Disparities in foot care-is inflammatory arthritis still a poor relation?

This editorial refers to ‘A clinical audit into the adherence of foot health management standards of rheumatoid arthritis compared with the foot health management standards of diabetes mellitus in North-East London’, by Christopher Joyce & Rizwan Rajak. doi.org/10.1093/rap/rkab006

Disparities between foot care for diabetes and rheumatoid conditions in the UK has been highlighted recently in an article published in Rheumatology Advances in Practice [1]. People with high-risk foot problems, such as diabetes or inflammatory arthritis, face many challenges in everyday activities. Specialized podiatrists have a prominent role to play in symptom relief and improving quality of life because of involvement of the feet, even to a mild degree, for all people with high-risk foot problems [2]. However, the role of specialist podiatrists as members of hospital-based multidisciplinary teams managing diabetic foot disease is well established in the UK [3]. In contrast, the number of podiatrists who are members of rheumatology multidisciplinary teams in the UK is highly variable [4].

Clinical guidelines in diabetes are more advanced compared with those in inflammatory arthritic conditions across the globe. In the UK, diabetes prevention and management of diabetic foot ulceration requires complex, well-coordinated multidisciplinary care across all health-care settings as recommended by the National Institute of Health and Care Excellence (NICE) and the ‘Putting Feet First’ National Framework [5, 6]. Normahani et al. [7] reported that care pathways are structured to include a Foot Protection Team to work in the community, comprising health-care professionals, often podiatrists, with specialist expertise in diabetic foot assessment and management. This team works closely with a multidisciplinary foot care team that manages diabetic foot problems in hospitals in addition to more complex cases in the community.

In the last decade there has been a significant expansion in the body of knowledge on the effects of RA and other inflammatory arthropathies, such as gout, PsA and SLE, on the foot and the management of these problems [2]. In a dedicated rheumatology foot health service, callus reduction, footwear advice and provision, and orthosis prescription are mainstays of management. Foot and ankle management for RA features in many clinical practice guidelines recommended for use. Unfortunately, supporting evidence in the guidelines is of low quality. Agreement levels are predominantly ‘expert opinion’ or ‘good clinical practice’. Hennessy et al. [8] suggested that more research investigating foot and ankle management for RA is needed before inclusion in clinical practice guidelines.

Although UK national guidelines and expert opinion call for timely and appropriate foot care [9], the provision of dedicated foot care services for inflammatory arthritis is variable and service provision reportedly poor [10, 11]. An annual review of patients’ feet and access to foot care services has been recommended in UK guidelines [11, 12]. However, surveys of rheumatology departments in the UK, The Netherlands, Singapore, Australia and New Zealand have shown that the provision of dedicated foot care services for patients with inflammatory arthritis is variable. In a UK study, Backhouse et al. [13] concluded that despite the known high prevalence of foot pathologies in RA, only one-third of 1237 patients with RA accessed podiatry. Multidisciplinary care is important in managing rheumatology patients, and there are two arguments to this. On the one hand, rheumatology patients are often complex medically. It is essential that the practitioner managing the foot problems has a dialogue with, and good back up from, the patient's rheumatology physician. For example, the increasing use of biologic agents and risks of foot ulceration require early and aggressive management. On the other hand, expertise in dealing with foot problems is often limited among rheumatologists, and a strong case can be made for better integration of foot health services into rheumatology [10-12]. Indeed, close collaboration between clinicians for access and management of foot problems in RA has long been advocated [14]. Wilson et al. [11] reported that the extent of current problems suggests that the provision of effective, timely and targeted care is a pressing need. Clinicians need to have clinical expertise in foot assessments and be knowledgeable about clinical management of foot problems. Additionally, foot care needs to be coordinated and tailored to the needs of individual patient in order to improve outcomes for patients. Commissioning integrated pathways for foot care in rheumatology has an important role, and guidelines similar to those that exist for diabetes would be welcome.

In summary, the article recently published in Rheumatology Advances in Practice [1] illustrates disparities in foot care between diabetes and inflammatory arthritis. Although the audit was conducted in a major city in the UK, previous studies have highlighted the variability of care across the UK. Future consideration by funders and health policy-makers should ensure that provision of foot care services for patients with inflammatory arthritis reflects the diabetes model.

Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.

Disclosure statement: The authors have declared no conflicts of interest.