Painful diabetic neuropathy: a new care model in Lazio

Treatment means, first and foremost, directing the patient towards the most appropriate healthcare professional and level of care. The initial assessment is carried out by a diabetologist, who uses screening to identify patients at risk at an early stage. Persistent or refractory cases are then referred for a multidisciplinary assessment involving a diabetologist, a neurologist and a pain management specialist, leading, where necessary, to access to the most advanced treatments at centres with extensive expertise.

The aim is to move beyond an approach based solely on geographical proximity or the availability of individual services, and to build a network in which every patient can follow a standardised, continuous and measurable care pathway.

The aim is to support each person through every stage of their care journey, from diagnosis to choosing the most appropriate treatment, right through to accessing the most innovative therapeutic solutions, such as spinal cord stimulation. This therapeutic solution is now able to offer new prospects to patients with refractory diabetic neuropathic pain and is a safe and effective method in high-volume centres such as ours, which has carried out 107 implantations, with just one revision and no cases of device removal, confirming a high level of appropriateness.

However, the innovation of spinal cord stimulation is not limited to pain management. The most recent evidence suggests that neuromodulation can lead to an improvement in peripheral nerve function and changes in their morphology, which can be documented by ultrasound. The reduction in the cross-sectional area of the tibial nerve observed in treated patients suggests that the effects of the therapy extend beyond symptomatic relief.

This means that therapeutic success is not assessed solely on the basis of subjective pain or quality-of-life scales, but also through objective and reproducible data capable of documenting changes in nerve function. This approach makes treatment outcomes even more measurable and reinforces the scientific value of the care pathway.

One of the key features of the PDTA is the introduction of process, outcome and appropriateness indicators.

The programme involves monitoring the percentage of patients undergoing screening, the time taken to admit patients, appropriate access to pain management and advanced procedures, adherence to scheduled follow-ups, and the reduction in inappropriate visits to A&E, hospital admissions and complications.

The ability to incorporate clinical, functional and instrumental indicators transforms the PDTA into a clinical governance tool, capable of documenting the effectiveness of organisational and therapeutic decisions using objective data.

As Roberta Della Casa, a member of the Lazio Regional Council, and the management of the health authority pointed out, pain management is a key element in the treatment of numerous conditions, which is why a dedicated regional coordination body has been set up, with the aim of improving the care of patients suffering from painful diabetic neuropathy and ensuring consistent access to specialist services. A structured approach to patient care – from prevention through to diagnosis and treatment – is the most effective way of integrating community and hospital care. This PDTA is a concrete example of integration between the different levels of care and demonstrates how a shared pathway can improve the appropriateness of interventions, continuity of care and, above all, patient outcomes.

The PDTA developed by ASL Roma 4 proposes a new approach to the management of painful diabetic neuropathy, based on collaboration between specialists, the standardisation of clinical decisions and the systematic measurement of outcomes. In summary, this integrated pathway represents a novelty for a number of reasons: firstly, among the main regional initiatives available, there are no PDTA programmes dedicated exclusively to painful diabetic neuropathy that also include a structured pathway towards spinal cord stimulation (SCS). Furthermore, the focus has shifted from pain management to the comprehensive management of the condition, and the principle of ‘guiding to treat’ is applied through a multidisciplinary network that supports the patient from diagnosis through to advanced therapies. Furthermore, diabetology, neurology and pain management are integrated into a single standardised pathway, and SCS is assessed not only for pain reduction but also for improvements in the function and morphology of peripheral nerves, which can be documented using ultrasound techniques.
Outcomes are measured using clinical, functional and instrumental indicators, making the pathway verifiable and results-oriented: the PDTA is proposed as a model of clinical governance capable of integrating community and hospital care, improving appropriateness, continuity of care and sustainability.

* Head of the Pain Management Centre – ASL Roma 4