Clinical C a r e /E d u c a tio n /N u tr itio n /P s y c h o s o c ia l Research

D ia b e tic F e e t P r e v e n tio n
A neglected opportunity in high-risk patients
L a w ren ce A . L avery , d p m 1 C ory L . B a x ter , d p m 1 Pedorthic services were identified from
N ath an A . H u n t , d pm 2 A g bor N d ip , m d 4 notes in the EMRs and durable medical
J avier L a F o n t a in e , d p m 1-3 A n d r e w J .M . B o u l t o n , md4 equipment codes (codes A5501, A5503-
A5508, A5512, and A5513). Diabetes ed­
ucation was defined as a session with a
OBJECTIVE - To evaluate the frequency of foot prevention strategies among high-risk pa­ certified diabetes educator (CPT codes
tients with diabetes. S9445, S9460, and S9465). Our diabetes
education program addressed “the dia­
RESEARCH DESIGN AND M ETHODS — Electronic medical records were used to betic foot” in the third of four education
identify 150 patients on dialysis and 150 patients with previous foot ulceration or amputation sessions. Podiatry care was assessed by re­
with 30 months follow-up to determine the frequency with which patients received education,
view of the EMRs to identify the number
podiatry care, and therapeutic shoes and insoles as prevention services.
of visits and determine whether the visit
RESULTS — Few patients had formal education (1.3%), therapeutic shoes/insoles (7%), or was for prevention, ulcer treatment, or
preventative podiatric care (30%). The ulcer incidence density was the same in both groups (210 other pathology. Foot assessment by any
per 1,000 person-years). In contrast, the amputation incidence density was higher in the dialysis health care provider was also identified.
group compared with the ulcer group (58.7 vs. 13.1 per 1,000 person-years, P < 0.001). Patients Peripheral vascular disease was de­
on dialysis were younger and more likely to be of non-Hispanic white descent (P = 0.006) than fined as at least two nonpalpable foot
patients with a previous history of ulcer or amputation. pulses or abnormal ankle-brachial in­
dexes (<0.9). Neuropathy was defined as
CONCLUSIONS — Prevention services are infrequently provided to high-risk patients. at least one site insensate to a 10-g
Semmes-Weinstein monofilament, ab­
Diabetes Care 33:1460-1462, 2010
normal vibration perception (> 25 volts),
or abnormal light-touch sensation. Pear­
he prevalence of foot complications the time of diagnosis. We enrolled sub­ son x 2 and Fisher exact tests were used to

T is 250% higher among dialysis- jects from 2000 to 2006. We verified

treated patients than among patients these diagnoses by reviewing comprehen­
without chronic kidney disease (1-3). sive electronic medical records (EMRs),
Similarly, patients with a past ulcer his­ including all patient care notes, imaging,
compare categorical data between study
groups. Student t test was used to com­
pare continuous data.

