Much has been written about the epidemic of preventable limb loss in the United States. When we say “preventable” limb loss, of course, we’re largely referring to limb loss that occurs as a complication of Type 2 diabetes or peripheral artery disease. Those conditions account for roughly half of all amputations in the United States, as we know from the Amputee Coalition’s new prevalence study, and the trend has persisted for decades despite some high-profile efforts to bend the curve.
The United States’ lousy track record is largely attributed to our gobbledly-gook healthcare system, with its arbitrary cost schemes and unbalanced distribution of benefits. However, according to a paper published this spring in the journal International Diabetes Nursing, Switzerland—which has the best healthcare system in the world, according to the most recent analysis from the World Index of Healthcare Innovation—doesn’t have diabetes management and limb care figured out, either.
The IDN article attributes the problem to “ambiguity and lack of consistency in the provision of services, which do not always align to national guidelines, as well as a lack of clarity of the roles of healthcare professionals in relation to diabetic footcare.” Sounds almost exactly like the situation here in the USA, where adverse diabetes outcomes are attributed to inaccessibility of basic health care, inconsistent education regarding preventative self-care, poor communication among care providers, absence of clear protocols for wound surveillance, and so forth.
Despite having significantly healthier citizens, longer life spans, and lower healthcare costs than the United States (which ranks just 14th on the World Index), Switzerland nonetheless struggles to mitigate the damage Type 2 diabetes inflicts on the lower extremities. What gives?
A quick bit of background: Switzerland’s healthcare model resembles our own in some key respects. It’s a private system, rather than a public, single-payer system like Canada’s or the UK’s. Swiss citizens are bound by a health insurance mandate, as Americans are. A third point of overlap: In both nations, care of diabetes and related issues (such as podiatry, nutrition, and wound care) are siloed within subspecialties that are not covered, or poorly covered, by basic insurance.
The IDN researchers identified three core weaknesses in the Swiss health system’s management of diabetes:
1. Footcare is neglected
The strength of Switzerland’s healthcare system lies in its devotion to comprehensive basic, preventive care. Footcare is excluded from that package, however—and as a result, patients with Type 2 diabetes are completely unaware that they need to take care of their feet, much less how to go about doing so. They’re also in the dark about the potential harms of neglect, including limb loss.
Even more alarming, patients who were referred to footcare specialists by their general practitioner did not get the information necessary to practice preventative self-care. Swiss patients generally didn’t receive the education necessary to maintain foot health until their feet already were unhealthy—ie, until they were experiencing pain, ulcers, numbness, or other concerning signs.
2. Provider roles and responsibilities are muddled
Swiss patients typically don’t consider foot care to fall within the purview of their primary care doctor. That’s partly because Swiss primary care doctors don’t conduct routine foot inspections during office visits, even for at-risk patients with Type 2 diabetes. However, they do focus on other diabetes-related issues, so the absence of foot inspections sends a signal that this form of care is relatively unimportant. Accordingly, patients tend not to raise the subject unless and until they’re having problems with their feet—and by then it’s too late for preventative approaches.
If and when referral to a specialist becomes necessary, primary care doctors remain largely out of the loop. Patients don’t regard them as useful resources and may even think it’s inappropriate to raise the issue during office visits. Foot care thus ends up being isolated and episodic, rather than integrated into a holistic health-management strategy that’s overseen by their primary doctor. “The multidisciplinary team approach does not feature routinely within the Swiss primary care system,” the authors note, and patients don’t realize such a model even exists.
3. Policies, protocols, and payment are unclear
This will sound familiar: Diabetes patients find the Swiss healthcare system impossible to navigate. “Access to care and healthcare professionals outside of general practice [is] restricted by the mandatory requirement of a referral and additional charges,” the paper observes. Patients can’t figure out whether (or to what extent) podiatric care is covered, and they’re completely uninformed about other resources (such as diabetes educators or diabetic nurse practitioners) that might be less costly and less burdensome to access. “To improve outcomes,” the authors conclude, “clarity around clinical roles, responsibilities, and referral processes are urgently required.”
The full paper is available online via International Diabetes Nursing.
