We engaged in a dialogue with two of the physician leaders of the Downtown East Toronto Ontario Health Team (DET OHT) Lower-Limb Preservation (LLP) project – Dr. Curtis Handford, family physician and Medical Director of the Primary and Community Care Program, and Dr. Charles de Mestral, a vascular surgeon and scientist – both affiliated with Unity Health's St. Michael’s Hospital site, a DET OHT partner organization. Together with interdisciplinary working groups comprising clinicians, community stakeholders, and patients, they collaborated to develop new change initiatives aimed at improving diabetic foot screening, enhancing care escalation, and expanding community-based chiropody capacity. Drs. Handford and de Mestral shared their perspectives on the program's significance and its prospects.
Before developing and implementing the DET OHT pathway for LLP, what were some of the significant care challenges for the providers and patients?
Dr. Curtis Handford: I can’t really speak for the patient perspective directly. Although, often the providers’ and patients’ perspectives overlap. From the providers’ perspective, we know there was a lot of confusion based on the preliminary environmental scan that we completed. One of the factors is that specialized foot care services covered by OHIP were generally not available to the majority of family physicians who do not work in team-based practices and their patients. So, patients who could not afford to pay for private chiropody services were often left with other ways to try to manage their problems, and then would at times end up needing to use the emergency room because of lack of other places to go. Confusion is the word I would use for the preliminary state.
Dr. Charles de Mestral: I would echo Curtis. My perspective as a provider at one end of the spectrum – receiving people who have wounds and sometimes performing amputations – is that there is a great disparity in both preventive care and timeliness of care across all different types of people and walks of life.
One thing related to disparities is the financial barrier. One of the areas where financial barriers come into play is footwear – people are not able to get a better pair of shoes to prevent wounds or prevent the recurrence of a wound after it is healed.
How is the LLP program at the DET OHT creating awareness about foot care and preventing non-traumatic, major lower-limb amputations for patients with diabetes and vascular diseases?
Dr. Curtis Handford: Primarily the way our demonstration program is creating awareness is amongst providers by creating tools and resources that guide providers in how patients can be managed and navigated through the system. Patient or public awareness is probably a little less well-developed at this stage of the project, but is something the OHT is beginning to explore.
Dr. Charles de Mestral: I do not think there was a lack of awareness about the risk of foot wounds and foot complications before this all started. But there was probably a need to support people’s knowledge around how to deal with this problem. From a hospital’s perspective, the whole program has raised the profile of limb preservation. It has acknowledged the expertise that exists at St. Michael’s Hospital, particularly chiropody and vascular. St. Michael’s has an important role in addressing this issue – a leadership role – certainly provincially and also nationally.
Dr. Handford – just to build on the point you made earlier about resources for primary care – how does the program support primary care providers, considering the context of limited primary care capacity in the current times?
Dr. Curtis Handford: That is a million-dollar question! If you want primary care providers to spend more time dealing with feet, you have to help them save that time somewhere else. In order to do more of something, they are going to have to do less of something else. I think the time saved is going to be through simpler navigation to cover chiropody resources and escalation to hospital-based care. We have tried to keep the screening recommendation as simple and as time efficient as possible and to not get providers bogged down in over- extensive screening of feet.
With current learnings and insights from the project, what do you hope the LLP can accomplish for the future of foot care and the overall quality of lives of patients?
Dr. Curtis Handford: For me, the hope is that everyone is getting care from the right place at the right time. The hope is that we can eliminate lower-limb amputations significantly over time. Being able to demonstrate an impact on that is a years-long, if not a generational endeavor. I think we can certainly start to see signals with the work that we have done in Downtown East Toronto by clarifying pathways for providers, providing education to the public, and ensuring we have an engaged team of partners across the Ontario Health Team.
Dr. Charles de Mestral: In the short term, perhaps, if our program can show some success based on the measures that we have for implementation, screening, and timely escalation of care, then we can maintain funding and see the lower-limb preservation become a priority at the same level as prevention of stroke, coronary ischemia, blindness, and kidney damage. And level the playing field when it comes to prevention at a health policy level provincially.
As this issue is not just contained to Downtown East Toronto, how do you think the pathway and the resources in the DET OHT can be leveraged beyond its catchment area?
Dr. Charles de Mestral: I think the screening tool is applicable in many places. There is some benefit to working within the Ontario Health Team framework, in that you can tailor the approach to screening and escalation of care to the resources that exist and tweak the capacity. The big-picture principles need to be applied everywhere and then they need to be tailored to the context people are in.
Any final thoughts and comments that you would like to add?
Dr. Curtis Handford: I am not saying that we do not still have work to do, but I will say that it is clinical pathways like this that give the Ontario Health Team the greatest chance of getting physicians excited about the work of the Ontario Health Team.