6 Key Steps to Preventing Diabetic Foot Ulcers and Amputations

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by Dr. Mark Hinkes, DPM

Twenty first century technology is helping people with diabetes to heal foot ulcers. An Australian colleague, for example, is developing an application that reminds people with diabetes to control their blood sugars with prompts and instructions, and allows them to upload a picture of their wound for their podiatrist to evaluate.

This is just one small example of the time, energy and resources being devoted to dealing with diabetic foot ulcers AFTER they happen.

The CDC National Diabetes Fact Sheet reports that between 45 and 85% of lower extremity amputations can be prevented.1 The questions I have asked myself many times are why is this not happening? What are we waiting for? Why are so many people with diabetes continuing to lose legs? Shouldn't more time, energy, and resources be devoted to preventing diabetic foot ulcers BEFORE they happen? I strongly believe that that the answer to my questions is prevention; an idea whose time has come for the diabetic foot.

Diabetic Foot Complications: Know the Facts

The fact is that one fourth of all people with diabetes will develop a foot ulcer2 and more than half of those foot ulcers will become infected, requiring hospitalization. Further, one in five will require an amputation.3

In the United States, there are approximately 100,000 non-traumatic lower extremity amputations performed for people with diabetes yearly -- one every six minutes. Worldwide, there are more than 1 million non-traumatic lower extremity amputations performed for people with diabetes yearly, or one every 30 seconds.4,5

The cost of that care is astronomical. In the U.S., diabetes-related amputation costs are approximately $3 billion/year [$38,000/amputation procedure].6 In a 1995 study, the average cost of a minor amputation was $43,000; a major amputation cost $65,000.7 And worse, after a major amputation, half of those patients will have their other limb amputated within two years.8,9 The five-year mortality rate associated with diabetic lower extremity amputations is GREATER THAN all forms of cancer, except pancreatic and lung cancers combined.10

The Key to Preventing Diabetic Foot Ulcers and Amputations

If we can prevent a foot ulcer, then we can prevent subsequent infections, hospitalizations, and amputations. So, why aren't foot ulcers being prevented?

I believe the answer is simple: People with diabetes are not currently getting an annual preventive foot health screening. Preventive foot health screenings that check circulation, identify foot deformities and incorporate a monofilament test can help people with diabetes keep their legs.

In a study released in 2010 by Thompson Reuters, the internationally recognized research and information firm, demonstrated that Medicare-eligible patients with a foot ulcer had a 18% lower risk of amputation, a 23% lower risk of a major amputation (constituting as a below-the-knee amputation or higher), and 9% lower risk of hospitalization when they had at least one visit to a podiatrist prior to the development of the ulcer.11

Here's how it can be done:

  1. Identify those patients who have diabetic sensory neuropathy by a monofilament test and stratify them into risk groups.
  2. Identify foot deformities of the bones, soft tissues or nails.
  3. Provide patient education on preventive foot health behaviors.
  4. Address the identified pedal risk factors and provide appropriate care on a multidisciplinary basis to ameliorate the risk factors for developing a foot ulcer.
  5. Offer ongoing foot care for local foot health problems.
  6. Follow up with yearly preventive foot health screenings.

It has become part of our healthcare culture to endorse certain, limited preventive health screenings. Women have annual PAP smears and mammograms. Men have digital prostate exams. Dental hygiene is an accepted method to prevent tooth decay and identify oral health pathology. Many of us also have an annual eye exam. These screenings help identify lurking pathology and take proactive measures to prevent the consequences of the identified risks. So, it makes perfect sense to me that every person with diabetes should have a preventive foot health evaluation every year.

Medicare will pay for a retinal photograph to identify vascular pathology in the eye in order to prevent blindness. They will also cover the cost of lab testing for kidney function. So, two of the three most devastating complications of diabetes have covered screening exams for early identification of the risks of retinopathy and nephropathy. But, unfortunately, a yearly preventive foot health exam to identify diabetic sensory neuropathy is not a covered service.

I believe that if more time, energy, and resources were devoted to preventing foot ulcers by screening patients for risk factors for developing foot ulcers and creating awareness that amputations can be prevented, patients with diabetes would have better foot health, a better quality of life, and the overall cost of health care will be reduced.

1. CDC National Diabetes Fact Sheet. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf
2. Singh N, Armstrong DG, Lipsky BA. Preventing Foot Ulcers in Patients With Diabetes. JAMA.2005;293(2):217-228. doi:10.1001/jama.293.2.217.
3. Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk Factors for Foot Infections in Individuals With Diabetes. Diabetes Care. 2006;29(6):1288-1293. doi: 10.2337/dc05-2425.
4. Boulton AJM, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. The Lancet. 2005;366(9498):1719-1724. doi:10.1016/S0140-6736(05)67698-2.
5. Bharara M, Mills JL, Suresh K, Rilo HL, Armstrong DG. Diabetes and landmine-related amputations: a call to arms to save limbs. International Wound Journal. 2009;6:2-3. doi: 10.1111/j.1742-481X.2009.00587.
6. www.amputee-coalition.org
7. Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U. Long-term costs for foot ulcers in diabetic patients in a multidisciplinary setting. Foot Ankle Int. 1995;16(7):388-394. doi: 10.1177/107110079501600702.
8. Goldner MG. The Fate of the 2nd Leg in the Diabetic Amputee. Diabetes. 1960;9(2)100-103. doi: 10.2337/diab.9.2.100
9. Armstrong DG, Lavery LA, Quebedeaux TL, Walker SC. J. Am. Podiatr Med. Assoc.. 1997:87(7):321-326.
10. Robbins JM, Strauss G, Aron D, et al. Mortality rates and diabetic foot ulcers: is it time to communicate mortality risk to patients with diabetic foot ulceration? JAMA. 2008;98(6):489-493.
11. Carls GS, Gibson TD, Driver VR, Wrobel JS, Garoufalis MG, DeFrancis RR, Wang, S, Bagalman EJ. Christina, JR. The Economic Value of Specialized Lower-Extremity Medical Care by Podiatric Physicians in the Treatment of Diabetic Foot Ulcers. JAPMA. 2011;101(2).

About the Author
Dr. Mark Hinkes is the Chief of the Podiatry Service and Director of Podiatric Medical Education for the Veterans Affairs Medical Centers in Nashville and Murfreesboro, Tennessee, part of the Tennessee Valley Healthcare System. He was Chairman of the Preservation Amputation Care and Treatment (PACT) Program for more than a decade. He is Board Certified by the American Board of Foot and Ankle Surgery, and the American Professional Wound Care Association, and is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Hinkes spends time consulting, lecturing, and writing about foot health issues on his website, www.dr-mark.net. His most recent book, Healthy Feet for People with Diabetes, is a practical self-care guide designed for patient education.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.

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