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Assessment of Primary Health Care Workers’(General Practitioners/ Nurse Practitioners) Knowledge of Diabetic… Isa, David 2021-04

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David Isa, MD, FRCSC  SURG 560  MASTER OF GLOBAL SURGICAL CARE APRIL 2021  Academic Advisor: Mark O’Driscoll MD FRCSC  Department of Surgery, Faculty of Medicine, Memorial University Newfoundland (MUN)  This project fulfills the Master of Global Surgical Care (MGSC) requirements for SURG 560 at the UBC Branch for International Surgical Care (BISC). Assessment of Primary Health Care Workers’(General Practitioners/ Nurse Practitioners) Knowledge of Diabetic Foot Ulcer/Infection (DFU/I) Standards of Care and their Awareness of Available Resources in Rural Central Newfoundland    Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  1 | 46      Final Report  Global Surgical Care Field Practicum (SURG 560)  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland  David Isa MD FRCSC Co-Investigator Student in Master of Global Surgical Care Program University of British Columbia  Emilie Joos MD FRCSC Co-Investigator Course Supervisor  Mark O’Driscoll MD FRCSC Academic Advisor, Field Supervisor           Date: March 28th, 2021 Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  2 | 46   Table of Contents Section I .................................................................................................................................................. 3 Abstract ............................................................................................................................................... 3 Section II: Introduction ............................................................................................................................ 4 Background Knowledge ....................................................................................................................... 4 Value of Study ..................................................................................................................................... 6 Literature Review ................................................................................................................................ 7 Goals and Objectives ........................................................................................................................... 9 Section III: Method ................................................................................................................................ 10 Study Design/ Intervention Description ............................................................................................. 10 Processes and Activities ..................................................................................................................... 10 Type of Statistical Analysis ................................................................................................................. 11 Budget............................................................................................................................................... 12 Ethical Considerations ....................................................................................................................... 12 Section IV: Results ................................................................................................................................. 14 Section V: Discussion ............................................................................................................................. 20 Interpretation .................................................................................................................................... 20 Description of Available Resources in Central Health ......................................................................... 22 Suggested Recommendations ............................................................................................................ 24 Study Limitations ............................................................................................................................... 26 Section VI: Conclusion ........................................................................................................................... 27 Section VIII: References ......................................................................................................................... 29 Section IX: Appendices .......................................................................................................................... 33 Appendix 1: Cover/Consent Letter to Potential Participants ............................................................... 33 Appendix 2: Project Questionnaire .................................................................................................... 35 Appendix 3: Question Grouping and Scoring System .......................................................................... 44       Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  3 | 46   Section I Abstract      Diabetic Foot Ulcer/Infection (DFU/I) is a challenging condition to manage and to live with for patients and the healthcare system. This is even more so in a rural setting such as Central Newfoundland as this condition requires a multidisciplinary approach. Primary healthcare workers (HCWs), family doctors and nurse practitioners, are usually the first point of contact with the healthcare system for patients with DFU/I. For optimal care to be delivered, these primary HCWs must have good knowledge of the condition and be well aware of what resources are available to them in their rural locale to provide optimal care. This study aims to determine if a knowledge gap exists among primary HCWs in rural Central Newfoundland, to quantify this gap if it exists, and to determine how aware they are of available local resources to help with DFU/I care.      To this end, a 57-question survey was mailed out to all 117 primary HCWs in the Central Health region of Newfoundland to assess their knowledge on DFU/I prevention, its management, and their awareness of available resources in the region. The results showed that primary HCWs have a high knowledge of DFU/I prevention and a high awareness of available resources. The results also showed that their knowledge on DFU/I management is just about optimal and there is considerable room for improvement here.       Available resources in Central Newfoundland and how primary HCWs could access them for their patients is described in this paper and suggested practice recommendations are given in order to improve DFU/I management by primary HCWs for improved patient outcomes.            Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  4 | 46   Section II: Introduction Background Knowledge      Diabetes mellitus is a chronic disease characterised by the body not making sufficient amounts of insulin or not being sensitive enough to the available insulin in the body to adequately regulate blood sugar levels. Over time, the resulting inadequate glycemic control has detrimental effects on various organs and tissues in the body (e.g the eyes, kidneys, nervous system, blood vessels). According to the World Health Organization (WHO), the global prevalence of diabetes mellitus in those over 18 years of age rose from 4.7% in 1980 to 8.5% in 2014.1 The International Diabetes Federation (IDF) gives an approximate figure of 493 million as the number of adults (20-79 years) worldwide living with diabetes in 2019. This is predicted to rise to 700 million by 2045.2 Diabetes Canada’s January 2021 report on the state of Diabetes in Canada states that 10% of Canadians are living with diabetes and 29% live with diabetes or prediabetes.3 In Newfoundland, 13% of the population lives with diagnosed diabetes and 35% live with diabetes or prediabetes.4       Diabetic Foot Ulceration is just one of the myriad complications of diabetes. It is a chronic and often times frustrating condition to manage both for patients and health care workers. Its management consumes a lot of resources and time. In diabetic patients, the prevalence of foot ulcers is 4-10% and the lifetime incidence of diabetic foot ulceration can be as high as 25%.5  Globally, it is estimated that about 18.6 million people were affected with diabetic foot ulcers in 2016.6 Foot ulcers are a very significant precursor to subsequent foot infections. In the study by Lavery et al (2006), about 60% of wounds were clinically infected at presentation.7 Foot infections in diabetic patients can still occur in the absence of an ulcer. The lower extremity amputation rate (both major and minor combined) in infected ulcers is as high as 28%.8 Long term follow up of patients with DFUs show major amputation rates of about 22% at 10 years.9 Patients with Diabetic Foot Ulcers (DFUs) have an increased risk of all cause mortality, fatal myocardial infarction, and fatal stroke when compared with diabetic patients without a history of DFUs.10        Central Health (CH) is the Regional Health Authority (RHA) responsible for health care delivery to most of Central Newfoundland. The population in this geographical area is 92,690 (as per 2016 census).11 This population is primarily rural. The 2 main referral hospitals in the region Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  5 | 46  big enough to have a general surgery service are located in the towns of Gander and Grand Falls-Windsor. Anecdotally, over the last 6 months, the General Surgery service in Grand Falls-Windsor has seen a surge in severe Diabetic Foot Infections (DFIs) presentations. No clear coordinated multidisciplinary strategy/ care pathway from prevention to management is present in the region. There are various resources available (scattered over a wide geographical area) to help manage this condition but it is unclear if primary HCWs (Health Care Workers), particularly GPs (General Practitioners) and NPs (Nurse Practitioners), and patients are either not aware of, or have trouble accessing them. This may be amplified by the high turnover of primary HCWs in the region. It is unknown if available resources are adequate enough as is to address the burden of disease of this condition as we are not sure if they are even being utilised to their full capacity. The reasons for not accessing the resources are unknown. Reasons why patients receive sub-optimal treatment in a number of cases are unknown. Primary HCWs are the gateway to these resources for most patients with DFU/Is who present to them. Assessing the HCWs knowledge and awareness of resources will help identify any knowledge gaps about DFU/Is and give an idea of how aware primary HCWs are of what resources are available in the region for optimal patient outcomes.       