Can Community-Based Programs Help Prevent Lower Extremity Amputations?

Ryan H. Fitzgerald, DPM

There are currently 24 million Americans — approximately 8 percent of the entire population — living with diabetes.1 Nearly 1.6 million new cases of diabetes are diagnosed in people 20 years and older each year. It is estimated that the number of patients living with diabetes will double to an estimated 48 million people by 2050.1

   As a consequence of this drastic increase in the numbers of patients with diabetes, clinicians anticipate a significant increase in diabetes-related complications, including lower extremity complications such as the development of diabetic foot ulcerations (DFUs) and subsequent progression toward lower extremity amputation. We are facing a rising epidemic of limb loss due to the development of DFUs.

   The consequences of major amputation in the lower extremity are well understood. Recent data suggests that the mortality rate associated with lower extremity amputation indeed rivals most cancers.2

   In addition to soaring mortality rates related to diabetes, the cost of diabetes care has continued to increase and has proven to be a source of significant expenditures of healthcare dollars, costing nearly $175 billion in 2007.1 Of this cost, approximately $116 billion was direct medical costs and an additional $58 billion was indirect costs. Research has demonstrated that, after adjusting for population, age and gender differences, the average healthcare expenditures among those patients living with diabetes were 2.3 times higher than the healthcare expenditures in the non-diabetic patient population.1

   There have been numerous attempts to manage both the increasing incidence of DFUs and address the spiraling cost of healthcare related to the management of patients with diabetes. Numerous studies have demonstrated the efficacy of interdisciplinary approaches to the management of this challenging patient population.3-5

   The limb salvage teams described in the literature are commonly located around major university settings or in large metropolitan areas. Despite successes in reducing the number of lower extremity amputations in various limb preservation centers (such as those at the University of Arizona or Georgetown University), the majority of patients with diabetes, due to limited access, still rely on community level providers of various specialties to manage their care.

Emphasizing The Value Of Risk Stratification And Preventative Screening

There have been numerous attempts to provide population-based screening and disease management algorithms for patients with diabetes. We can apply these algorithms universally from the largest metropolitan center to the smallest rural community. These screening measures attempt to provide risk classification and stratification among those patients with diabetes.

   Risk stratification involves the determination of those factors — such as neuropathy or musculoskeletal deformity — that may lead to negative outcomes in patients with diabetes. Such stratification based upon risk assessment allows the clinician to triage high-risk patients for appropriate, timely intervention. Stratification can also provide treatment and follow-up algorithms that provide continued surveillance for those patients with diabetes who demonstrate reduced overall risk.6

   Accordingly, it is vital that clinicians are able to appropriately determine risk. Numerous studies have elucidated the major risk factors for the development of lower extremity ulceration. These risk factors include vasculopathy, loss of protective sensation (LOPS), musculoskeletal deformity, history of a previous amputation and hyperglycemia.7,8

   One algorithm that clinicians can utilize to stratify this patient population appropriately is the Foot Risk Classification system.9 Armstrong and Lavery proposed this system, which categorizes patients into four different risk groups and provides suggested treatment and follow-up algorithms.

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