The APP-HRFG committee has submitted the following recommendations to the MBS Review Taskforce to be considered for plans to modify the MBS in relation to high risk foot services:
5.1.1 Recommendation 1
- We question the rationale of the age requirement of patients at risk of developing a chronic wound being over 75 years; we recommend that the committee consider no age restrictions in patients with comorbidities or any known diabetes complication. As cited in the rationale/reference to recommendation 1 (page 32) people 65 years and older account for 85% of non-healing wounds in the USA. An age restriction on access to a chronic wound review may delay referral to an appropriate service and expert care.
5.1.3 Recommendation 2:
Referral to a specialist may be necessary if the following is occurring:
- We suggest an amendment in replacing the current ABPI cut-off of 0.5 and changing the language to be in line with the evidence presented in the International Working Group of the Diabetic Foot (IWGDF) guidelines 2019.
- The review must include toe pressures or TcPO2 readings as indicators of peripheral artery disease – instead of ABPI – in line with IWGDF guidelines, as ABPIs are known to be inaccurate (falsely elevated) in people with diabetes and chronic kidney disease due to Monckberg’s calcification. This reflects the best current evidence available.
5.1.9 Recommendation 5:
- Allied health services (podiatry in particular) should have specified item numbers for neuro/vascular assessment, wound debridement and specific offloading interventions and not just an increase in number of visits. Funding appropriate assessment will improve treatment planning and longer-term care. An increase in number of services without demonstrated requirements of evidence-based assessments and interventions may be subject to misuse.
- Appropriate evidence of documentation and additional communication with the patient’s treating team is required, consistent with current requirements for correspondence under TCAs.
5.1.11 Recommendation 6:
- We suggest incorporating existing referral guidelines including those from the Foot Forward project for consistency and to assist GPs in decision-making for timely onward referrals. The IWGDF and the Foot Forward project have compiled the evidence base for interventions that aid the management of the diabetic foot; and Diabetic Foot Australia have published local guidelines for offloading diabetic foot wounds which are known cornerstones in diabetic foot wound management. There is sufficient evidence for cost effectiveness of offloading to be standard care as part of chronic wound management on the foot.
6. Education, credentialing and accreditation
- We suggest that it should be mandatory for allied health practitioners working in private practice to be able to claim specific item numbers – should additional requirements for credentialing or evidence of experience or expertise in advanced wound care be required, it is imperative that this is done through AHPRA and not membership-based organisations.
6.1.9 Recommendation 20:
- Allied health and nurse practitioner services should also meet similar requirements to access subsidised wound consumables. Failure to do so will place further burden on patients who will be required to travel from their podiatrist to their GP for a dressing change following a podiatric debridement of a diabetic foot ulceration.
6.1.13 Recommendation 22:
- AHPRA is the only appropriate organisation to manage and monitor accreditation. If this requirement is to be taken on by another body, there would be duplication, and a further level of bureaucracy. There would be a delay in establishing the credentialing process and which organisations could undertake such credentialing. Wound/Ulcer management is a core podiatry competency.
7.2.1 Recommendation 24: Development of a wound consumables scheme:
- As highlighted in our response to Recommendation 6, there is strong evidence for the cost effectiveness of offloading modalities in the healing and prevention of chronic foot wounds. Funding streams are currently inadequate, resulting in poor outcomes for people at risk of or living with these wounds. For example, in Victoria an approved State-Wide Equipment Program (SWEP) application can take 6 months before funding is available, and the Tasmanian Southern Footwear Scheme has similar wait times. The NDIS is only available to patients under 65 so a significant proportion of individuals with chronic foot wounds have inadequate access to footwear or offloading modalities.
- As such, we suggest the inclusion of medical grade footwear and offloading modalities such as a CAM Walker or Total Contact Cast as part of the scheme.
We also ask that members of the taskforce consider the following recommendations:
- Include podiatrists, in addition to general practitioners and nurses, as professionals trained and credentialed to access MBS wound care item numbers. Assessment, prevention and management of chronic foot wounds are part of podiatry core competencies and podiatrists are acknowledged to play a crucial role in this field. Podiatrists should also be subject to education and training requirements to ensure those who claim in primary care are equipped to do so safely.
- The mandated referral to a ‘specialist wound care practitioner’ should refer specifically to local High Risk Foot Services for treatment of chronic foot wounds. The national, federally funded Foot Forward project is currently defining a national referral pathway to minimise delays in referring individuals with diabetic foot wounds to tertiary, multidisciplinary services where highest levels of evidence-based care are provided.
ANZPAC Podiatry competencies: http://www.anzpac.org.au/files/Podiatry%20Competency%20Standards%20for%20Australia%20and%20New%20Zealand%20V1.1%20211212%20(Final).pdf
International Guidelines for the prevention and management of diabetic foot disease (2019): https://iwgdfguidelines.org/
Foot Forward project (National Association of Diabetes Centres): https://nadc.net.au/foot-forward/