Optimising care of DFU/I in a rural setting such as central Newfoundland, in addition to improved patient outcomes, can have significant cost implications as well. The per annum cost for DFUs in Canada is significant: $320.5 million in acute institution care costs; $125.4 million in homecare costs; and $63.1 million in long-term care costs for the year 2011.12 The life-time net modeled cost of diabetic foot ulcer was estimated to be $619,300 from Ontario administrative healthcare data (2005-2011).13 One can assume the cost has gone up with the increasing prevalence of diabetes and subsequent DFU/Is. Timely management and healing of DFU/Is can help mitigate these costs.    Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  6 | 46   Value of Study      The target population for this study is primary HCWs (GPs/NPs) working in the Central Health region of Newfoundland. This is primarily a rural area. This project will help identify a knowledge gap (if one exists) which can be targeted to ultimately improve DFU/I patient outcomes. It is unclear how well medical schools, nursing schools, and Family Medicine residency training programs in Canada prepare their trainees with respect to the multidisciplinary care needed to manage and even prevent DFU/Is. Short of going for specific wound care conferences specifically dealing with this condition, no standardised formal course we are aware of is uniformly included in the core curriculum in all training institutions. Seemingly even these conferences (Wounds Canada for example)14 usually tend to attract the various members of the multidisciplinary team involved in DFU/I management with relatively few primary HCWs working in low resource settings in attendance. There may be a myriad of reasons for this. Primary HCWs may be too busy. Their scope of practice may be broad and, as such, the conferences and CME (Continuing Medical Education) events they choose to go to are related to other disease entities. Interest in dealing with DFU/I’s may be low was well. Methods to intervene if a knowledge gap is identified can be tailored to fit the local context. Various studies have demonstrated the effectiveness of such intervention programs when implemented.15-17       This study has potential value to the host surgical system. In the Central Health Region, there is no regional standard protocol or guideline with respect to managing this chronic condition which requires a multidisciplinary approach. As such, patient care can be disjointed and uncoordinated with patients possible falling through the cracks. A significant proportion of patients that eventually present to the surgical service would have had disjointed care which would vary depending on which primary HCW referred them. Patients would also present with more severe disease (like associated osteomyelitis) resulting in worse outcomes, higher morbidity (more amputations) and mortality rates.18,19 The management of severe DFU/Is involves a lot of personnel and material resources in an inpatient setting which places a significant amount of strain on the surgical service more so than if the DFU/Is were optimally managed from the start (in the outpatient setting) or even prevented in the first place by identifying those most at risk for developing them and taking proactive preventative steps. Guidelines for all aspects of care of the diabetic feet and DFU/I are available in the literature. Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  7 | 46  The International Working Group on the Diabetic Foot (IWGDF)20 has developed guidelines for various care aspects which can be applied to different clinical settings. If an intervention does materialise out of a need identified from this study, these guidelines would be a reliable resource to use in designing such an intervention. A management protocol could be developed as well in order to standardise and hopefully optimise care of DFU/I patients in the most efficient way possible given the local context on the ground.      There are relatively few studies in the literature that look at evaluating primary HCWs knowledge of DFU/I in low resource settings. This projects’ results will contribute to filling the knowledge gap in the literature and will perhaps contribute to any efforts aimed at medical training institutions and regulatory bodies to optimise the education of primary HCWs particularly in low resource settings to manage a condition that will only get more prevalent should the current upward trend in diabetes mellitus prevalence persist. In Newfoundland, diabetes mellitus prevalence is projected to increase by 21% in the next 10 years.4 DFU/I prevalence can be expected to follow the same trajectory.  Literature Review      No study asking the same research question as this project has been conducted in Central Newfoundland that the authors are aware of. A similar 2020 study out of Australia was found.21 This was a survey to identify current preventative and early intervention diabetes related foot care practices among Australian primary health care professionals. These professionals included GPs (about 10%), and CDEs (Credentialed Diabetic Educators a few of which were diabetic NP’s). Both rural and urban professionals were included in the study. This study showed that just 45% of the healthcare professionals surveyed removed the shoes and socks of diabetic patients to examine their feet. The study also showed suboptimal referral frequency to specialist multidisciplinary foot care teams. The IWGDF (International Working Group on the Diabetic Foot) 2019 guidelines were used as the standard against which practice patterns were measured against.20       A few studies evaluated the effectiveness of educational intervention strategies on healthcare professionals with respect to diabetic foot care ranging from prevention and screening to managing pre-ulcerative lesions on the diabetic foot.22-25 Some were targeted at nurses only22,24, Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  8 | 46  and others at multiple health professional types (physicians, podiatrists and nurses included)23,25,26. These studies utilised a pre-post survey design to demonstrate effectiveness of their educational interventions (outcomes being increased knowledge and confidence in diabetic foot examination and risk stratification). The pre-workshop surveys in these studies do provide some answers to the research question in our project though in different geographical contexts amongst other things. Schoen et al in Australia showed that pre-intervention just 59% of rural and remote practitioners regularly checked the feet of patients with diabetes.23 Pre-workshop confidence in performing a diabetic foot assessment was 34%. In this study, only 1% of the study population were physicians. Nurses made up the majority (58%).       Taksande et al targeted diabetic patients as their study population using a validated questionnaire.27 This study out of rural India found that amongst diabetic patients, foot care examination and education on foot complications was not suggested by treating physicians as indicated by 63% of the responses. Furthermore, only 3% of respondents had had their feet examined in the past by physicians. The study’s conclusion makes reference to creating educational strategies that not just target patients but also physicians as well.      A common thread in these studies from different geographic regions is the variable and often times low rates of diabetic foot examination by primary healthcare workers. Then again, evidence is still scanty in this regard when it comes to quantifying the knowledge gaps in DFU/I care by primary HCWs. Jeffcoate et al opines that diabetic foot care attracts relatively few clinicians interested in research and also fails to attract the same level of interest as other diabetic complications.28 The paper goes on to elaborate on the variation in clinical outcomes of DFU/I being reflective of the variable care received which could be explained in part by the lack of emphasis on DFUs in basic training and continuing education of doctors and nurses. Margolis et al make the point that globally, it is difficult to make meaningful comparisons due to the variation in different criteria (case definitions and classifications), heterogenous populations, clinical factors, and social factors.29 They do however note that with respect to in-country outcome variation (and between different comparable communities) especially when variations are large, consideration has to be given to aspects related to the structure of care which includes the training and beliefs of individual clinicians amongst other things. Mullan et al (2019) in their scoping review mention as some of the enablers to delivering preventative and early intervention Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  9 | 46  footcare to people with diabetes, education, clear definition of staff roles and a development of a foot assessment reminder system.30      A common theme can be seen in the studies found on the literature review: Increase the capacity of primary HCWs to tackle diabetic feet care. Defining the knowledge gap with respect to the local context is a key first step. This project serves to do this in a rural Canadian setting. Data obtained from this study, as already mentioned, will add to what is currently available in the literature and will contribute to increasing what we know about the knowledge gaps that need to be addressed with respect to diabetic foot care by primary HCWs especially in rural and remote locales. With the rising prevalence of diabetes globally, arming front line HCWs (especially in the rural and remote regions) with context specific knowledge and management capabilities is paramount with respect to one of the least appealing and most debilitating complications of diabetes, DFU/Is. Identifying the knowledge gaps will increase the effectiveness of planned interventions.   