Introduction The rise of non-communicable diseases such as diabetes is one of the New Zealand (NZ) health system’s greatest challenges. In NZ, diabetes rates are forecasted to grow 70-90% by 2040, with an associated cost of care increase of 63% to NZD$3.5 billion. Arguably, the most serious complication of diabetes is the development of diabetes-related foot ulcers. Much of the foot ulcer research has been on ulcer healing; however, there have been increasing calls for more focus on prevention. There are suggestions that up to 75% of foot ulcers can be prevented by applying guideline-recommended care. However, the extent to which these guideline recommendations are implemented into clinical practice in relation to the prevention of diabetes-related foot ulcers remains unknown.

Aim This thesis intends to determine how guideline recommendations relating to the prevention of diabetes-related foot ulcers are implemented within clinical practice. This was undertaken through two aims. Firstly, to review studies that have evaluated interventions designed to increase guideline-recommended foot screening rates within health systems and to determine whether these interventions have resulted in a change in foot screenings. Secondly, to assess the alignment of assessment and management used in the prevention of diabetes-related foot disease by NZ podiatrists to the international prevention guideline recommendations.

Methods This thesis involved two central studies. Firstly, a scoping review was undertaken to review existing literature, evaluating the implementation of guideline recommendations relating to foot screening to prevent diabetes-related foot ulcers. This review primarily aimed to determine whether these implementation interventions resulted in changes in foot screening rates in clinical practice. Secondly, a survey of NZ podiatrists was undertaken to assess the level of self-reported adherence in clinical practice to international guideline recommendations relating to the prevention of diabetes-related foot ulcers and what barriers and enablers they considered existed to implement those recommendations in clinical practice.

Results The scoping review screened 2900 studies, of which forty-nine studies were included in the review. The primary population targeted were doctors (n=23, 47%), health centres (n=12, 24%), allied health professionals (n=7, 14%), patients (n=4, 8%) and nurses (n=3, 6%). Most studies (82%) used between one and three intervention modalities, with clinician education and training used most frequently, followed by provision of clinical resources, feedback reports and infrastructure. In total, 83% (n=41) of the studies identified an improvement in foot screening rates, with 10% (n=5) identifying no change and 2% (n=1) identifying a decrease in foot screening rates.

The survey of NZ podiatrists had seventy-seven responses (16.3% of the NZ podiatry workforce) which were received, of which 52 completed >50% of items and were included. Of those 52 podiatrists, 73% were from the private sector. Public sector podiatrists reported higher weekly caseloads of patients with diabetes (p=0.03) and foot ulcers (p<0.001). The NZ Society for the Study of Diabetes (NZSSD) risk stratification pathway and IWGDF guidelines were the two most frequently utilised guidance documents. Participants reported median scores of at least “often” (<2) for all items in the assessment and management, inspection, screening, and education provision domains for people with a high-risk foot. More than 50% of respondents reported screening more frequently than guideline recommendations for people with a very low to moderate risk foot. A structured education program was only used by 4 (5%) participants. Public sector podiatrists reported greater provision of custom-made footwear (p=0.04) and multi-disciplinary team care (p=0.03).

Conclusions The scoping review identified that doctors continue to remain the population most often targeted for foot screening initiatives and that a range of interventions can result in an improvement of foot screening rates if their selection is guided by the needs of the population. The survey identified that NZ podiatrists generally follow international guidelines for the prevention of diabetes-related foot ulceration; however, there may be an over-screening of people with very low to medium risk in clinical practice. Podiatrists are less adherent to more complex recommendations, such as structured education and integrated care, which may require resourcing. Future directions include an increasing emphasis on the personalisation of preventative care strategies with the development of a conceptual framework, the need for investigation into the state of play and application of integrative care systems to support the care of the person with diabetes, and the potential need for locally adapted guidelines to support the provision of diabetic foot care within NZ.