Do we screen, examine or assess to identify the “at‐risk” foot in diabetes—time for agreed terms and definitions?

Diabetic foot ulcers place considerable burden on patients and healthcare systems.1 The key to managing diabetic foot ulcers is prevention. A cornerstone in ulcer prevention is identifying the “at risk” foot, as the presence of one or more risk factors, such as peripheral neuropathy, peripheral artery disease, or foot deformity, places a person with diabetes at increased risk of developing ulceration and subsequent amputation.2 Identification of risk factors also allows for risk stratification, and implementation of appropriate management plans depending on the risk factors identified. Identification of the “at-risk” foot by an appropriately trained healthcare professionals is a key recommendation in diabetic foot care guidelines (inter)nationally.3-7 However, when comparing different guidelines, we noted that different terminology is used. Yet, consistency in language is important in diabetes care and education.8 The International Working Group for the Diabetic Foot (IWGDF) in their 2020 update on definitions and criteria for diabetic foot disease emphasize the importance of a common vocabulary for clear clinical communication.9 In this commentary, we discuss the variation in terminology used within diabetic foot guidelines to describe identification, and monitoring, of the “at-risk” foot in diabetes and explore whether use of terminology aligns with current Merriam-Webster dictionary definitions. By doing this, we aim to draw attention to the variation in terminology and highlight the need for international consensus when writing guidelines on identifying the “at-risk” foot in diabetes. We selected a purposive sample of guidelines to reflect approaches and terminology used by guideline writers in different regions of the world. We limited our selection to guidelines published in English and Dutch because (a) these are the native languages of the authors of this commentary and (b) we recognised that translation may not effectively capture meaning and context. Following review of the guidelines from the IWGDF,3 United Kingdom,6 Ireland,4 Scotland,5 Singapore,10 the Netherlands,11 and United States of America,7 we identified a range of terms used to describe review of both the foot with no previously identified risk factors for ulceration and the at-risk foot (See Table 1). “To inspect closely or to test the condition of” OR “To test by questioning to determine progress, fitness, or knowledge” IWGDF3 Recommends examining a person at very low risk of ulceration (IWGDF risk 0) annually for signs or symptoms of LOPS and PAD No—The IWGDF recommend examining those not “at-risk” for a diabetic foot ulcer for LOPS and PAD. However, an examination is part of the screening process, so screening is the more appropriate term here Recommends screening a person with diabetes “at-risk” of foot ulceration (IWGDF risk 1–3) for: a history of foot ulceration or lower-extremity amputation; diagnosis of end-stage renal disease; presence or progression of foot deformity; limited joint mobility; abundant callus; and any pre-ulcerative signs Yes—Screening is carried out to identify risk factors for the disease/condition being screened for, in this case the at-risk foot in diabetes Recommends screening the feet in diabetes regardless of level of risk. Frequency of screening differs depending on level of risk Yes—In line with above definitions, and our interpretations, screening allows for a person to be identified as being “at-risk” or not “at-risk” As part of the screening process, they recommend a peripheral sensory and vascular assessment No—A healthcare professional would be assessing a person's level of risk, but screening for LOPS and PAD, rather than assessing for them Recommends screening when risk factors for ulceration have not been previously identified Yes—In line with above definitions, and our interpretations, screening allows for a person to be identified as being “at-risk” or not “at-risk” Recommends assessing those with one or more risk factors and providing them with a management/treatment plan No—Here, they recommend assessing those at-risk, but an assessment (i.e. a judgement) should be made after a person has been screened for risk factors and level of risk identified Singapore10 Recommends screening to detect the “foot at risk” or risk factors for ulceration Yes—In line with above definitions, and our interpretations, this allows for a person to be identified as being “at-risk” or not “at-risk” Recommends an examination which consists of a neurological and vascular assessment No—Testing for LOPS/PAD would have been carried out during screening. In the foot in diabetes, assessment allows one to make a judgment about a person's risk of developing a diabetic foot ulcer, after they have been examined for risk factors United States of America7 Recommends at least an annual evaluation to identify risk factor for ulceration and carry out a detailed foot assessment in those with risk factors for ulceration No—Evaluation does not allow for testing or questioning to determine the level of risk. An assessment should be made once an individual has undergone an examination for all potential risk factors Recommends an examination which includes inspection of the skin, assessment of foot deformities, neurological assessment and vascular assessment No—Examination is a component of screening s, whereas assessment would allow one to make a