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Dr. Irfan Dhalla

Improving Care: Using Evidence for Change

Earlier this week, Health Quality Ontario released a quality standard on diabetic foot ulcers.

Diabetic foot ulcers are a significant health problem. An estimated 1 in 10 people in Ontario have diabetes and up to 25% of these individuals will develop a foot ulcer during their lifetime. Sometimes these ulcers eventually lead to amputation of the foot or lower leg. Diabetic ulcers can also cause pain and limit mobility.

Quality standards are designed to provide guidance for just this type of health issue, where there is significant variation across the province in how the condition is managed. In this instance, the rate of below-knee amputations varies eightfold between the Local Health Integration Network (LHIN) with the highest rate and the LHIN with the lowest rate.

One of the 12 statements in the standard detailing how diabetic foot care could be improved stated that people with a diabetic foot ulcer or foot complications should be offered “pressure redistribution devices as part of their individualized care plan.”

These devices – which look like boots or casts – redistribute pressure around the heel, ankle and toes so the foot can heal. Many clinicians recommend these devices, but patients were often being asked to pay out-of-pocket, and some patients found the costs unaffordable.

However, just weeks prior to the release of the quality standard, the Ontario Ministry of Health and Long-Term Care announced it would be covering the costs of these devices as the direct result of a health technology assessment Health Quality Ontario conducted.

Health Quality Ontario has been providing health technology assessments and funding recommendations based on these assessments for many years. The situation with diabetic foot ulcers represents a clear linkage between the funding recommendations and an initiative to improve health care through publication of the quality standard.

The funding recommendations from technology assessment and quality standards should align – funding recommendations can make their way into quality standards, and the advisory committees that formulate our quality standards might identify topics where a funding recommendation is needed.

A fundamentally important factor underlying both health technology assessments and quality standards is use of the best available evidence and expert consensus to inform decisions. Patient and caregiver involvement and lived experience also plays an important role.

Don Berwick, a U.S. expert in health quality issues, has said, “Not all change is improvement, but all improvement is change.”

Sometimes we make changes that aren’t rooted in evidence, and these changes can harm patients or waste resources. But even when we know what works – like offloading devices for diabetic foot ulcers – to actually see improvement, we need change. We hope that the work we do at Health Quality Ontario supports clinicians and patients in making changes that are evidence-based, patient-centred and cost effective.

(This blog is adapted from part of a presentation given as part of the Canadian Agency for Drugs and Technology in Health lecture series)


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