7 doctors, 1 medex, 4 nurses, 3 rehabilitation specialists, and 1 diabetic foot care worker) participated in the International Interprofessional Wound Care Course in 5 cohorts; 14 completed the course and 10 are currently working in the KOL team. The KOL team then trained a total of 340 other Guyanese health care professionals (F/M = 1.8) (Phase 1: 65 HCP in 4 workshops; Phase 2: 275 HCP in 18 workshops). These professionals staff 8 DFCs and 89 health facilities providing chronic disease care.
The simplified 60-second screening tool was developed in Guyana [
From July 2010 to March 2013, 7567 PWD were assessed with F/M = 2.09 [
In the 42 months before the DFC opened, the mean monthly number of amputations was 7.95 (SD ± 4.05) and this fell significantly to 3.89 (SD ± 2.30) in the 54 months after the DFC opened through to December 2012 (
Of even greater significance is the marked reduction in proportion of inpatients with diabetic foot complications subjected to major amputation (Table
Diabetic foot (DF) admissions and amputation rates at Georgetown Public Hospital Corporation.
Variable | Before DFC (30 months) | After DFC (22 months) | Analysis |
---|---|---|---|
DF admissions (ward records) | 633 | 924 | |
Number of amputations | 262 | 110 | |
Average monthly proportion DF patient with major amputation | 41.4% | 11.9% |
|
The number of specific types of major amputations, their means, and medians are shown in Table
Major amputations by type at Georgetown Public Hospital Corporation.
Variable | Before intervention | After intervention | Test statistic |
|
---|---|---|---|---|
Time in months | 42 | 48 | ||
|
124 | 113* | ||
Mean (SD) | 2.95 (2.44) | 2.13 (1.81) | −1.82 ( |
0.07 |
Median (IQR) | 2 (1–4) | 2 (1–3) | 1.47 ( |
0.14 |
|
166 | 41* | ||
Mean (SD) | 3.95 (2.64) | 0.77 (1.05) | −7.35 ( |
<0.0001 |
Median (IQR) | 3 (2–5) | 0 (0-1) | 6.82 ( |
<0.0001 |
The changes in the frequency of AKAs and BKAs before and after the intervention give an indication of the limitations of this kind of project focused on primary care. While BKAs showed an 80% and significant reduction after the DFC was opened, AKAs showed no change. Currently there is no vascular surgical capacity in Guyana to treat vascular insufficiency, a common comorbidity in diabetic foot complications. We suggest that patients with both diabetic foot complications and uncorrected vascular insufficiency are more likely to require AKAs. This service gap could explain the lack of decline in AKAs after intervention. It would also speak to the need for developing a vascular surgical capacity in resource-constrained settings, if limb salvage in the diabetic foot is to be optimized. Figure
We have already reported on the divergence from global averages of the sex ratios of type 2 diabetes in Guyana and have estimated that the odds ratio for women compared to men is 2.486 (95% CI 2.442, 2.531,
The MoH embraced the model, which is described in detail elsewhere [
We demonstrated that it is possible to introduce the best practice methods to evaluate for the high risk foot in people with diabetes and achieve sustained improvements in evaluation and care of foot ulcers. After the project began GPHC achieved a marked and sustained reduction both in major amputation numbers and in the proportion of inpatients with diabetic foot complications requiring major amputation. That this reduction occurred almost immediately after project commencement suggests that surgeons embraced the importance of maintaining limb integrity. Change was likely sustained by provision of new alternate methods and dedicated clinic spaces for treatment based on context specific practice guidelines. Vascular surgery capacity is essential to maximize limb salvage.
Translating clinical guidelines and QI principles into practice, in both the developed and developing world is challenging. In low and middle income countries (LMIC) the challenge is to deploy interventions that are cost saving or cost effective. This requires empirical research in a variety of contexts. Our project contributes to this research. One of our next steps is to investigate the transferability of our model to another limited resource setting.
