In a recent retrospective study out of India, researchers found that patients with diabetic foot complications treated via virtual video consultations during the COVID-19 pandemic had similar wound healing, amputation and mortality rates as patients treated on-site at a diabetic foot clinic the year prior to the pandemic.
According to the study, published recently by PLoS One, the first treatment group was comprised of 549 patients with diabetic foot complications who were assessed and treated through teleconsultations between April and September 2020.1 The second treatment group had 650 patients who received on-site evaluation and care at a diabetic foot clinic between April and September 2019. Rastogi and colleagues noted the first treatment group included 227 patients who had an active diabetic foot ulcer (DFU) at the start of the pandemic-related lockdown and 32 patients who developed a new DFU during the pandemic. The pre-pandemic treatment group included 366 patients with an active DFU. The study authors noted that patients with severe DFUs were excluded from the study.
Wound reduction or closure occurred in 78.4 percent of the pandemic treatment group treated via teleconsultations in comparison to 76 percent of the pre-pandemic treatment group treated on-site at a diabetic foot clinic, according to Rastogi and coworkers.1 They also noted that amputations (major and minor) were necessary in 5.4 percent of the pandemic treatment group in comparison to 6.8 percent of the pre-pandemic treatment group. The study authors also noted similar mortality rates with 3.8 percent in the teleconsultation group versus 4.3 percent in the pre-pandemic group.
Barbara Aung, DPM, DABPM, CWS, was not surprised by the study results as the findings mirrored what she saw in her patients during the pandemic.
“Patients who were previously seen in the clinic on a set schedule, based on a risk classification system, experienced few complications when we reserved face-to-face visits for those at highest risk and virtual visits for those with low risk for wounds or infections during the pandemic-related lockdowns,” notes Dr. Aung, a Fellow of the American Professional Wound Care Association and a Diplomate of the American Board of Podiatric Medicine. “For patients who had the greatest risk for ulceration and infection, if we were able to get them in the office clinic early in the disease process, the resulting complication was mitigated to a minor amputation or debridement.”
While Dr. Aung notes her practice never shut down during the pandemic, she offered virtual visits since the outset of the pandemic for patients who felt uneasy coming into the office. However, she acknowledges some challenges with lighting and images for virtual visits.
“Often, camera images are not well lit so they can give you a deceiving view of wounds and cellulitis,” points out Dr. Aung, who is in private practice in Tucson, Ariz.
In the study, Rastogi and colleagues noted that patients for virtual visits were instructed to lie supine in a well-lit room with a family caregiver and local community nurse close by.1 Dr. Aung notes that having a trained nurse or caregiver is more advantageous than the patient being alone for virtual visits “as patients often can’t get to the bottom of their feet.”
While Dr. Aung recalls other specialists, such as vascular surgeons, in her area having availability virtually or in-person during the height of the pandemic, she says referring patients back to primary care providers was particularly challenging.
“The primary care providers were in most instances shut down completely for several weeks and some for months,” recalls Dr. Aung. “I am not sure what that was due to. Patients were not able to get a hold of their doctors and waited several days, if not weeks, to have someone from the office call back. Personally, I was able to call some of them as I had their cell phone numbers, but it was a strain.”
Dr. Aung says she is continuing to offer telemedicine options that are either self-pay options for patients or covered by insurance. However, she does note that Arizona Gov. Doug Ducey recently signed an executive order requiring any insurance plan in the state to pay for telemedicine visits.2
While Haywan Chiu, DPM, FACFAS, says it remains to be seen where virtual visits can fit into the current health-care system, he says there is potential for this technology in rural areas where it may take hours to get to a physician for care.
“Even if access to the technology required to successfully execute a virtual encounter is limited due to financial reasons, I foresee a great public health benefit to setting up depots for virtual health-care visits in these rural areas,” suggests Dr. Chiu, who is board-certified in foot surgery and reconstructive rearfoot and ankle surgery.
Dr. Chiu says virtual visits can’t replace in-person visits for wound care. Dr. Aung notes there are situations that may be conducive to telemedicine such as discussing lab results or monitoring ongoing therapy with medications. When it comes to monitoring stable healing wounds, Dr. Aung suggests that video monitoring may enable patients to come in once a month rather than every week. That said, Dr. Aung concurs that in-person care is essential for optimal wound management.
“… In situations in which there is a need to palpate or debride, or situations on virtual exam in which the condition appears worse than what the patient may have thought, there is no substitute for palpation of the patient and face-to-face exchange with the patient,” maintains Dr. Aung.
- Rastogi A, Hiteshi P, Bhansali AA, Jude EB. Virtual triage and outcomes of diabetic foot complications during Covid-19 pandemic: a retrospective, observational cohort study. PLoS One. 2021;16(5): e0251143.
- Office of the Governor Doug Ducey. Governor Ducey signs legislation to dramatically expand telehealth. Available at: https://azgovernor.gov/governor/news/2021/05/governor-ducey-signs-legislation-dramatically-expand-telehealth . Published May 5, 2021. Accessed July 20, 2021.