Disease Management Program

Disease Management Program Cuts Lower Extremity Amputation Rate in Diabetes Patients: Presented at ADA

By Jill Stein

NEW ORLEANS, LA -- June 17, 2003 -- Population-based lower extremity screening combined with a treatment program leads to a progressive decrease in the rate of amputation in patients with diabetes, researchers reported here June 15^th at the 63^rd Scientific Sessions of the American Diabetes Association.

Dr. Robert Wunderlich, from the Diabetes Research Group, in San Antonio, Texas, United States, 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 bilaminar 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."