A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration

Patients presenting with chronic limb threatening ischaemia (CLTI) and diabetic foot ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern exists regarding late presentation and delayed management contributing to increased amputation rates. Despite multiple guidelines existing on the management of both conditions, there is currently no accepted timeframe in which to enact specialist care and treatment. This systematic review aims to investigate potential time delays in the identification, referral and management of both CLTI and DFU.

Methods

A systematic review, conforming to the Preferred Reporting Items for Systematic Review of Meta-Analysis (PRISMA) statement standards, was performed searching MEDLINE, Embase, The Cochrane Library and CINAHL from inception to 14 13 th November 2018. All English language qualitative and quantitative articles investigating or reporting the identification, causes and outcomes of time delays within ‘high income’ countries (annual gross domestic product per person >$15,000) were included. Data were extracted independently by the investigators. Given the clinical cross-over, both conditions were investigated together. A study protocol was designed and registered at the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42018115286).

Results

A total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and 1,388 healthcare professionals were included. Twenty-three articles focussed predominantly on DFU. Considerable heterogeneity was noted and only 12 articles were deemed of high quality. Only 4 articles defined a ‘delay’ however this was not consistent between studies. Median times from symptom onset to specialist healthcare assessment ranged from 15 to 126 days with subsequent median times from assessment to treatment ranging from 1 to 91 days. A number of patient and healthcare factors were consistently reported as potentially causative including, poor patient symptom recognition, inaccurate healthcare assessment and difficulties in accessing specialist services. Twenty articles reported outcomes of delays, namely rates of major amputation, ulcer healing and all-cause mortality. Although results were heterogeneous, they elude to delays being associated with detrimental outcomes for patients. Conclusions

Time delays exist in all aspects of the management pathway, which are in some cases considerable in length. The causes of these are complex but reflect poor patient health-seeking behaviours, inaccurate healthcare assessment and barriers to referral and treatment within the care pathway. The adoption of standardised limits for referral and treatment times, exploration of missed opportunities for diagnosis and investigation of novel strategies for providing specialist care are required to help reduce delays.