judgment on the level of risk and most appropriate treatment/management plan As outlined in Table 1, there are two potential sources of variation in the use of terminology. Firstly, different terms are used within different guidelines, although often similar actions are meant. Secondly, even with the use of the same terms across guidelines, terms may have different meanings or be used to explain different actions. For example, in Ireland they recommend screening regardless of level of risk, but in Scotland they recommend screening only when the person has not been previously identified as “at-risk”. In addition, when we compared these against the Merriam-Webster definitions for screening, and our own interpretations of the definitions, the terms used did not always, or only partially, align with the definitions provided. We also explored how each guideline defines the “at-risk” foot. All guidelines agree that the presence of one or more risk factors places a person at risk of ulceration and subsequent amputation. All, except the one from the United States of America, state the need for risk stratification depending on the number of risk factors identified. The consensus is that those with no risk factors are classified as very low risk, whereas those with neuropathy or peripheral artery disease are classified as low/moderate risk. If someone has more than two risk factors or a history of ulceration/amputation, they are then classified as moderate/high risk. Depending on the level of risk, management plans will differ. However, we did not explore management recommendations within guidelines, as this was not the aim of this commentary. After examining the literature and exploring the different terms used, we consulted with six individuals with lived experience of diabetes; four who had a diagnosis of Type 1 diabetes, one who was a former healthcare professional with experience of working within the Irish health system and one who is a primary carer for a person with a diagnosis of Type 1 diabetes. All were women who volunteered to be part of a patient and public involvement (PPI) panel for the corresponding author's PhD. The aim of this group is to work with the corresponding author to ensure any planned research is relevant, and of benefit, to those with a diagnosis of diabetes. As this is a voluntary group, we have not collected demographic information. All individuals identified diabetic foot screening as an opportunity to identify the most important risk factors (loss of protective sensation and peripheral artery disease) for ulceration using specific and validated tests. They viewed screening as a preventative measure, which enables them to have discussions with their healthcare professional around diabetic foot care, and potentially be referred to a diabetic foot ulcer prevention programme if they are identified as being “at-risk”. Most individuals felt examination involved “a number of specified steps and checks” that the professional must carry out during a screening. Finally, they viewed the term assessment as an ongoing information gathering process, where the clinician considers signs and symptoms of risk factors while looking at the progression (or regression) of the foot, and felt this term was more appropriate once an individual has been identified as been “at-risk”. However, we acknowledge that these are the opinions of a small group people with experience of one healthcare system (Ireland's Health Service Executive). For consistency in language, we need to stop using different words to describe the same thing. Common vocabulary allows for clearer communication and easier comparisons of study methodology. Others have recognised what a valuable resource the IWGDF definitions have been, and how they bring clarity to the diverse terminology in the multidisciplinary field of diabetic foot disease.12 With this in mind, we call for clarity in the forthcoming 2023 IWGDF guidelines around terminology used to describe identification, and management, of the “at-risk” foot in diabetes, and subsequently in updates to any local or national guideline. All listed authors contributed to this piece of work and have provided permission for this final version to be published. The authors and their contribution are listed below: Jennifer A. Pallin: Conceptualization, methodology, original draft preparation writing, review & editing. Jaap Van Netten: Conceptualization, writing, review & editing. Patricia M. Kearney: Conceptualization, review & editing. Sean F. Dinneen: Conceptualization, review & editing. Claire M. Buckley: Conceptualization, review & editing. We thank the Patient and Public Involvement contributors Deirdre Murphy, Jennifer Duggan, Aisling White, Siobhan Gaffney, Anne Dale and Karen Buckley-O'Farrell for their input into this piece. Open access funding provided by IReL. Jennifer Pallin is a PhD student funded by the Health Research Board Ireland (Grant Number: CDA-2019-007). The views and opinions expressed within this commentary are those of the author and do not reflect those of the Health Research Board. The authors declare no conflicts of interest. The data outlined within this commentary was obtained from publicly available sources, which have been appropriately referenced within the body of text. Information relating to perspectives of people living with diabetes arose from discussions with the lead author's patient public involvement (PPI) panel, and due to the nature of these discussions supporting data in not available.