National Diabetes Foot Care Audit 2018 to 2023

Shorter times to FEA are associated with a greater chance of being AAUF after 12 weeks.

Figure 1 illustrates the percentage of people who are AAUF at 12 weeks after FEA, by time to FEA for the 5 year audit period 2018-23.

The best outcomes are for patients who self-refer into a service. Over half of those who self-refer are AAUF at 12 weeks.

For those people with a FEA within 13 days of referral, approximately half have a positive healing outcome being AAUF at 12 weeks.

For those with a FEA after 2 months of referral, there is a notable decline, with only approximately a third of patients having a positive healing outcome being AAUF at 12 weeks.

Between 2018 and 2023:

• 56.1% of patients are AAUF at 12 weeks when they self-refer
• 51.0% of patients are AAUF at 12 weeks when FEA is less than or equal to 2 days after referral
• 49.5% of patients are AAUF at 12 weeks when FEA is between 3 and 13 days after referral
• 44.6% of patients are AAUF at 12 weeks when FEA is between 14 days and 2 months after referral
• 36.3% of patients are AAUF at 12 weeks when FEA is greater than 2 months after referral

There is wide variation at integrated care board (ICB) level ranging from less than 50% achievement to greater than 70% achievement of FEA within 0-13 days.  Region, ICB and primary care network (PCN) data can be accessed via the NDFA dashboard. 

Assessment

At a national level, the mean percentage of people with a FEA within 0-13 days has remained stable over the 5 year period (2018-23) ranging from 44.3% to 45.6%. However, despite this stable national picture, there remains great variation at provider level (Figure 2). (For further information about the interpretation of box plots, please refer to the 'Explanatory notes' tab of the detailed analysis file). 

The percentage of people with a FEA within 0-13 days after referral in 2022-23 ranges from 4.8% to 100%. This means that, in terms of the data submitted to the NDFA, some providers are seeing very few patients within this referral window, while others are seeing all patients within this window.

These findings indicate differences in effectiveness of pathways to expert assessment across providers, which will have an impact on the number of people AAUF at 12 weeks.

NB. Out of range refers to values that differ significantly from most other data points (in this instance, greater than the lower / upper quartile + 1.5 times the interquartile range). Ideally a data set will have a minimal number of out of range values.

Outcomes

At a national level when looking at all outcomes, including those with an unknown outcome, there has been an overall decline in the percentage of people AAUF at 12 weeks after FEA (45.7% in 2018-19 to 42.2% in 2022-23 (all ulcers)). Unknown outcomes include situations where the outcome has not been recorded or where there was no further contact with the patient.  When those with an unknown outcome are excluded, the data shows less variation over the 5 year period 2018-23 (51.0% in 2018-19 to 49.0% in 2022-23). However, there has still been a decline in the most recent year (51.4% in 2021-22 to 49.0% in 2022-23). The data also shows that healing outcomes as a whole are declining in the most recent years.

When considering variations in outcomes at a provider level, Figures 3 and 4 show the range in positive healing outcomes in terms of patients being AAUF at 12 weeks after FEA for both less severe and severe ulcers respectively (see glossary for definition of ulcer severity). 

For less severe ulcers (Figure 3) the percentage of people AAUF at 12 weeks after FEA in 2022-23 ranges from 23.1% to 74.5% (excluding values that are out of range). It can also be seen that both the mean and median values are at their lowest in 2022-23.

For severe ulcers (Figure 4) the percentage of people AAUF at 12 weeks after FEA in 2022-23 ranges from 3.6% to 54.2% (excluding values that are out of range) and again, the mean and median values are at their lowest in 2022-23.

These findings show that in some cases healing outcomes are very low for some providers, while for others, a much greater proportion of patients are AAUF. It also shows that healing outcomes as a whole are declining in the most recent years.

Ulcer registration rates

The number of new foot ulcers in people with diabetes in England and Wales is not certain. Data from Lancashire in 2002 suggested that the incidence was just over 2 per 100 person years² but more recent data from Scotland¹ suggested that the current figure may be closer to 1 per 100 person years. These citations are the most recent research regarding population based estimates of diabetic foot ulcer prevalence in the UK.

The NDFA data for 2022-23 shows wide ranging ulcer registration rates by ICB from 0.1 to 1.3 per 100 person years (excluding values that are out of range, see Figure 5). These data suggest that while many ICBs were gathering information on nearly all new foot ulcers in the most recent year, many others were not. This can be seen to be true across each of the 5 years. (See glossary for definition of person years). 

Severe ulcers

The percentage of severe ulcers has fluctuated over the 5 year period 2018-23 with a slight increase from 42.5% in 2018-19 to 43.0% in 2022-23.

At provider level, there is clear variation in the percentage of severe ulcers (Figure 6) ranging from 17.6% to 83.3% in 2022-23, and in all years there are a number of providers who have not submitted any severe ulcers. This suggests that some providers were not registering information on all foot ulcers, including severe ulcers, to the NDFA.