Goals and Objectives      The underlying goal of this project is to improve DFU/I patient outcomes. As a starting point, we are targeting those whom DFU/I patients would most likely first present to with this condition, primary HCWs (GPs and NPs). Determining primary HCWs baseline knowledge of this condition and their awareness of what local resources are available is a first step.       Stated objectives of this study are: 1. To determine if a knowledge gap exists in primary HCWs knowledge of DFU/Is. 2. To quantify this knowledge gap if one exists. 3. To determine how aware primary HCWs are of available local resources to help with DFU/I management.     Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  10 | 46  Section III: Method Study Design/ Intervention Description      This is a quantitative survey with questions covering respondents’ demographics, knowledge of DFU/I prevention, DFU/I management, and their awareness of resources available in Central Health. Some questions gauge respondents’ confidence levels with respect to managing this condition and some are general survey questions on respondents’ practices/ preferences. The survey contains a total of 57 questions and would take about 15 minutes to complete.       The Research population is all primary HCWs (GPs and NPs) working in Central Newfoundland in the area covered by the Central Health Regional Health Authority (CH RHA) whether fully or provisionally licensed (Inclusion criteria). Exclusion criteria was all GPs/NPs still in training (for example Family Medicine Residents).   Processes and Activities      Survey questionnaire was developed by the investigators. A list of all GPs and NPs working in the Central Health RHA region was obtained from the Central Health administration (designated liaison for this study was a member of the Central Health Ethics Review Committee, Mr. Doug Prince, whom this study’s proposal went through). Printed surveys with cover/consent letters and self-addressed, prepaid return envelopes were mailed out using Canada Post on January 11, 2021. The total number of potential respondents who were mailed was 117 (93 GPs and 24 NPs). Deadline for receipt of survey responses was February 19, 2021. A total of 22 responses were received by this deadline. None were received after.      All responses were anonymous as per the study protocol. Survey responses were then coded and entered into a Microsoft Excel data sheet which was used for data analysis. Data analysis was performed by co-investigator David Isa. After data analysis, final report was written up and reviewed by the investigator and site & academic supervisor. Submission of final report to the Master of Global Surgical Care Program SURG 560 (Global Health Practicum) Course Instructors was made on March 28th, 2021. An electronic copy of the final report was submitted Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  11 | 46  to Central Health. Digital copies were also sent to the target population via Central Health liaison Mr. Doug Prince.       Paper copies of the mailed-out survey were shredded utilising the services of Iron Mountain Data & Records Management Company that disposes of confidential documents from Central Health facilities. One of the confidential document collection bins in the Central Newfoundland Regional Health Centre will be used to dispose of paper copies of the surveys. Prior to disposal, electronic copies (scanned) will be made. These copies along with the electronic data spreadsheets (Microsoft Excel documents) will be sent via password protected email to Dr. Emilie Joos, course coordinator and co-investigator in this study.  These will be stored on a password protected computer in a UBC associated facility for 5 years after which they would be permanently deleted. Physical address of the storage computer is: Room H1B, 767 west 12th avenue, Trauma Services, Vancouver, BC, Canada, V5Z1M9.  Type of Statistical Analysis      The knowledge-based questionnaire covered broad categories of demographics, awareness of resources, and DFU/I knowledge (knowledge category questions were sub-grouped into prevention/screening of asymptomatic patients; and management of active DFU/I). Most questionnaire items were based on a Likert scale frequency response set (i.e. always, often, sometimes, rarely, never) with additional true/false questions and multiple-choice questions with correct answers. Some survey questions were included as well.       Once responses were collated, an aggregated “knowledge score” was obtained from the knowledge category questions and an “awareness score” from awareness category questions. This was done by assigning a value to each Likert scale response (i.e. 1–5, with lower numbers indicating less knowledge or awareness) and obtaining a total value per survey respondent. The responses to the other non-Likert type response questions were assigned lower or higher numerical values depending on if they indicate lower or higher levels of knowledge (or awareness) respectively. Reference can be made to appendix 3 on how the individual question options are scored. Knowledge sub-groups were investigated by obtaining separate knowledge scores for each sub-group: Knowledge Prevention scores; and Knowledge Management scores.  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  12 | 46       Demographics of interest include: age group; total years in practice; years in practice in a rural setting (including time in Central Newfoundland); GP versus NP; and location of residency/nurse practitioner training (In Canada, Outside Canada, or Both).  Budget      Total cost of the project was borne by the co-investigator David Isa. Breakdown of the costs incurred follows below: Envelopes: …………………………$81.77 Stamps and Mailing (Canada Post): $533.21 Printing cost: ………………………$253.90  Total: ………………………………$868.88  Ethical Considerations      Ethics approval was received from the UBC Ethics Review Board (Ethics ID number: H20-03174), the Newfoundland and Labrador Health Research and Ethics Board (HREB number: 2020.288), and the Central Health Research Review Committee.       Participants data (from the self-administered questionnaires mailed to them) were anonymous to all (including investigators) hence there was minimal risk of any one individual participant being identified. The research project posed minimal risk from a physical, social, or psychological perspective. The questionnaire did not involve any questions that touch on sensitive and emotional subjects that could trigger/precipitate any distressing reactions. The primary contact and coinvestigator in this study, David Isa, is a General Surgeon in the region where the study was performed. He receives referrals and is consulted by potential study participants (GPs/NPs) on the surgical condition being studied in question (DFU/I). As such he had a dual role as an investigator in this study and also as a consultant to the participants.       To address this potential conflict of interest, a cover letter (appendix 1) was sent out to all potential study participants along with the questionnaire (appendix 2) introducing and naming the investigator(s) and explaining the investigator(s) roles. The purpose of the study was explained. In the letter, the challenging nature of DFU/I was acknowledged to put participants at Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  13 | 46  ease if they have any deficiencies in their knowledge as this is very understandable. The concern that the study will be used to identify those with insufficient knowledge was allayed by informing potential participants about the confidentiality of their responses and the anonymous nature of the data collected. Part of the questionnaire asked if the participants residency training was obtained in Canada or outside Canada. This was addressed directly. While the investigators are familiar with the medical/nursing school and residency curricula in Canada with respect to DFU/I, they are not knowledgeable about the same outside of Canada. Data gathered here will help determine if location of residency training has any influence on knowledge of DFU/I and will not be used to blacklist those who trained within or outside Canada. Implications of this is the identification of potential sources of knowledge that may positively impact patient care (possibly primary practitioners with some of their training done outside of Canada).      Consent was explained in the cover letter. Returning the filled-out survey will be indicative of consent and due to the anonymous nature of the data collected, it would not be possible for survey responses to be removed once they have been sent in. All this was stated in the cover/consent letter.             Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  14 | 46  Section IV: Results      The low response rate (18.8%) meant that regression models could not be used to analyse the data as had been planned. As such, simple means  and counts were calculated and compared for each demographic grouping relevant to this study. Demographic characteristic Subcategories Number (% of total subjects) GP vs NP *  GP 14 (63.6%) NP 7 (31.8%) Years in Practice in General 0-5 years 5 (22.7%) 6-10 years 2 (9.1%) 11-15 years 2 (9.1%) 16-20 years 5 (22.7%) >20 years 8 (36.4%) Training Site In Canada 20 (90.9%) Outside Canada 1 (4.5%) Both  1 (4.5%) *One respondent did not give indicate if status was GP or NP.  GP vs NP Knowledge Prevention Score  Average score Range GP 59.79 45-71 NP 65.57 59-74 Total (GP+NP) 62.50 45-79* *One respondent did not indicate if GP or NP but the respondents score was factored into the Total (GP+NP) calculation.  