Team approach to foot care lowers risk of amputation in diabetes

August 19, 2010 By Elaine Zablocki

People with diabetic foot problems can lower their risk of leg amputation by relying on coordinated care that includes a podiatrist, according to a recent study. For instance, those with diabetes-related foot ulcers can reduce their risk of amputation by 31 percent.

Diabetes leads to poor circulation and damaged nerves, which make foot injuries more likely. When injuries occur, slows the healing process. That is why 30 percent of people with diabetes over age 40 have diabetes-related foot problems. If you have diabetes, your lifetime risk of developing a foot ulcer is 15 percent or more. About a quarter of diabetic foot ulcers refuse to heal and eventually require amputation.

In a study published online in the journal Health Services Research, researchers classified diabetic foot problems into four stages:
• Stage one: Nerve problems - when the patient loses the ability to feel pain in feet and might not notice injuries.
• Stage two: Cellulitis - when the cells just below the skin become infected. In addition, Charcot foot - which involves deteriorated ligaments and cartilage.
• Stage three: Foot ulcers.
• Stage four: Gangrene, which could require amputation.

Lead author Frank Sloan, Ph.D., and colleagues looked at six years of Medicare claims data on nearly 190,000 diabetic patients with foot problems. The study included about 118,000 patients diagnosed as stage one, about 32,000 in stage two, 31,000 in stage three and 55,000 in stage four (some participants experienced more than one stage).

The researchers found that people who saw both a podiatrist and a medical doctor specializing in care of diabetic feet during the year before diagnosis were much less likely to need amputation eventually. Physicians included surgeons, neurologists, dermatologists and other specialists. Podiatrists receive four years of post-college training in a school of podiatry and generally have licenses to care only for the foot and ankle.

“This study shows that coordinated care substantially reduces amputation rates,” said David Armstrong, M.D., a podiatrist and co-founder of the Southern Arizona Limb Salvage Alliance. “We already knew that when care teams are developed to prevent amputation, in every case we see success. The study documents that this is true across the country.” Armstrong has no affiliation with the study.

The first step in preventing foot problems is to see a physician regularly for help in controlling the underlying diabetes disease process. In addition, “check your feet every day,” Armstrong said. “Whenever you see your general doctor, take your socks off, since this improves the likelihood that your feet will be evaluated.”

Diabetic patients with foot problems ideally should see a physician who specializes in care of diabetic feet, as well as a podiatrist. In some cities, group practices have set up coordinated efforts that include general diabetes care, a podiatrist and a physician foot specialist, functioning together as a team.

“A podiatrist is able to follow the patient and identify small problems before they become big problems,” Armstrong said. “These efforts demonstrate that prevention really pays.”

Armstrong said that foot infections are the most common reason hospitals admit someone with diabetes. “These problems are common, complicated and costly,” he said. “The data in this study fairly clearly show that seeing a podiatrist has a net protective effect in preventing amputations.”

In locations where no team is available, people with foot problems due to diabetes proactively should seek care from both a foot specialist and a podiatrist, Sloan said. “Each patient has to be his or her own advocate, and seek out the care that they need.”

More information: Sloan FA, Feinglos MN, Grossman DS. Receipt of care and reduction of lower extremity amputations in a nationally-representative sample of U.S. elderly. Health Services Research online, 2010.

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