Above knee amputation
Below knee amputation
Blood pressure
Confidence interval
Canadian International Development Agency
Continuous medication education
Diabetes and foot center
Female to male ratio
Guyana Diabetes and Foot Care Project
Georgetown Public Hospital Corporation
Glycosylated hemoglobin
Health care professional
International Diabetes Federation
International Interprofessional Wound Care Course
Knowledge to action
Key opinion leader
Lower extremity amputation
Low and middle income countries
Ministry of Health
Plantar pressure redistribution
Person with diabetes
Quality improvement
Standard deviation.
The funding organizations were independent of the design and conduct of the study, the collection, management, analysis, and interpretation of the data, or the preparation of the paper. Drs. Brian Ostrow, R. Gary Sibbald, and Julia Lowe received travel funding to Guyana from Guyana Diabetes and Foot Care Project. Drs. R. Gary Sibbald and Julia Lowe received honoraria for their participation. Dr. Gerald Lebovic’s institution received payment for statistical analysis.
R. Gary Sibbald, Brian Ostrow, and Julia Lowe wrote the first draft of the paper. Julia Lowe, R. Gary Sibbald, Nashwah Y. Taha, Gerald Lebovic, Brian Ostrow, Madan Rambaran, RK, Indira Bhoj, and Carlos Martin contributed to the writing of the paper. Julia Lowe, R. Gary Sibbald, Nashwah Y. Taha, Gerald Lebovic, Brian Ostrow, Madan Rambaran, Indira Bhoj, and Carlos Martin read and met ICMJE criteria for authorship. Julia Lowe, R. Gary Sibbald, Nashwah Y. Taha, Gerald Lebovic, Brian Ostrow, Madan Rambaran, Indira Bhoj, and Carlos Martin agree with paper results and conclusions.
Funding for this study was provided by the Government of Canada through the Canadian International Development Agency: Phase 1: Canadian-Caribbean Cooperation Fund, Project no. 530-0272-G015: “Technical Assistance for the Development of an enhanced diabetic foot program at GPHC in Guyana,” Lead Organization Georgetown Public Hospital Corporation, and Phase 2: Canadian Partnership Branch, Project no. S064802: “Regionalization of Comprehensive Diabetes Care in Guyana, The Guyana Diabetic Foot Project, Phase 2,” Lead Organization Canadian Association of General Surgeons. Further financial support was provided by the Pan American Health Organization, the Guyana Ministry of Health, and the Georgetown Public Hospital Corporation. The Banting and Best Diabetes Centre at the University of Toronto funded the statistical analysis. The authors gratefully acknowledge the participation and contributions of Guyanese Ministers of Health: Hon. Dr. Leslie Ramsammy and Hon. Dr. Bheri Ramsaran; Guyana Diabetes and Foot Care Project Team: Guyanese Team: Rolinda Kirton (project manager), Reneeka Persaud (KOL doctor), Sonia Gray (KOL doctor), Rajiv Singh (KOL doctor), Kumar Sukhraj (KOL doctor), Alexis Reid (KOL nurse), Melinda Thomas (KOL nurse), Joanne Blenman (KOL nurse), Maria Jeffers (KOL medex), Debita Harripersaud (KOL physiotherapist), Amanda LaRose (KOL rehabilitation assistant), Melanie Alleyne-English (KOL rehabilitation assistant), Jacqueline Williams (KOL dietitian), Carlos Martin (KOL doctor), Indira Bhoj (KOL doctor), Pheona Rambaran (laboratory director GPHC), Madan Rambaran (University of Guyana), and Shamdeo Persaud (chief medical officer, Ministry of Health, Republic Guyana); Canadian Team: R. Gary Sibbald (doctor, University of Toronto), Brian Ostrow (project coordinator, University of Toronto), Julia Lowe (doctor, University of Toronto), Nashwah Taha (doctor, University of Toronto), Kevin Woo (nurse), Marjorie Fierheller (nurse), Pat Coutts (nurse), Sunita Coelho (nurse), Heather Nesbeth (diabetes nurse educator), Carolyn Lawton (diabetes nurse practitioner), Laura lee Kozody (chiropodist), Anamelva Revoredo (chiropodist), and Jasmin Lidington (executive director, Canadian Association of General Surgeons).