Maximum Knowledge-Prevention score: 82  Minimum Knowledge-Prevention score: 15       Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  15 | 46  GP vs NP Knowledge Management Score  Average score Range GP 36.71 28-46 NP 37.29 29-44 Total (GP+NP) 37.18 28-46 Maximum Knowledge-Management score: 58  Minimum Knowledge-Management score: 8  GP vs NP Total Knowledge Score  Average score Range GP 96.50 75-117 NP 102.86 88-114 Total (GP+NP) 99.68 75-117 Maximum Total Knowledge score:140 Minimum Total Knowledge score: 23  GP vs NP Awareness Score  Average score Range GP 13.50 11-16 NP 14.57 12-16 Total (GP+NP) 13.95 11-16 Maximum Awareness score: 16 Minimum Awareness score: 2  Knowledge Prevention Score by Years in Practice in General  Average score Range 0-5 years 64.00 57-71 6-10 years 55.50 47-64 11-15 years 60.50 60-61 16-20 years 60.80 45-74 >20 years 64.88 55-79  Maximum Knowledge-Prevention score: 82  Minimum Knowledge-Prevention score: 15      Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  16 | 46  Knowledge Management Score by Years in Practice in General  Average Score Range 0-5 years 40.80 34-46 6-10 years 37.00 37-37 11-15 years 30.50 28-33 16-20 years 34.60 29-42 >20 years 38.25 32-44 Maximum Knowledge-Management score: 58  Minimum Knowledge-Management score: 8  Total Knowledge Score by Years in Practice in General  Average score Range 0-5 years 104.80 91-117 6-10 years 92.50 84-101 11-15 years 91.00 89-93 16-20 years 95.40 75-114 >20 years 103.13 93-122 Maximum Total Knowledge score:140 Minimum Total Knowledge score: 23 Question 6: DFU/I are a significant problem in my practice Answer Number of respondents Strongly Agree 1 Agree 11 Neutral 5 Disagree 5 Strongly Disagree 0  Question 7: I am comfortable managing DFU/I Answer Number of respondents Strongly Agree 1 Agree 9 Neutral 8 Disagree 4 Strongly Disagree 0    Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  17 | 46  Question 30: I am comfortable performing limited debridement (callus parring, removal of sloughy tissue) of mild DFI Answer Number of respondents Strongly Agree 6 Agree 6 Neutral 2 Disagree 4 Strongly Disagree 2  Question 44: I have had formal teaching in prevention of DFU/I in diabetic patients Answer Number of respondents (% of total) True 7 (31.8%) False 15 (68.2%)  Question 45: I have had formal teaching in management of DFU/I Answer Number of respondents (% of total) True 5 (22.7%) False 17 (77.3%)        When it comes to the provision of footcare education to diabetic patients and their families, most respondents (72.7% or 16/22) used a combination of different methods with almost all (93.8% or 15/16) verbally doing so in clinic. In total, 81.8% (18/22) of all respondents provided some diabetic foot care education verbally in clinic. 77.3% (17/22) of all respondents referred patients to community/public health, podiatry/orthotics, wound care, diabetes clinic, or footcare nurses. Brochures/Written material were used by 22.7% (5/22) of respondents and 9.1% (2/22) used demonstrations in teaching.       Regarding use of an antibiotic prescription guide to help manage DFI cases, some respondents used a combination of various sources (40.9% or 9/22). Sources favoured by participants of the study were UptoDate37 (59.1% or 13/22), Local DFU/I management guide (31.8% or 7/22) [see accompanying pdf document], Anti-Infective Guidelines for Community Acquired Infections38 (27.3% or 6/22), Bugs & Drugs39 (13.6% or 3/22), and some respondents prescribed antibiotic based on their personal preferences (9.1% or 2/22). Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  18 | 46       As to what imaging study is usually ordered by respondents when osteomyelitis is suspected, X-rays were ordered by 72.7% (16/22), nuclear medicine scan by 22.7% (5/22), and MRI by 4.5% (1/22). Three respondents (13.6%) had noted that they would order CTs as subsequent tests following initial X-rays though this was not asked specifically in the study question.      When asked how good they thought they were at identifying DFU/I patients who may need social supports, 22.7% (5/22) responded Excellent, 50% Good (11/22), and 22.7% (5/22) Fair.       As to what deters respondents from checking the feet of diabetic patients, 45.5% (10/22) indicate they do check patients’ feet. Time constraints was indicated by 36.4% (8/22), patient’s reservation to having feet checked was indicated by 22.7% (5/22), and not being appropriately paid for diabetic care and not liking feet were each indicated by 4.5% (1/22).      When respondents were asked if the first time they usually assess diabetic patients feet in their practices was when an ulcer or skin related problem on the lower extremities had developed, 18.2% (4/22) answered True and 77.3% (17/22) answered False. There was 1 non-response to this question.       On the use of a validated foot screening tool when screening diabetic patients’ feet, 13.6% (3/22) indicated they use one, and 81.8% (18/22) indicated that they do not. With respect to what learning modalities on DFU/I appeal to the respondents, multiple answers were given by 45.5% (10/22). Seventeen respondents (77.3%) indicated their preference for online learning in the form of modules, conferences, webinars, or teaching. Seven (31.8%) respondents expressed a preference for in-person symposiums. Seven (31.8%) respondents also expressed a preference for printed resources. Four (18.2%) respondents indicated a Wound conference (such as Wounds Canada14) preference.       Question 57 of the survey was open-ended asking respondents for suggestions on how to improve DFU/I care in Central Newfoundland. General themes of the responses touch on systems issues, education/knowledge resource factors, care delivery resource factors, and clinical care practice suggestions.      With respect to systems issues, a standardized referral pathway (or stream-lined system) to multidisciplinary care with clear referral and treatment algorithms was suggested for footcare. It was also suggested such a system would also co-ordinate foot care education as well. A targeted Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  19 | 46  emphasis on patient DFU education was suggested as GPs and NPs have time restraints that result in not enough time for them to teach diabetic patients all aspects of diabetic care. A team based approach program was suggested. Incorporating footcare into primary clinics was also mentioned by way of having Licensed Practical Nurses (LPN) taking lead roles to educate diabetic patients, perform foot screens and footcare. Having travelling clinics was also suggested.      With respect to education/knowledge resource factors, the suggestions were targeted at GPs/NPs and diabetic patients. Those specific to GPs/NPs include: More available online self-learning resources; having a written document outlining available resources for managing DFU/I patients; having formal education sessions geared towards GPs and NPs scope of practice; having regular information sessions on the newest guidelines; and having a Central Health intranet resource link that highlights up to date guidelines. The suggestion aimed at patients was to have easily accessible and easy to understand resources for patients both electronic (to be found online) and printed material.      Care delivery resource factors primarily focused on manpower. Increasing manpower available to the Diabetic Education Clinic (Diabetic Care Program) was called for to have more available time for teaching and ensuring comprehension by patients given that many patients  come from low socioeconomic backgrounds and have lower education levels. More staff for providing care in the community was also called for (presumably footcare and wound care).       Clinical practice suggestions include the need for GPs and NPs to look at feet regularly when seeing patients for their diabetes care. Having a dedicated surgeon to approach with respect to diabetic wounds was also suggested.              Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  20 | 46   Section V: Discussion Interpretation      Choosing a minimal acceptable score for all question categories (determined based on the answer option that we deemed would at the very least be acceptable in clinical practice), we can say if HCWs knowledge and awareness were either high or low. The minimum acceptable scores for each question category are as follows: Knowledge Prevention 50; Knowledge Management 37; Total Knowledge 87; Awareness 12. From the average Total Knowledge and Awareness scores of all participants, we can say that HCWs in general have high knowledge and awareness with respect to DFU/I prevention, management, and use of available resources in the Central Health Region. When we look at the Knowledge Prevention and Knowledge Management categories separately, while both GPs and NPs have high knowledge in DFU/I prevention, DFU/I management tells a different story. Both NPs and GPs scored fractionally higher (37.29) and fractionally lower (36.71) than the minimum acceptable score (37) for the Knowledge Management category respectively. The combined average score of both GPs and NPs was just over this score at 37.18 designating them (combining GPs and NPs under the umbrella of HCWs) as having high knowledge. The scores in the Knowledge Prevention category (GPs: 59.79, NPs: 65.57) were sufficiently high enough to bring the Total Knowledge scores well above the minimum acceptable score for this category (87). This can be interpreted as HCWs being more knowledgeable in DFU/I prevention than in DFU/I management where there is more room for improvement. Reasons for any differences between GPs and NPs scores are difficult to ascertain from our data given our inability to perform regression analysis and control for other factors due to the low response rate to our survey. We can theorise on why DFU/I management knowledge is at just about the minimum acceptable level and on what could be done to increase this knowledge.       