tory have a 34-times-greater risk of devel­ labs, and prescriptions. Scott and White is
oping another ulcer (4,5). Programs to an integrated, multispecialty physician RESULTS — We studied 300 patients
prevent foot ulcers and amputations gen­ group with ~ 550 physicians, 14 clinics, (dialysis group, n = 150; ulcer group, n =
erally involve therapeutic shoes and in­ three dialysis centers, and a 535-bed 150), and 92.3% had type 2 diabetes (Ta­
soles, regular foot care, and patient hospital. ble 1). Compared with the ulcer group,
education (6 -8 ). This study evaluated For the ulcer group, our evaluation dialysis patients were 10 years younger on
the frequency of prevention services began after the initial ulcer healed. For the average and less likely to be of Hispanic
among high-risk patients. dialysis group, our evaluation began with (P = 0.006) or African (P < 0.001) de­
the initiation of dialysis. Subjects with scent. The incidence of ulceration and
RESEARCH D E S IG N A N D HIV/AIDS, trauma from motor vehicle ac­ am putation was high in both study
M E T H O D S — We used claims data cidents, bilateral amputations, and pa­ groups. Incidence of ulceration was 210
for diabetes (ICD-9 250.X), ulceration tients with < 30 months follow-up were per 1,000 person-years in both groups.
(ICD-9 707.10,707.14, and 707.15), and excluded. However, amputation incidence was sig­
dialysis (CPT 90935-90937) from the Three prevention therapies were eval­ nificantly higher in the dialysis group
Scott and White Health Plan to identify uated: pedorthic care (professionally fit­ (58.7 vs. 13.1 per 1,000 person-years,
150 consecutive patients in each group ted therapeutic shoes and insoles), P < 0.001).
with at least 30 months follow-up from diabetes education, and podiatry services. Few patients received prevention ser­
vices (Table 1). Two patients (1.3%) in
From the 'Department of Surgery, Scott and White Hospital and Texas A&M Health Science Center College the dialysis group had formal diabetes ed­
of Medicine, Temple, Texas; the 2Orthopaedic Center of the Rockies, Fort Collins, Colorado; the 3Podiatry ucation, and neither attended the diabetic
Section, Central Texas Veterans Healthcare System, Temple, Texas; and the 4Department of Diabetes and foot care session. No one in the ulcer
Medicine, Manchester Royal Infirmary, Manchester, U.K.
Corresponding author: Nathan A. Hunt, [email protected].
group received formal education. A small
Received 17 February 2010 and accepted 19 April 2010. Published ahead of print at http://care. proportion of patients received therapeu­
diabetesjoumals.org on 27 April 2010. DOl: 10.2337/dcl0-0310. tic shoes. During the first 12-month eval­
© 2010 by the American Diabetes Association. Readers may use this article as long as the work is properly uation period, 21 patients (7%) received
cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.
org/licenses/by-nc-nd/3.0/ for details.
shoes and insoles. Only four patients
The costs o f publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby (1.3%) received a second pair of thera­
marked “advertisement” in accordance with 18 U.S.C. Section 1 734 solely to indicate this fact. peutic shoes and insoles during the sec-

