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Institutional toe & flow programs: How and why the teams work.

Ahmed A Naiem1, Ryan T Callahan1, Alexander M Reyzelman1

  • 1Center for Limb Preservation and Diabetic Foot, Division of Vascular and Endovascular Surgery, University of California, San Francisco, San Francisco, CA.

Seminars in Vascular Surgery
|March 14, 2025
PubMed
Summary

The Toe & Flow model, a multidisciplinary approach, improves outcomes for diabetic foot ulcers and chronic limb-threatening ischemia. This integrated care strategy reduces limb loss and enhances patient survival through streamlined treatment and community partnerships.

Keywords:
Chronic limb threateningDiabetic foot ulcersIschemiaLimb preservationMultidisciplinaryToe & flow

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Area of Science:

  • Podiatry
  • Vascular Surgery
  • Diabetology
  • Public Health

Background:

  • Diabetic foot ulcers (DFUs) with chronic limb-threatening ischemia (CLTI) present a significant risk for limb loss and mortality.
  • Current treatment paradigms often lack integrated, multidisciplinary approaches, leading to suboptimal patient outcomes.
  • Effective management requires a coordinated effort addressing both the ulceration and underlying vascular compromise.

Purpose of the Study:

  • To introduce and evaluate the "Toe & Flow" model, a novel, multidisciplinary care pathway for patients with DFUs and CLTI.
  • To demonstrate how this integrated model streamlines treatment, improves access to care, and enhances patient outcomes.
  • To highlight the model's success in reducing amputation rates and improving survival in a high-risk population.

Main Methods:

  • The Toe & Flow model is a multidisciplinary team-based approach led by podiatry/orthopedic foot and ankle specialists and vascular specialists.
  • It integrates other medical professionals and community partners to create a comprehensive care ecosystem.
  • The model establishes clear referral pathways, utilizes evidence-based treatment guidelines, and incorporates aggressive surveillance and community collaboration.

Main Results:

  • Institutional Toe & Flow programs have demonstrated successes in managing complex diabetic foot cases.
  • The model facilitates a high standard of care through community education, engagement, and streamlined access.
  • Outcomes data collection and reporting serve as a regional educational hub, informing policy and resource allocation.

Conclusions:

  • The Toe & Flow model offers a successful framework for optimizing the management of diabetic foot ulcers with chronic limb-threatening ischemia.
  • This integrated, multidisciplinary approach significantly reduces the risk of limb loss and improves patient survival.
  • The model's emphasis on community integration, evidence-based pathways, and outcome reporting provides a scalable solution for improving diabetic limb care nationally.