One possible explanation is whether or not respondents as a whole received any formal teaching in DFU/I prevention and management. From our survey, HCWs in general had low rates of formal teaching with 31.8% reporting having had formal teaching in DFU/I prevention and 22.7% reporting having had formal teaching in DFU/I management. Another potential reason is scope of practice. When asked if DFU/I was a significant problem in their practice, Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  21 | 46  54.5% agreed or strongly agreed. The other respondents’ answers were split evenly between neutral and disagree. In rural settings, HCWs have very varied practices depending on their location, available resources, established practice patterns & protocols in their health facilities, what departments in the hospital they work in predominantly, and also if they have niche practices (for example: dialysis management, mental health, ER). Those respondents who did not deem DFU/I a significant problem in their practice may have practices that do not bring them into much contact with patients with DFU/I.       The comfort levels with managing DFU/I in general (45.45% choosing Agree or Strongly Agree to this question) and with performing limited debridement of mild DFI (54.5% choosing Agree or Strongly Agree to this question) may be a reflection of the low rates of formal instruction in DFU prevention and management. These results could be confounded by the inclusion of responses from those who do not have DFU/I as a significant part of their practice being included in the analysis.       We looked to see if experience was a relevant factor in DFU/I prevention and management. All but 3 of the respondents had equivalent number of years in practice in general and number of years in rural practice. All these 3 each had over 20 years of practice in total with various lengths of time in rural practice and all had Total Knowledge scores well above the minimal acceptable score. As such, the variable we chose to analyse was the number of years in practice in general, categorising participants into 5 groups. All groups had average Total Knowledge scores well above the minimum acceptable Total Knowledge score. The same went for the Knowledge Prevention scores. In the Knowledge Management category, the 11-15 years and 16-20 years groups had low scores (30.5 and 34.6 respectively). The 6-10 years group had the minimum acceptable score of 37. The 0-5 years group had the highest average score of 40.8 followed by the >20 years group at 38.25. There was a similar trend with the Total Knowledge and Knowledge Prevention scores with the 0-5 years and >20 years groups having the highest scores even though all groups scored higher than the minimum acceptable score in this category. Experience could account for why >20 years group had high scores. Why the scores decreased with less than 20 years work experience (the 0-5 years group being the exception) could reflect less experience with DFU/I or perhaps different training received or different frequency of DFU/I presentation over the years favouring those with more than 20 years work experience. The Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  22 | 46  high scores in the 0-5 years group could reflect different degrees of training in DFU/I management and prevention and perhaps a new awareness of DFU/I in the community.      Both GPs and NPs had high awareness of available resources based on the average scores in the Awareness question category (GPs: 13.5, NPs: 14.57, Combined: 13.95, minimum acceptable score: 12).       Almost all participants had their Residency/NP training in Canada with just 1 having trained outside Canada and 1 indicating training both in and outside Canada. As such, we could not analyse Knowledge and Awareness scores with location of training as a variable. Hence no new potential knowledge sources identified here.   Description of Available Resources in Central Health           There are various allied health services located all around the Central Health (CH) region that have important roles to play in managing DFU/Is. Wound Care Nursing/ Community Health Nursing (CHN) are vital to the multidisciplinary management. As of September/October 2020, it was estimated this service had 90-100 active DFU/I patients they were following. This is probably a fair estimate of their monthly DFU/I caseload. Services are provided in clinics and also via home visits. These services include wound debridement, callous paring, wound dressing and vac dressings. This is in addition to their non-DFU/I caseload which encompasses administering outpatient intravenous therapy, central line care, post-operative follow-ups, and follow up of patients from the Emergency Department who had injuries managed there. DFU/I patients remain on their caseload till wound care is no more needed. There is no waitlist for wound care. Referrals are screened daily and patients could be seen on the same day if urgently required. There are 22 Community Health Clinics scattered across the CH region maximising this service’s accessibility. A recurring theme from feedback from this service is the late referrals and presentations that they see with most being treated by their primary GP or NP and being seen by wound care nursing when the wound is already well-established. This touches more on the preventative aspect of care of this condition rather than the curative aspect. It is acknowledged however that there is overlap between preventative and curative aspects of care and it may also be viewed as a continuum of care from the preventative to the curative.  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  23 | 46       A Feet First program exists in CH. This program was initially under the auspices of Public Health. There are organizational restructurings ongoing to try and bring this program under the wing of the Diabetes Care Program. Currently the program is not as active as it could be which could be partly explained by the ambiguity as regards who had chief responsibility for it. Transitioning the Feet First program to the Diabetes Care Program will make for a more comprehensive diabetes management support program.      The Diabetes Care Program is offered at multiple sites in CH. These have Nurse/NP and dietician coverage. These sites are: Baie Verte, Green Bay, Connaigre Peninsula, Exploits, Lewisporte, Fogo, Twilingate & New World Island, and Kittiwake Coast. Care is tailored to patients’ individual needs ranging from patient education sessions, to aiding patients new to  insulin pumps amongst other things. Integrating Feet First into this program is an attempt to incorporate standard foot assessments of diabetic patients into the program.      Offloading is a crucial component of DFU/I care. The Occupational Therapy (OT) service is primarily responsible for facilitating/providing this in the CH region. Services they provide to patients with DFU/I include: foot posture assessment, lower limb biomechanics assessment, gait pattern assessment, balance review, assessment of foot condition and wound location. Based on these, they provide the intervention as needed such as offloading devices, education on appropriate footwear, referral to Health Quest31 (a Newfoundland and Labrador company providing products for injury recovery and performance optimization) for orthopedic shoes, and referral to the Orthotics services at the Miller Centre in St. John’s, Newfoundland which is one of the major rehabilitation centres in the Province. Other non-DFU/I targeted services they provide include pre-driving screening, seating and positioning services, and post-stroke rehabilitation. Patients with DFU/Is are deemed as urgent and are targeted to be seen by the OT service within a week. Follow up duration is on average about 2 months.       Feedback from OT on the DFU/I patients they encounter are that a number of them are from low socioeconomic backgrounds with limited resources and a number of them have insufficient capability to engage in good chronic disease management.  The OT service usually finds itself involved in DFU/I care when wounds are already present. The ideal situation would be for the Diabetes Care Program (with the Feet First program integrated into it) identifying callousing Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  24 | 46  patterns and potential wound developments so that interventions to prevent wound occurrence can be taken by OT (a preventative rather than a reactive approach).       The Vascular Laboratory service is another resource available to CH. This is primarily based out of St. Johns (Eastern Health region) but they see referrals from CH and also perform regular travelling clinics to the CH region (Gander) where Non-Invasive Vascular studies are performed. Identification of Peripheral Arterial Disease (PAD) is an important component of DFU/I management.   Suggested Recommendations           As of the time of writing this report, the Feet First program is still in limbo with respect to under whose auspices this will be run. Central Health is working to get it integrated into the Diabetes Care Program with no timeline for implementation as yet.      Most GPs/NPs already have some established practice patterns with respect to managing DFU/Is and to providing comprehensive care geared towards the diabetic patient. Some suggested considerations for GPs/NPs to consider implementing in their practices if they are not doing so already are: 1. The regular use of Inlow’s 60-second Diabetic Foot Screen when seeing all diabetic patients.32 Suggested frequencies for screening are included in the guide depending on the patient’s risk classification. 2. Regular Non-Invasive Vascular testing for all diabetic patients (possibly every 2-4 years) regardless of absence of foot wounds (Referrals written out the same way one is sent to other physician colleagues can be sent to the Vascular Lab in St John’s through fax at 709-579-0613 or by contacting the Lab directly by phone at 709-579-0542). 