Patients in Focus Awards 2007 - Large Unit Winner - Foot Health Provision for Rheumatology Patients: Leeds Clinical Model

04/07/07 : Heidi J Davys, Philip S Helliwell, Anthony C Redmond, Paul Emery

Introduction:

Foot pain is a major problem in patients with rheumatoid arthritis (RA) and indeed the foot has been identified as the second most frequent site for symptoms. Approximately 90% of people with RA complain of painful feet during the course of their disease, with many people suffering right from the onset of the disease. The presence of foot complaints, both in the early and in the chronic stages of RA, has been shown to affect patients’ daily activities severely, especially walking and associated functional abilities.

There is concern that foot health services are not well provided generally. In a recent large national survey to evaluate the provision of foot health services in rheumatology, fewer than one in five of the departments reported that there was an adequate foot health service dedicated to rheumatology patients. Awareness of guidelines for referral or of standards of foot care provision was even lower (6%), which indicates that care in this area is poorly structured and lacks strategic coordination.

The foot health needs of people with rheumatic diseases are highly variable, ranging from minor requirements such as assistance with nail care and foot hygiene, to the need for expert management of painful structural changes and high-risk vasculitic lesions. It is essential that the rheumatology community has adequate access to all levels of foot care but also that health professionals are aware of the foot health needs of rheumatology patients. In particular professionals should have knowledge of how to access the appropriate services and pathways should be in place to support this. In addition to the clinical support it is necessary for clinicians, usually podiatrists, to be exposed to adequate training to effectively provide for the complex presentations encountered in this group of patients.

Leeds Rheumatology Foot Clinic:

Until 1999, foot health services in Leeds, in common with most other such services in the UK, were provided by a community team comprised of generalist podiatrists, supplemented by a small hospital based service specialising mainly in diabetes. In 2000, the hospital-based service was extended to include provision for patients attending the rheumatology department.

In the past seven years the rheumatology foot clinic has become firmly established within rheumatology out patients, now situated at Chapel Allerton hospital in Leeds and providing full time podiatry input from the hospital Foot Health Department. Patients can be referred directly from the outpatient medical and nursing teams, as well as from other allied health professionals and the regional rheumatology ward situated at Chapel Allerton hospital. The clinic provides general foot care and footwear advice to patients, assessment and management of all rheumatology foot pathologies, regular podiatric treatment of complex high risk foot pathologies and ensures patients are referred appropriately to other health professionals when required. At the time of our most recent comprehensive audit in 2004 there were 724 active patients (77% female, 23% male), one third of whom were receiving ongoing ‘general’ foot care, with a further third receiving mechanical (orthotic) intervention. The remaining third received a variety of interventions but half of these were ‘high-risk’ having treatment for either current or recent ulceration. The established clinic and close working relationship with members of the rheumatology team now ensures that patient’s foot impairments are managed effectively and efficiently. Recent research conducted here in Leeds has shown that in patients with RA who have early correctable valgus deformity of the rearfoot, the prescription of custom-rigid foot orthoses results in a significant reduction in foot pain and disability7. The management regime provided in the rheumatology foot clinic is highly evidence-based where research is available, and in those instances where evidence is lacking, principles of best clinical practice and expert consensus are used to manage patients.

Leeds is a regional rheumatology centre providing care to patients who regularly travel long distances to the clinic. Having a foot health service within the rheumatology department has enabled people to be assessed by the podiatrist immediately on diagnosis and allowed for follow-up appointments to be made on the same day as the patient is seeing the doctor or nurse. Additional benefits include the implementation of a foot ulcer clinic for rheumatology patients at the highest risk of tissue compromise, modelled on the service provided to patients with diabetes.

Until 2002 patients with connective tissue diseases and painful, sometimes non-healing foot ulcers in Leeds were being cared for by different health professionals with care pathways depending on point of first presentation rather than on need. Approaches to treatments were varied and sometimes conflicting. For example patients were managed by the GP, practice nurse, community or private podiatrist, district nurse, dermatology nurse or friends and family. Some of these carers would have had limited experience with foot ulcers or with the complexities of conditions such as systemic sclerosis and medical management such as the biologic immunotherapies used to treat RA. It was clearly preferable that these patients would receive timely, co-ordinated care by an experienced foot health clinician with the appropriate medical back up and so in 2002, the rheumatology foot health service was reconfigured to provide an additional high-risk service.

The weekly foot ulcer clinic was set up and led by the specialist rheumatology podiatrist. This now allows rapid and reciprocal access between members of the medical team and allied health and nursing staff, serving four main purposes:

•  sharing of important medical information necessary to facilitate diagnosis and treatment
•  to allow rapid prescription of antibiotics and other medications as necessary
•  to allow rapid medical attention to new and deteriorating cases of ulceration, including admission
•  to gain prompt access to diagnostic and imaging modalities, including radiology.

Current provisions are being made for a joint clinic in conjunction with the orthotists to provide a complete high-risk service that has been shown to be effective in managing diabetic foot ulcerations.

A strong link has been established with the regional rheumatology ward and patients from the foot ulcer clinic are frequently admitted for IV antibiotics and/or iloprost infusions to aid healing. Liasing with the ward staff ensures that the patients’ wound care is continued on admission and on discharge the patient is followed up appropriately. Ward staff can refer patients to the in-patient foot health service; this often allows the opportunity for the patient to receive a multidisciplinary assessment and a management plan is established.

