GEHWOL Diabetes Report 2023-2024: More data, more insights

People with diabetes now have an entire network of care services at their disposal to treat the disease and its accompanying symptoms. Nevertheless, it is still evident that one third of diabetes patients undergoing treatment are at high risk of developing diabetic foot syndrome, which is particularly dangerous. It is caused by a complex interplay of nerve damage, vascular insufficiency and a weakened immune system. In the worst case, such processes lead to complete or partial foot amputation. (1) Around 70% of all amputations are still performed on diabetics. (2) This well-known health problem is addressed in the current GEHWOL Diabetes Report. (3) Nevertheless, 5 out of 6 diabetes patients say they know about the disease and are forewarned. But there is clearly a gap between self-assessment and doctors' assessments. The doctors surveyed, which include diabetologists and endocrinologists as well as GPs, state that 4 out of 10 patients on average do not pay any particular attention to their feet. These and other findings on examination measures and disease awareness can be found in this year's GEHWOL Diabetes Report. Unlike the previous reports, which only reflected the views of doctors, it now also contains the opinions of 500 diabetes patients.

Further development of the Diabetes Report

The Diabetes Report is a biennial survey conducted by the leading foot care specialist Eduard Gerlach GmbH (GEHWOL) in cooperation with Statista. In the current wave, 120 doctors and, for the first time, 500 patients were recruited via an online survey. Doctors and patients each received two different questionnaires with comparable questions. Patients were recruited via an online questionnaire in May and June 2023. By including patients in the survey, the GEHWOL Diabetes Report does more than creating a larger data basis. Instead, information from patients additionally helps to provide a different perspective on the topic and gain a better understanding of the impact of prevention and care. The results impressively demonstrate how doctors' view of their patients' assessment of important parameters such as disease awareness differs or has developed further as compared to previous years. The report also allows conclusions to be drawn about the extent to which doctors' views and patients' self-assessments differ on topics such as compliance, regular check-ups, knowledge of concomitant illnesses, preventive measures, etc.

Diverse additional findings in diabetes patients

Doctors regularly observe a wide range of complaints in their patients. These include neuropathy, lack of blood flow to the skin, dry skin and a lack of pressure on the feet. All these findings represent factors that favour serious nerve diseases, such as diabetic foot syndrome, which is still responsible for a large proportion of annual amputations. In order to prevent serious concomitant diseases at an early stage, patients need to undergo regular examinations and be made aware of their diabetes. Doctors say that only 60% of patients know that they need to look after their feet. One in four people have the recommended check-ups less than once a year. This is notable in that 94% of patients state that they know that diabetes can also lead to foot complications. 61% are afraid that their own foot health will deteriorate.

Further extensive examination measures by the doctor

As part of a disease management program (DMP), a thorough examination of the foot is provided for in full. (4) However, this is generally recommended by the professional associations for every medical examination. Doctors have a wide range of measures at their disposal. The Diabetes Report also provides information on this. In addition to the general medical history, medical examinations include taking the skin temperature, checking the shoes, and palpation of the foot pulses. If foot pulses are absent, this is a warning sign of a diabetic foot. Reassuring: If foot pulses are not palpable, all doctors carry out a follow-up diagnosis or refer directly to a specialist. 84% do this at least partially even if the foot pulses are palpable. The overwhelming majority of doctors are in favour of and also use almost all available examination measures. It should be noted that some measures such as checking the skin status, checking the muscles, the presence of foot deformities and shoe quality are carried out by the doctors, but the check is not carried out at every doctor's visit - as recommended.

Regular foot checks are very important. However, sometimes a foot ulcer is already too far advanced and amputation is medically indicated. Due to a change in the law, patients have been able to obtain a second opinion for this serious diagnosis since May 2021. (3) In this context, 58% of the doctors surveyed in the GEHWOL Diabetes Report state that they advise every patient to get a second opinion before a foot amputation; among diabetologists/endocrinologists, this figure is as high as 67%. Only 8% generally advise against obtaining a second opinion. The remainder advise at least certain patients to have this safeguarding diagnosis.

Spreading prevention across several shoulders

In addition to obtaining findings, doctors have an important role to play in prevention. For patients, the doctor treating them is the most important source of information before the media and their relatives. It is therefore also up to doctors to carry out good preventive work. There is often only a small time window available for this. As many as two thirds of all doctors inform their diabetic patients about foot care measures which they can carry out themselves, and also recommend further treatment by a specialized podologist; in many cases (39%), they do so even if there is no prescription entitlement. The majority of doctors are in favour of an evaluation of prevention services that includes patients’ psychosocial situation in particular. (5) In addition, better remuneration for specialist professions and simultaneous clarification of cost coverage through an increase in health insurance subsidies should help to further improve the range of care on offer. The most important individual measures are diabetic training and podological prevention.

In order to reach patients for this, it is particularly important for doctors to provide broad information in mass media. However, this competence is also attributed to specialist staff and health insurance companies. Sharing prevention responsibilities between different stakeholders can therefore help to increase patients' daily self-monitoring of their feet. An awareness of foot care is a prerequisite for this. Once again, however, this reveals a discrepancy: On the one hand, 85% of patients state that foot care is important or very important to them; on the other hand, most doctors (48%) give their patients a ‚satisfactory’ school grade at best in this area. According to doctors' estimates, almost half of patients do not know that they need to look after their feet, or what a foot ulcer is and how it develops. The majority of doctors also rate shoe care and pressure relief measures as satisfactory at best.