3. Early referral to the Diabetes Care Program for all diabetic patients irrespective of foot ulcer presence or absence. Hopefully the Feet First program is up and running under this program very soon. Liaisons with Wound Care, OT and SW can be made on behalf of patients who need them by the Feet First program.  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  25 | 46  4. Early referral to Wound Care or Community Health Nursing for wound and foot care preferably when pre-ulcerative lesions noted (e.g: calluses, bony deformities) and certainly when ulcers have developed already. 5. Consider OT referral early rather than hoping Feet First will arrange this (consider Feet First as a safety net to catch patients not already referred to OT). 6. Consider SW referral early if needed (consider Feet First as a safety net to catch patients who need support and are not already referred to SW). Offloading footwear can have significant financial ramifications for patients with DFU/I from low socioeconomic backgrounds.      For DFU/I cases that GPs/NPs want to refer to General Surgery, consider use of the easy-to-use SINBAD classification system in communicating with the surgeon to provide pertinent information.33 Other pertinent information would include the results of any vascular studies ordered (or indication that they have already been ordered and are pending), imaging results (if any done), MRSA status, whether OT referral sent or off-loading device already in use, and if Wound Care is involved already.      Suggested comprehensive resources for the primary HCW to avail of with respect to the management of DFU/Is are the IWGDF guidelines20, and Wounds Canada (Best Practice Recommendations for the Prevention and Management of Diabetic Foot Ulcers)34. Wounds Canada also has an online learning module on DFU (Focus on the Prevention and Management of Diabetic Foot Ulcers: Knowledge [A101MWN]).35 A good pocket resource to wound care in general (diabetic ulcers included) is the Wound Management Quick Reference Pocket Guide issued out as a collaborative amongst all the health regions in Newfoundland.36 Copies can be obtained by reaching out to any of the Wound Care Nurses. A suggested DFU management guide put out by the General Surgery group out of Grand Falls-Windsor is another resource modified to local needs (see attached pdf document).      A proposed area of study going forward carried out through the Feet First Program would be to get the views and input from DFU/I patients and their support network on what barriers to care they face. Going forward, ongoing data collection would facilitate effective improvements to DFU/I care in the region. A data gathering process/mechanism via the Feet First program and Wound Care Nursing could be instituted with defined data collection points agreed upon by Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  26 | 46  stakeholders (patients, patients support network, doctors, nurses, NPs, Wound Care, CHN, OT, SW, pharmacy). Possible data collection points could be: number of antibiotic courses and duration; length of time to wound healing; offloading adherence; wound characteristics; presence/absence of PAD; HbA1C; and presence/absence of osteomyelitis amongst others.   Study Limitations      This study had a low response rate at 18.8% (22/117) with a resulting small sample size for statistical analysis. Given that this study was surveyed based, it is subject to response bias. Non-response bias is another limitation of this study. Attempts to limit this were made by trying to follow up with respondents’ offices by phone and by email (via Central Health’s liaison with the study investigators, Mr. Doug Prince). The questionnaire used was created by the co-investigator David Isa for this study with no prior formal validation (predictive or concurrent validation) as no validated surveys that could answer our research question could be found in the reviewed literature. Face validation of the questionnaire was established by the investigators.             Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  27 | 46   Section VI: Conclusion      DFU/I prevention knowledge amongst Primary HCWs (GPs and NPs) in rural Central Newfoundland is high. Their DFU/I management knowledge, while considered high, could be improved. Their awareness of the available resources in the region to help manage DFU/Is is high as well as evidenced by their high utilisation of the same. Available resources and how primary HCWs can access them has been described in this paper. Some suggested recommendations for primary HCWs in Central Newfoundland to consider implementing in their practice have been given and helpful resources have been listed as well.                Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  28 | 46   Section VII: Acknowledgements      We would like to thank Wound Care/ Community Health Nursing (CH), OT (CH), the Vascular Laboratory in St. John’s, and the Diabetes Care Program (CH) for helping provide a clearer picture of what resources are available in Central Newfoundland with respect to DFU/I management. We would also like to acknowledge the statistical advice from the STAT551 course at the University of British Columbia and NL SUPPORT (Newfoundland and Labrador Support for People and Patient Oriented Research and Trials).        Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  29 | 46  Section VIII: References  1. World Health Organization Fact Sheet on Diabetes. https://www.who.int/news-room/fact-sheets/detail/diabetes Last accessed January 28, 2021. 2. International Diabetes Federation. https://www.idf.org/aboutdiabetes/what-is-diabetes/facts-figures.html Last accessed January 28, 2021. 3. Diabetes in Canada Backgrounder. Diabetes Canada. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2021_Backgrounder_Canada_English_FINAL.pdf Last accessed January 28, 2021. 4. Diabetes in Newfoundland and Labrador. Diabetes Canada. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Advocacy-and-Policy/Backgrounder/2021_Backgrounder_Newfoundland_FINAL.pdf Last accessed January 28, 2021. 5. Singh N, Armstrong DG, Lipsky BA. Preventing Foot Ulcers in Patients with Diabetes. JAMA 2005; 293(2): 217-228 6. Zhang Y, Lazzarini PA, McPhail SM et al. Global disability burdens of diabetes-related lower-extremity complications in 1990 and 2016. Diabetes Care 2020; 43(5): 964-974 7. Lavery LA, Armstrong DG, Wunderlich RP et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29(6): 1288-1293 8. Pickwell K, Siersma V, Kars M et al. Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer. Diabetes Care 2015; 38(5): 852-857 9. Morbach S, Furchert H, Groblinghoff U et al. Long-term prognosis of diabetic foot patients and their limbs: amputation and death over the course of a decade. Diabetes Care 2012; 35(10): 2021-2027 10.  Brownrigg JR, Davey J, Holt PJ et al. The association of ulceration of the foot with cardiovascular and all-cause mortality in patients with diabetes: a meta-analysis. Diabetologia 2012; 55(11): 2906-2912 11. RHA - Newfoundland & Labrador Statistics Agency. https://stats.gov.nl.ca/Statistics/Topics/census2016/PDF/RHA_AgeSex2016.pdf Last accessed January 29, 2021 Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  30 | 46  12. Hopkins RB, Burke N, Harlock J et al. Economic burden of illness associated with diabetic foot ulcers in Canada. BMC Health Serv Res 2015; 15: 13 13. Chan BCF, Cadarette SM, Wodchis WP et al. Lifetime cost of chronic ulcers requiring hospitalization in Ontario, Canada: a population-based study. Wound Med 2018; 20: 21-34 14. Wounds Canada 2021 Annual Conference (Virtual). https://www.woundscanada.ca/health-care-professional/education-health-care-professional/2021virtual#agenda Last accessed January 31, 2021 15. Schoen DE, Gausia K, Glance DG et al. Improving rural and remote practitioners' knowledge of the diabetic foot: findings from an educational intervention. J Foot Ankle Res 2016; 9: 26 16. Jones J, Gorman A. Evaluation of the impact of an educational initiative in diabetic foot management. Br J Community Nurs. 2004; 9(3): S20-S26 17. Murugesan N, Shobana R, Snehalatha C et al. Immediate impact of a diabetes training programme for primary care physicians--an endeavour for national capacity building for diabetes management in India. Diabetes Res Clin Pract. 2009; 83(1):140-144 18. Dutra MLA, Melo MC, Moura MC et al. Prognosis of the outcome of severe diabetic foot ulcers with multidisciplinary care. J Multidiscip Healthc. 2019; 12: 349-359 19. Gershater MA, Londahl M, Nyberg P et al. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study. Diabetologia 2009; 52(3): 398-407 20. International Working Group on the Diabetic Foot. https://iwgdfguidelines.org/guidelines/guidelines/ Last accesses January 31, 2021 21. Mullan L, Wynter K, Driscoll A et al. Preventative and early intervention diabetes-related foot care practices in primary care. Aust J Prim Health. 2020; 26(2): 161-172 22. Shiu AT, Wong RY. Diabetes foot care knowledge: a survey of registered nurses. J Clin Nurs. 2011; 20(15-16): 2367-2370 23. Schoen DE, Gausia K, Glance DG, Thompson SC. Improving rural and remote practitioners' knowledge of the diabetic foot: findings from an educational intervention. J Foot Ankle Res. 2016; 9: 26 Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  31 | 46  24. Parker MT, Leggett-Frazier N, Vincent PA et al. The impact of an educational program on improving diabetes knowledge and changing behaviors of nurses in long-term care facilities. Diabetes Educ. 1995; 216: 541–5 25. Bondi ME, Rahim SSSA, Avoi R et al. Knowledge, Attitude and Practice on Diabetic Wound Care Management among Healthcare Professionals and Impact from A Short Course Training in Sabah, Borneo. Medeni Med J. 2020; 35(3): 188–194 26. Watson J, Obersteller EA, Rennie L et al. Diabetic foot care: developing culturally appropriate educational tools for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Australia. Aust J Rural Health. 2001; 9(3): 121-126 27. Taksande BA, Thote M, Jajoo UN. Knowledge, attitude, and practice of foot care in patients with diabetes at central rural India. J Family Med Prim Care. 2017; 6(2): 284-287 28. Jeffcoate WJ, Vileikyte L, Boyko EJ et al. