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Free foot care pilot project in Abbotsford, B.C. showing positive signs for patients

Dr. Scott Schumacher poses for a photograph at his podiatry practice in Surrey, B.C., on Jan. 6, 2018.

DARRYL DYCK/THE GLOBE AND MAIL

Daryl McCall sits back in an orange clinic room in the renal unit of Abbotsford Regional Hospital and lifts his feet for inspection.

On the ball of Mr. McCall's left sole is a diabetic ulcer, a hole in the skin at risk for infection. He used to have three on that foot and was worried he'd lose his leg. But it hasn't come to that, in part due to a pilot project at the hospital that provides patients like him with free podiatry care.

"I'd be screwed, blued and tattooed," the 75-year-old said. "I don't know what they're doing with the program, I don't even care. I just know that it sure as hell has helped me."

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The program in Abbotsford, about an hour's drive east of Vancouver, is studying the impact of providing a free foot clinic to vulnerable patients in the dialysis unit. Poor circulation paired with neuropathy, a lack of sensation in the feet, means these patients are prone to developing open wounds and infections that put them at risk for amputation.

Initial results from the three-year study indicate the free care has reduced the number of leg amputations by half, echoing larger studies from the United States that have shown access to foot care reduces leg amputation in diabetics.

However, the clinic's future is in doubt. Funding from the BC Renal Agency, which is overseen by the Provincial Health Services Authority, for the three-year project ended at the end of 2017, though the renal agency recently provided additional funding to keep the clinic open until March.

Dr. Scott Schumacher, a podiatrist who specializes in diabetic wounds and works at the foot clinic, said there's no question the clinic is saving patients' legs – while also saving the health-care system money.

"So [the government] will be glad to pay for the amputation. They'll be glad to pay for the hospitalization at $1,000 a day. But they won't pay for [an orthotic] that costs maybe $200 to save that leg," said Dr. Schumacher.

The foot clinic runs every Tuesday, when Dr. Schumacher cleans the patients' wounds, removes dead tissue and helps offload their weight so the ulcers can heal.

He said that when it comes to sick patients, those in the dialysis unit are "the worst of the worst." They're often diabetic and their kidneys are failing. They come to the hospital three times a week for a machine to clean their blood and regulate their fluids.

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According to the BC Renal Agency, there are nearly 3,300 dialysis patients in the province. Dr. Daniel Schwartz, the medical lead for the study, estimates 160 of them per year undergo an amputation.

The dialysis unit of 250-350 people at the Abbotsford hospital had six leg amputations in the year before the foot clinic started. After patients were given free foot care, that number fell to an average of only three per year.

British Columbia's health-care system used to cover podiatry care, but it was delisted from provincial coverage in 2002. While the province still provides $23 per visit up to $230 a year for patients making less than $42,000, Dr. Schumacher says that's not nearly enough.

The Fraser Health Authority, which runs the Abbotsford hospital, is considering a request to provide permanent funding for the free foot clinic, but wouldn't say whether that will happen.

"We understand the funding is nearing an end and Fraser Health has been approached to fund this," said the health authority's spokesperson, Tasleem Juma. "We are currently reviewing the proposal and the outcomes."

Saskatchewan discontinued provincial podiatry coverage last year, but low-income families and those on disability assistance or in a seniors' home are still covered. Alberta provides $250 per patient per year for podiatry. Ontario pays up to $135 per patient per year. Podiatry is not covered in Manitoba, any province east of Ontario or in the territories.

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But the costs of providing preventive foot care pale in comparison to the costs of not providing it, says Dr. Schumacher.

A U.S. study that examined what happened when Arizona delisted podiatry in 2009 found that for every dollar the state saved by eliminating Medicaid spending on foot care, the costs of patient care increased by $44. There was a 38-per-cent increase in hospital admissions for diabetic foot infections, patients stayed in hospital 29 per cent longer and there was a nearly 50-per-cent increase in severe outcomes from hospitalization such as death, amputation or sepsis.

Losing a leg can be devastating for patients on dialysis, Dr. Schumacher says. It means struggling to transfer from a chair to a bed and sometimes means not being able to live at home with a loved one.

On top of that, there are the financial costs of leg amputations. Dr. Schumacher estimates the surgery itself costs $25,000 and that subsequent hospitalization costs $1,000 a day.

The uncertainty has been anxiety-inducing for patients, said Dr. Schumacher.

Marnie Honeyman, who is not diabetic but suffers from neuropathy because of a genetic condition, said she's certain she would have lost a second leg without the clinic.

Ms. Honeyman, who's been on dialysis since 2013, lost her right leg above the knee in 2016 after a blood blister on her foot became infected. She can't wear a prosthetic, and so is wheelchair-bound.

This year, she developed a callus on her remaining heel. One day she tried pressing on it and her thumb pushed right down into a hole in the flesh. When she came to Dr. Schumacher's clinic, she was worried she'd lose her second leg.

"I know I would have lost that leg because of that problem with my heel," she said. "And I truly don't know whether I'd be able to still live at home. My husband can only do so much."

At 60, she said she's too young to move into a care facility.

"My youngest [grandchild] now is 7. And there are so many memories I want to make with them. And I can't if I have no limbs," she said. "So it's very, very important for me to save this leg."

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