1460 D iabetes C are, volume 33, number 7, J uly 2010 care.diabetesjournals.org

 Lavery and Associates

T able 1— Patient demographics and results appropriate prevention services could

have significantly reduced the high rate
Dialysis Ulcer history Total of amputation.
We believe the results of this study
n 150 150 300 can be generalized to high risk patients in
Male (%) 61 (40.7) 62 (41.3) 123 (41.0) other health care settings. Perhaps, pre­
Race* vention services would be provided less
W hite 116(77.3) 64 (42.7) 180 (60.0) frequently in community practices that
Black 20 (13.3) 54 (36.0) 74 (24.7) are not integrated and that do not have
Hispanic 1 1 (7.3) 28 (18.6) 39 (13.0) electronic medical records because it is
O ther 3 (2.0) 4 (2.7) 7 (2.3) more difficult to communicate and coor­
Age* 64.9 ± 0.98 74.25 ± 1.04 70.22 ± 0.58 dinate care.
Type 2 diabetes (%) 139 (92.6) 138 (92.0) 277 (92.3) Specialized diabetic foot programs
A m putation (%)* 22 (14.7) 5 (3.3) 2 7 (9 ) have been reported to reduce the inci­
Ulceration (%) 79 (52.7) 79 (52.7) 158 (52.6) dence of amputations by 50% (6 -8 ).
N europathy testing Uccioli et al. (12) demonstrated ~50%
Semmes W einstein monofilament 40 (26.7) 41 (27.3) 81 (27) reduction in foot ulceration when thera­
Vibration perception threshold 4 (2.7) 3 (2.0) 7 (2.3) peutic shoes were prescribed for patients
O ther assessment 5 (3.3) 12 (8.0) 17 (5.7) with an ulcer history compared with pa­
No neuropathy testing 101 (67.3) 94 (62.7) 195 (65) tients that selected their own shoes, and
Vascular assessment others have demonstrated that patients
Pedal pulse evaluated 71 (47.3) 84 (56.0) 155 (51.7) receiving regular foot care have fewer re­
Ankle-brachial index evaluated 19 (12.7) 13 (8.7) 32 (10.7) current ulcers (13).
No assessment 60 (40.0) 53 (35.3) 113(37.6) Prevention services for the diabetic
Diabetes education foot are simple to establish and can be
Session 1 (n) 1 (0.6) 0 1 (0.3) made easily accessible through organized
Session 2 (n) 1 (0.6) 0 1 (0.3) multidisciplinary care. This data provide
Sessions 3 -4 0 0 0 further evidence that preventative foot
Podiatry care is not regularly provided, even
Podiatry (anytime)* 74 (49.3) 121 (80.6) 195 (65) among patients with the highest risk for
Podiatry before an ulcer* 63 (42) 27 (18) 90 (30) lower-limb complications. It also high­
Total podiatry visits 296 362 658 lights an opportunity to improve preven­
Therapeutic shoes and insoles tion services for the diabetic foot with
Received shoes or insoles 11 (7.3) 10 (6.6) 21 (7.0) simple protocols for evaluation and
Received second shoes or insoles 1 (0.6) 3 (2.0) 4 (1 .3 ) referral.
Received third shoes or insoles 0 0 0
Data are n (%) or means ± SH. *P < 0.001.
A ckn o w led g m en ts— T his stu d y w as s u p ­
ported by a research grant provided by the
ond 12-month study period, and no one amputations (1,9). As expected, the am­ American Podiatric Medical Association.
received a third pair of shoes in the final 6 putation incidence density was high in No potential conflicts of interest relevant to
this article were reported.
months. There was no difference in the both groups (ulcer group 13.1 and dialy­
L.A.L. researched data, wrote the m anu­
proportion of patients that received ther­ sis group 58.7 per 1,000 person-years). script, and reviewed/edited the manuscript.
apeutic shoes between the dialysis and ul­ The amputation incidence in the general N.A.H. contributed to the discussion and re­
cer groups (7.3 vs. 6.7%, P = 1.0). population with diabetes ranges from 4.4 viewed/edited the m anuscript. J.L. reviewed/
During the 30-month evaluation pe­ to 9.5 per 1,000 person-years (10). edited the manuscript. C.L.B. researched data.
riod, 195 patients (65%) received care by Prevention services were infrequently A.N. reviewed/edited the m anuscript. A.J.M.B.
a podiatrist. However, the majority of pa­ provided to patients in both risk groups. reviewed/edited the manuscript.
tients (70%) were seen after they devel­ In our study, only 7% of patients received The data in this study were presented as an
oped a foot ulcer. Only 90 patients (30%) therapeutic shoes, 1.3% received profes­ oral presentation at the 68th Annual Scientific
were seen for preventative care prior to sional education, and 30% received pre­ Conference of the American College of Foot
and Ankle Surgeons, Las Vegas, Nevada, 24
ulceration. Significantly fewer patients in ventative care by a podiatrist. Other
February 2010.
the ulcer group were seen by a podiatrist reports suggest a poor referral pattern for
for preventative care (18%) compared therapeutic shoes as well. In a study by
with the dialysis group (42%, P < 0.001). Sugarman et al. (11) only 2.9% of subjects
Additionally, neuropathy (35%) and vas­ with diabetes that met the criteria for R eferences
1. N dip A, Lavery LA, Lafontaine J, Rutter
cular assessments (62.4%) were infre­ “high risk” received therapeutic foot­
MK, Vardhan A, Vileikyte L, Boulton AJ.
quently performed. wear. Although the high rate of am pu­ High levels of foot ulceration and amputa­
tation may be due to our study patients’ tion risk in a multiracial cohort of diabetic
CONCLUSIONS— This study fo­ inherent risk for foot complications, it is patients on dialysis therapy. Diabetes Care
cused on two high-risk groups for devel­ possible that poorly utilized prevention 2010;33:878-880
o p i n g d i a b e t i c foot u l c e r s a nd services played a role. We expect that 2. Dossa CD, Shepard AD, Amos AM,

care.diabetesjournals.org D iabetes C are, volume 33, number 7, J uly 2010 1461

Diabetic foot and high-risk patients

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1462 D iabetes C are , volume 33, number 7, J uly 2010 care.diabetesjournals.org

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