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care. 2018; 41(4): 645-652 29. Margolis DJ, Jeffcoate W.  Epidemiology of foot ulceration and amputation: can global variation be explained? Med Clin North Am. 2013; 97(5): 791-805 30. Mullan L, Driscoll A,Wynter K et al. Barriers and enablers to delivering preventative and early intervention foot care to people with diabetes: a scoping review of healthcare professionals’ perceptions. Australian Journal of Primary Health. 2019; 25: 517–525 31. Health Quest. https://www.healthquestnl.ca/ Last accessed February 21, 2021 32. Inlow’s 60-second Diabetic Foot Screen. https://www.diabetes.ca/DiabetesCanadaWebsite/media/Health-care-providers/2018%20Clinical%20Practice%20Guidelines/Inlows-60-second-diabetic-foot-screen-Wounds-Canada.pdf?ext=.pdf Last assessed March 21, 2021. 33. Ince P, Abbas ZG, Lutale JK, Basit A, Ali SM, Chohan F, et al. Use of the SINBAD classification system and score in comparing outcome of foot ulcer management on three continents. Diabetes care. 2008;31(5):964-7.   Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  32 | 46  34. Botros M, Kuhnke J, Embil J, Goettl K, Morin C, Parsons L, et al. Best practice recommendations for the prevention and management of diabetic foot ulcers. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada; 2017. 68 pp. Retrieved from: www.woundscanada.ca/docman/ public/health-care-professional/bpr-workshop/895-wc-bpr-prevention-andmanagement-of-diabetic-foot-ulcers-1573r1e-final/file 35. Focus on the Prevention and Management of Diabetic Foot Ulcers: Knowledge (A101MWN). https://www.woundscanada.ca/future-students/251-the-learning-institute/courses-programs/online-courses/309-focus-on-the-prevention-and-management-of-diabetic-foot-ulcers-knowledge Last accessed March 2, 2021 36. Beresford-Osborne M, McCarthy S, Morey P. Wound Management Quick Reference Pocket Guide. 2018. 37. UptoDate. https://www.uptodate.com/home Last accessed February 24, 2021 38. Anti-infective Review Panel., & MUMS Guidelines Clearinghouse. (2019). Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse. 39. Bugs & Drugs. http://www.bugsanddrugs.org/ Last accessed February 24, 2021                Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  33 | 46  Section IX: Appendices Appendix 1: Cover/Consent Letter to Potential Participants  Dear Potential Participant,      You are being invited to participate in a study titled “Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland” [HCWs- Health Care Workers; GPs- General Practitioners; NPs- Nurse Practitioners; DFU/I- Diabetic Foot Ulcer/Infection]. This study is being conducted by David Isa MD as part of a Master’s project through the University of British Columbia (UBC). Diabetic Foot Ulcers/ Infections (DFU/I) are challenging conditions to manage and involves a multidisciplinary approach for optimal management. The purpose of this research is to identify knowledge gaps with respect to DFU/I and how aware primary HCWs are of available resources in the Central Health region. If you agree to take part in this survey, you will be asked to fill out the questionnaire which appears on the following pages. This should take about 15-20 minutes to complete.       Your participation in this survey is voluntary. You may refuse to take part in it without any penalty. You are free to decline to answer any particular question you do not wish to for any reason. Due to the anonymous data collection, survey responses cannot be removed once they are sent in.      There will be no immediate benefit to you in participating in this study. This survey/questionnaire will ask some demographic questions, questions about DFU/I care and about your practice with respect to DFU/I. Demographic questions are to determine if these have any effect on DFU/I care with the potential benefit of identifying what aspects of a practitioner’s experience/training positively impacts care and can be generalised to all others. The knowledge gained from this study may help with developing a targeted intervention to improve DFU/I care and outcomes in the Central Health region.      There are no foreseeable risks involved in participating in this study. All questionnaire responses are anonymous with no way of personally identifying participants or knowing if you did or did not participate in the study. Please mail back the completed questionnaire in the included addressed and stamped envelope by February 19th, 2021.       Research data will be open access. If study results are used in future journal publications or research, other researchers will have access to it if needed. Data will be stored in pdf format on a secure, password protected computer in a UBC facility. All stored data will be made available upon a request from the publishing journal or from other researchers. Once data is made available, the study participants will not be able to withdraw it.        If you have any questions about this research project, you may contact the co investigator David Isa MD via phone at 709-293-2211 or via email at d32adi@mun.ca. He is a General Surgeon practicing out of Grand Falls-Windsor, Newfoundland who receives referrals for DFU/I Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  34 | 46  management from around the Central Health region. As part of a declaration of a perceived conflict of interest, David Isa MD has a dual role as both a co-investigator in this study and as a consultant who receives referrals from all potential study participants. The primary investigator is Dr. Emilie Joos, Clinical Assistant Professor in the Faculty of Medicine, Department of Surgery, UBC.      By proceeding with the survey on the next page, you are indicating that you have read and understood this consent form and agree to participate in this study. Please keep this page for your records and return the questionnaire only. Please do not write your name on the questionnaire.       If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the UBC Office of Research Ethics at 604-822-8598 or if long distance e-mail RSIL@ors.ubc.ca or call toll free 1-877-822-8598."           This study has approval from the Regional Health Authority, Central Health.        Thank you.  David Isa MD Co- Investigator                Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  35 | 46   Appendix 2: Project Questionnaire  Please circle or tick your answers as appropriate to the questions below. Write in answers where indicated as well.  1. GP or NP?................. 2. Age bracket a) 20-35 b) 36-50 c) >50 3. Years in practice in general? a) 0-5 b) 6-10 c) 11-15 d) 16-20 e) >20 4. Years of practice in a rural setting (including time in current practice in Central Newfoundland).  a) 0-5 b) 6-10 c) 11-15 d) 16-20 e) >20 5. Where was Residency/ Nurse Practitioner training obtained? a) In Canada b) Outside Canada c) Both (multiple residencies) 6. DFU/I are a significant problem in my practice a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree 7. I am comfortable managing DFU/I a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  36 | 46   8. I take a history of previous ulceration when I see my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 9. I take a history of previous lower extremity amputation from my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 10. I take a history of claudication from my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 11. I document presence or absence of end stage renal disease in my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 12. I elicit social isolation or other social factors that may affect my diabetic patients ability to assess health resources and resources for adequate footcare a) Always b) Often c) Sometimes d) Rarely e) Never 13. I ask about foot pain or numbness at diabetic patient encounters a) Always b) Often c) Sometimes d) Rarely e) Never   Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  37 | 46  14. I am aware of at least one diabetic foot risk stratification system (such as the IWGDF 2019 Risk Stratification System or others) and its corresponding foot screening frequency recommendations a) True b) False 15. I perform skin assessment (skin colour, temperature, presence of callus or edema, pre-ulcerative signs) at diabetic patient encounters a) Always b) Often c) Sometimes d) Rarely e) Never 16. I check for pedal pulses (palpation or doppler) when I see my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 17. I look for bone or joint deformities (e.g claw toes, hammer toes, large bony prominences or limited joint mobility) when I see diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 18. I assess for Loss of Protective Sensation (LOPS) at diabetic patient encounters by either one of the following methods: Pressure perception with a Semmes-Weinstein 10 gram monofilament; Vibration perception with a 128 Hz tuning fork; or Tactile sensation by lightly touching the tips of the toes of the patient with the tip of your index finger for 1-2 seconds a) Always b) Often c) Sometimes d) Rarely e) Never 19. I make note of my diabetic patients footwear whether they are ill-fitting, inadequate, or lack of footwear. a) Always b) Often c) Sometimes d) Rarely e) Never Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  38 | 46  20. I make note of proper/improper foot hygiene in my diabetic patients (e.g improperly cut toe nails, superficial fungal infections, unwashed feet, or unclean socks) a) Always b) Often c) Sometimes d) Rarely e) Never 21. How do you provide foot care education to diabetic patients and their families to prevent DFU/I development. a) Verbally in clinic b) Via demonstration c) Brochures/ Written material d) I don’t usually e) Referral to someone else (please elaborate…………………………) f) A combination of ways (please elaborate…………………………..) 