A monthly foot-specific ultrasound clinic has been set up for rheumatology patients with complex and inflammatory related foot conditions. The team, consisting of a rheumatologist, specialist registrar and two podiatrists provide an extensive clinical and ultrasound assessment of the patient’s foot pathology to aid diagnosis and assist in the development of an effective management plan for the patient.
Education and Research:

The hospital rheumatology foot clinic is integrated with and supports the clinical branch of the Foot and Ankle STudiEs in Rheumatology (FASTER) programme within the Academic Unit of Musculoskeletal Disease, University of Leeds. FASTER is an externally funded research program dedicated to the study of, and care for musculoskeletal disorders affecting the foot and ankle. The clinical branch aims to develop a model of best practice for rheumatology foot health services and to promote best practice in care of the foot and ankle in musculoskeletal disease from an academic perspective. Work in this area is both published and in further development 8,9. The Leeds Foot Impact Scale (LFIS) 10, developed by this unit is a self-completed foot health outcome tool designed for completion by people with RA and intended to better represent the patient reported impact of RA on the foot and its function. People newly diagnosed with RA and enrolling in the Yorkshire Early Arthritis Register, all people with RA attending the foot clinic and now all those starting on biologic therapies are currently completing the questionnaire. The first set of longitudinal data has just been submitted as an abstract for EULAR 2007 and will prove vital in the future planning of foot health provision.

A particularly novel initiative of the FASTER program has been the installation of an integrated clinical/research gait analysis facility within the rheumatology department at Chapel Allerton Hospital. The lab, which is situated next door to the rheumatology foot clinic, offers advanced assessment of gait for complex cases as well as being a useful tool in clinical research.

It would be impossible for the Leeds-based rheumatology foot clinic to provide ongoing management to patients nationwide and therefore one key role of the service has been to educate other podiatrists in managing the foot health of rheumatology patients. Our experiences have been promulgated through more than 20 Society of Chiropodists and Podiatrists-validated CPD days delivered either in-house or through talks at other centres. The knowledge and experience has also recently been distilled into the BSR accredited two-day Foot and Ankle course and this year in an accompanying Churchill-Livingstone book: The Foot and Ankle In Rheumatoid Arthritis11. Locally, an education initiative combined with a care pathway covering primary care and hospital trusts has resulted in a system in which patients can now be regularly referred to the podiatry team in primary care once their acute episode of care has been managed. In return, the podiatrists treating rheumatology patients in the community clinics now also have referral access to the specialist rheumatology foot clinic and the formalised pathway clearly defines the most appropriate management protocols when patients present with acute or complex conditions that will be more effectively managed by the multidisciplinary team at Chapel Allerton hospital8.

Conclusion:

The Leeds Clinical Model has provided an example of how the frequently unmet need for foot health services to rheumatology patients can be provided effectively. The key is a comprehensive primary care based service of generalists supplemented by a small, specialised extended scope role integrated into the hospital outpatients department. Supporting letters have been provided by a rheumatology specialist registrar and the lead rheumatology clinical nurse specialist within the unit and also by a patient of the rheumatology foot clinic. These highlight the significant benefit to patients of having a generalist service supplemented by a specialist team articulating with an academic unit.

In summary, the Leeds rheumatology foot health model:

•  Provides for collaboration between and utilisation of the multidisciplinary team across primary and secondary care to provide efficient and effective foot care
•  Provides a focus for the foot health needs of rheumatology patients with specialist needs
•  Is part of a long-term strategic plan to develop of a model of best practice for rheumatology foot health services and promote best practice.

The authors would also like to acknowledge the work of Professor Jim Woodburn and Dr Deborah Turner in developing the rheumatology foot clinic.

References:

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7. Woodburn, J. Barker, S. Helliwell, P.S. (2002) A randomised controlled trial of foot orthoses in rheumatoid arthritis. The Journal of Rheumatology. 29(7) 1377-1383

8. Redmond, A.C. Ferguson,C., Spencer,L., Dickie, T.,Rogers, J., Conaghan, P.G, (2006) A new care pathway for musculoskeletal foot health interface clinics based on five years experience. Proceedings of the British Society of Rheumatology Meeting, Glasgow 2nd-5th May. Rheumatology 45(1)i127

9. Conaghan, P.G, Rogers, J., Redmond, A.C. (2006) How effective are musculoskeletal care pathways? An audit of a primary-care led, city-wide musculoskeletal service. Proceedings of the British Society of Rheumatology Meeting, Glasgow 2nd-5th May. Rheumatology 45(1)i127

10. Helliwell, P. Reay, N. Gilworth, G. Redmond, A. Slade, A. Tennant, A. Woodburn, J. (2005) Development of a Foot Impact Scale for Rheumatoid Arthritis. Arthritis & Rheumatism. 53(3) 418-422

11. Helliwell P.S. Woodburn J., Redmond A.C., Turner DE. Davys, HJ., (2007) The Foot and Ankle in Rheumatoid Arthritis: a comprehensive guide. Churchill Livingstone, Edinburgh. ISBN 0-443-10110-8