ADA: Disease Management Program
Cuts Lower Extremity Amputation Rate in Diabetes
Patients
Population-based lower extremity screening combined
with a treatment program leads to a progressive
decrease in the rate of amputation in patients
with diabetes.
Dr. Robert Wunderlich, from the Diabetes Research
Group, in San Antonio, Texas, presented 4-year
results in 2,700 diabetes patients who participated
in such a program.
The screening evaluation focused on identifying
factors that would put patients at risk of subsequent
diabetic foot pathology. These factors included
a history of ulceration or amputation, peripheral
sensory neuropathy, peripheral vascular disease,
and musculoskeletal deformities of the foot.
After screening, patients were placed into a
low-risk or high-risk group. Low-risk patients
had no history of ulceration or amputation, had
intact protective sensation, and had no evidence
of peripheral arterial occlusive disease. High-risk
patients had one or more of the following: a history
of foot ulceration or amputation, loss of protective
sensation, or evidence of peripheral arterial
occlusive disease.
Patients in the low-risk group were referred
to a patient education program supervised by a
certified diabetes nurse educator, and foot care
was provided on an as-needed basis. Screening
evaluations were repeated annually.
Patients in the high-risk group were evaluated
by a staff podiatrist and referred to a certified
pedorthist for fitting of therapeutic shoes and
insoles. Most patients were prescribed extra-depth
shoes with dual density bi-laminar accommodative
insoles. These patients were seen at 8- to 12-week
intervals for infrared dermal temperature testing
and palliative foot care. Acute foot problems
were treated immediately by a staff podiatrist.
Patients with acute peripheral arterial occlusive
disease were promptly referred to a vascular surgeon.
All patients in the high-risk group were also
referred to a patient education program.
The investigators identified an amputation incidence
of 70.4 per 10,000 patients during the first year
of intervention (1999). After continued implementation
of the screening and prevention program, the amputation
incidence was reduced to 48.4 per 10,000 patients
during the most recent year of intervention (2002)
-- a 31.3% reduction.
There was a 47.3% reduction in above-knee and
below-knee amputation incidence compared to the
first year of the study.
"From a financial standpoint, traditional
health care spending models focus only on the
most acute cases," Dr. Wunderlich said. "Our
approach focuses on the entire population. This
effectively shifts the spending mean to a lower
value, thus reducing health care costs for the
entire diabetic population."
Researchers reported at the 63rd Scientific Sessions
of the American Diabetes Association.
[Study title: Progressive Reduction in Diabetes-Related
Lower Extremity Amputation Incidence in a Disease
Management Model. Abstract 1042]