22. I refer my diabetic patients to orthotics or Occupational Therapy for appropriate footwear when I have concerns about their footwear a) Always b) Often c) Sometimes d) Rarely e) Never f) I do not inspect their footwear 23. I refer patients with pre-ulcerative signs on their foot (parring of abundant calluses, protecting blisters or draining them if necessary) to community health for adequate care. a) Always b) Often c) Sometimes d) Rarely e) Never 24. I manage modifiable risk factors for DFU/I development such as fungal infections and ingrown or thickened toe nails when present in my diabetic patients a) Always b) Often c) Sometimes d) Rarely e) Never 25. I am aware of an infection classification system for diabetic wounds such as the IDSA/IWGDF  a) Yes  b) No   Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  39 | 46  26. I use this infection classification system when assessing patients with DFU/I a) Always b) Often c) Sometimes d) Rarely e) Never f) I am not aware of a classification to use 27. How important is off-loading in the treatment of DFU/I once they have developed a) Extremely important b) Very important c) Moderately important d) Slightly important e) Not at all important 28. In diabetic patients who develop DFU/I, I refer them for Non-Invasive Vascular tests to assess for Peripheral Arterial Disease (PAD) a) Always b) Often c) Sometimes d) Rarely e) Never 29. In patients with DFU/I, I emphasize cardiovascular risk reduction efforts like smoking cessation, control of hypertension, glycemia and dyslipidemia, use of anti-platelet drugs a) Always b) Often c) Sometimes d) Rarely e) Never 30. I am comfortable performing limited debridement (callus parring, removal of sloughy tissue) of mild DFI a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree 31. I know (or have a guide on) what antibiotics to prescribe depending on the severity of DFI, local wound and patient factors, and local microbiological sensitivity. a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  40 | 46  32. What antibiotic prescription guide do you use for DFI cases? a) Personal preference b) UptoDate c) Local DFU/I management guide d) Other source (please elaborate-……………………………………………….) 33. When selecting an antibiotic for mild cases of diabetic foot infection without any other complicating factors (e.g PAD), coverage of what organism(s) is recommended: a) Aerobic Gram positive pathogens b) Gram negative pathogens c) Obligate anaerobes d) Pseudomonas e) a, b and c f) a, b, c, and d 34. What pathogens should be covered in moderate to severe DFI, in patients who have been on antibiotics recently, and in patients with a severely ischemic affected limb  a) Aerobic Gram positive pathogens b) Gram negative pathogens c) Obligate anaerobes d) Pseudomonas e) a, b and c f) a, b, c and d 35. What imaging study do you usually order when osteomyelitis suspected? a) MRI b) Xray c) Nuclear Medicine Scan d) CT/PET scan e) Other (please elaborate-………….) f) None 36. The recommended duration of antibiotic treatment for osteomyelitis in the setting of DFI is: a) No longer than 1 week b) No longer than 1 month c) No longer 6 weeks d) No longer than 3 months 37. I refer all patients with DFU/I to community health nurse for wound care a) Always b) Often c) Sometimes d) Rarely e) Never  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  41 | 46  38. All DFU/Is regardless of infection status or severity should be referred to a General Surgeon a) True b) False 39. I am familiar with the various types of dressing used on DFU/I and their indications a) Strongly Agree b) Agree c) Neutral d) Disagree e) Strongly Disagree 40. I use this knowledge/ guide when seeing patients with DFU/I a) Always b) Often c) Sometimes d) Rarely e) Never 41. Soaking the affected foot is a key aspect to wound care in patients with DFU/I a) True b) False 42. These dressings are good for exudate management except: a) Nuderm (Calcium Alginate) b) Tegaderm c) Aquacel Foam d) Mepilex 43. I refer all my diabetic patients to the Diabetic Nurse Educator (Central Health’s Diabetic Clinic) a) Always b) Often c) Sometimes d) Rarely  e) Never 44. I have had formal teaching in prevention of DFU/I in diabetic patients a) True  b) False 45. I have had formal teaching in management of DFU/I a) True b) False     Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  42 | 46  46. How good do I think I am in identifying DFU/I patients who may need social supports a) Excellent b) Good  c) Fair  d) Poor e) Very Poor 47. I refer all DFU/I patients I think may be in need of social supports to receive adequate care to social work a) Always b) Often c) Sometimes d) Rarely e) Never 48. What deters you the most from checking the feet of diabetics? a) Smelly b) Dirty c) Time constraints d) Not within my practice scope e) Don’t like feet f) Patient’s reservation to having feet checked g) Others (please elaborate…………….) h) I check  49. When can one expect a DFU to heal with good optimal care baring no other confounding factors: a) Within 2-3 weeks b) Within 4-6 weeks c) Within 2-3 months d) Within 4-6 months 50. I assess and document patients self-care capacity for their own feet (i.e impaired vision, ability to reach own feet, hearing problems, others) when seeing diabetic patients at least once a year. a) Always b) Often c) Sometimes d) Rarely e) Never 51. The first time I usually assess diabetic patients about their feet in my practice is when there is an ulcer or skin related problem on their lower extremities. a) True b) False  Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  43 | 46  52. I use a validated foot screening tool when screening my diabetic patient’s feet (example the Inlow’s 60 second diabetic foot screen etc) a) True b) False If True chosen, please give name of screening tool used:…………………………. 53. I know how to refer patients for vascular studies a) True b) False 54. I know how to refer patients to the Diabetic Nurse Educator at the Diabetic Clinic a) True b) False 55. I know how to refer patients to community health and wound care nursing a) True b) False 56. What learning modality appeals to you most with respect to DFU/I a) Online module b) In-person symposium c) Wound conference (for example Wounds Canada) d) Other conference that has a panel/presentation on DFU/I e) Printed resource f) Other……………………… (please elaborate) 57. What suggestions do you have for improving DFU/I care in Central Newfoundland? …………………………………………………………………………………………. …………………………………………………………………………………………                Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  44 | 46  Appendix 3: Question Grouping and Scoring System Question number Question category Knowledge subgroup (if applicable) Question type Scores to knowledge questions options (if applicable) 1 Demographic N/A MCQ N/A 2 Demographic N/A MCQ N/A 3 Demographic N/A MCQ N/A 4 Demographic N/A MCQ N/A 5 Demographic N/A MCQ N/A 6* Survey N/A Likert N/A 7* Confidence N/A Likert N/A 8 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 9 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 10 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 11 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 12 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 13 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 14 Knowledge Prevention True/False True:2, False:0 15 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 16 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 17 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 18 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 19 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 20 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 21* Survey N/A MCQ N/A 22 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1, f)0 23 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 24 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 25 Knowledge Management Yes/No Yes:2, No:0 26 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1, f)0 27 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 28 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 29 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 30* Confidence N/A Likert N/A 31 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 32* Survey N/A MCQ N/A 33 Knowledge Management MCQ a)2, b)0, c)0, d)0, e)0, f)0 34 Knowledge Management MCQ a)0, b)0, c)0, d)0, e)2, f)0 35* Survey N/A MCQ N/A Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  45 | 46  36 Knowledge Management MCQ a)0, b)1, c)3, d)1 Question number Question category Knowledge subgroup (if applicable) Question type Scores to knowledge questions options (if applicable) 37 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 38 Knowledge Management True/False True: 1, False:2 39 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 40 Knowledge Management Likert a)5, b)4, c)3, d)2, e)1 41 Knowledge Management True/False True:0, False:2 42 Knowledge Management MCQ a)0, b)2, c)0, d)0 43 Awareness N/A Likert a)5, b)4, c)3, d)2, e)1 44* Survey N/A True/False N/A 45* Survey N/A True/False N/A 46* Confidence N/A Likert N/A 47 Awareness N/A Likert a)5, b)4, c)3, d)2, e)1 48* Survey N/A MCQ N/A 49 Knowledge Management MCQ a)1, b)3, c)1, d)0 50 Knowledge Prevention Likert a)5, b)4, c)3, d)2, e)1 51* Survey N/A True/False N/A 52* Survey N/A True/False N/A 53 Awareness N/A True/False True:2, False:0 54 Awareness N/A True/False True:2, False:0 55 Awareness N/A True/False True:2, False:0 56* Survey N/A MCQ N/A 57* Participant suggestions N/A Open-ended question N/A  *Individual analysis of these questions will be performed using descriptive statistics.   Number of Demographic questions: 5 Number of Knowledge-Prevention questions: 17 Maximum Knowledge-Prevention score: 82 Minimum Knowledge-Prevention score: 15 Number of Knowledge-Management questions: 16 Maximum Knowledge-Management score: 58  Minimum Knowledge-Management score: 8 Maximum Total Knowledge score:140 Minimum Total Knowledge score: 23 Number of Awareness questions: 5 Maximum Awareness score: 16 Minimum Awareness score: 2   Assessment of Primary HCWs (GPs/NPs) knowledge of DFU/I standards of care and their awareness of available resources in rural Central Newfoundland P a g e  46 | 46             

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