Foot care products make an important contribution to health

Most doctors would also like their patients to be more dedicated when using foot care products. But what is actually important for a good foot care product? It should have a positive effect on the skin's microcirculation, say 82% of doctors - knowing that around 1/3 of their patients suffer from neuropathy, with 26% developing microangiopathy (lack of blood flow to the skin) as a typical diabetic cause of skin dryness (32%). This condition, which is known as xerosis, is often the beginning of a cascade of problems that can develop into diabetic foot syndrome. Proof of the effectiveness of care products is also welcomed (74%). Furthermore, the urea content is an indicator for a recommendation. According to medical opinion, this should be 10% for dry skin and more for calluses. Lipid-containing creams are favoured among the formulations (38%).

But even the best cream is useless if it is not applied regularly. Among the most frequently used foot care measures, a good two-thirds of patients cite applying cream and regularly checking their feet for injuries and skin abnormalities. Just under a quarter (26%) of respondents, on the other hand, either irregularly or never care for their feet.

Socio-economic status plays a decisive role in foot care

It takes time and money to practise foot care consistently and effectively. For the first time, the patient survey provides interesting conclusions for the report regarding the correlation between socio-economic status and foot care measures. 51 % of patients with a household income of less than € 2,000 generally do not visit a podologist. For people with a household income of over €4,000, this proportion is only 17%. Podological services are only covered by health insurance if there are corresponding skin findings. Just under half (46%) of persons surveyed stated that they pay for all podological services themselves, while a good quarter of those with the lowest incomes still do so. On the other hand, 39% of doctors only recommend complex podological treatment if there is a prescription entitlement and a prescription can be issued. The same applies to biomechanical examinations at an orthopaedic footwear facility, which are only recommended without a prescription by 42% of doctors.

The Diabetes Report once again clearly shows that patients and doctors have different assessments and attitudes towards health awareness. According to the doctors, the following applies to prevention:

• Practices that are part of a foot care network inform all their patients more frequently than practices that are not part of a foot care network.
• The most frequently recommended measures that patients can implement themselves include examining their feet and shoes, applying cream and cutting their toenails straight across.
• The patient's risk awareness is the decisive factor in preventing foot complications.
• A reduction in risk can be achieved by simple measures such as pressure relief, diabetic training and adequate podological care.

Sources:

• Mohamad A. et al. Population-based secular trends in lowerextremity amputation for diabetes and peripheral artery disease. CMAJ Sep 2019; 191 (35): E955-E961; DOI: 10.1503/cmaj.190134
• Eckhard, M. Deutsches Ärzteblatt 2023 (120) Nr. 19 A864-A870.
• GEHWOL Diabetes-Report 2023. Strukturierte standardisierte schriftliche Befragung mit n = 500 Patienten sowie n = 120 Ärzte. Erhebung und Auswertung durch Statista. April bis Juni 2023. Im Internet: https://www.gehwol.de/Aktuelle...
• Gemeinsamer Bundesausschuss. 2022. Richtlinie zum Disease Management Programme, Diabetes Mellitus abrufbar unter: https://www.g-ba.de/downloads/...
• Hilienhof, A. Deutsches Ärzteblatt 2016; Diabetes: Ärzte betonen die Bedeutung der Prävention. 113(15): A-693 / B-585 / C-577

Key Findings:

Risk and foot care awareness of affected persons

• 94% of diabetics know that diabetes can lead to complications related to the foot. For comparison: Doctors take a more critical view. According to their estimate, an average of 42% of their patients do not realise that they need to take special care of their feet.
• Among the various consequential diseases, foot health in particular is often a cause for concern: For example, 47% of patients fear damage to the skin, particularly on the feet.
• 61% are afraid that their foot condition will worsen in the future.
• Foot care is correspondingly important: This is what 85% and 93% of diabetics who are concerned about possible damage to their feet say.
• In this group, 81% of diabetics also report that they care for their feet frequently, regularly or even daily. A total of 74% of patients said this. For comparison: Here too, doctors have a more critical view: Only 18% of doctors rate their patients' foot care awareness as good or very good.
• In addition to home care, podological care is also important: The majority of patients visit a podologist at least once every 3-6 months. 42 % would like to go more often.
• However: Only a quarter of the costs are fully covered by health insurance; the rest pay for care themselves, at least in part.
• Accordingly, the economic situation of patients also influences their preventive care behaviour: In the lower-income group, 51% of patients do not make use of podological foot care. In the higher-income group, this proportion is only 17%.

Top measures for the prevention of foot lesions in diabetes:
(agreement by doctors)

• consistent pressure relief: 92%
• diabetic training courses: 91%
• podological care: 88%
• regular medical check-ups: 88%
• independent foot care at home or by relatives: 85%
• training of relatives: 80%
• foot exercises and mobility: 79%
• treatment as part of disease management programmes: 78%
• treatment as part of regional diabetic foot care networks: 73%
• orthopaedic footwear technology: 67%
• improving the socio-economic situation of patients: 73%

Specific recommendations for action on foot health
(agreement by doctors)

• straight toenail clipping by
  the patient or relatives: 99%
• examination of the feet and shoes: 99%
• application of foot cream
  by the patient or relatives: 98%
• arrangement of podological treatment for pre-ulcerative skin problems, such as callus formation, ingrown toenails, fungal infections: 98%
• arranging for integrated foot care including professional foot care, appropriate shoe care and systematic information about self-care: 98%
• arranging a diabetic training programme incl. instruction of advisory personnel: 97%
• daily foot washing by the patient or relatives, followed by drying - especially the spaces between the toes: 96%
• arrangement of therapeutic shoe fitting: 95%
• no treatment of calluses or corns with chemical agents, plasters or other skin-damaging techniques by the patient or relatives: 91%
• instructions for carrying out foot and movement exercises: 89%
• use of pressure relief measures, such as pressure protection products made of polymer gel: 88%
• daily measurement of skin temperature by the patient or relatives to detect foot inflammation at an early stage: 60%

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