Can Community-Based Programs Help Prevent Lower Extremity Amputations?
The U.S. Department of Health and Human Services has created a five-step lower extremity amputation prevention (LEAP) program, which clinicians can utilize in the evaluation of patients with diabetes.10 Developed in 1992, the LEAP program focuses on identifying patients who have LOPS. The program includes annual patient screening, patient education, daily self-inspection, appropriate footwear selection and early management of simple foot problems to reduce risk.
The LEAP Diabetic Foot Screen uses a 5.07 monofilament, which delivers 10 g of force, to identify patients with a foot at risk of developing problems.10 The LEAP system recommends performing an initial foot screen on all patients with diabetes and at least annually thereafter. At-risk patients should present at least four times a year for a check of their feet and shoes to help prevent lower extremity complications.
Improving Access And Actively Engaging Patients As ‘Partners’ In Their Care
Considering the staggering evidence in support of screening measures and risk stratification of patients with diabetes, the question remains as to how best to implement these screening programs where they are most needed to effectively reduce the development of lower extremity ulceration and subsequent non-traumatic amputations.11,12
To be effective, these screening measures and intervention algorithms must be accessible to the patient populations. Therefore, it stands to reason that community-based programs will demonstrate superiority. Indeed, a study demonstrated that following the institutionalization of a LEAP program in a local hospital system in New Jersey, there was a trend toward an overall reduction in the number of lower extremity amputations at participating institutions.13
Furthermore, community programs must partner healthcare providers — such as internists, endocrinologists and podiatric surgeons — with their respective patients. This way, patients assume personal responsibility for their care and become full partners with the healthcare team in preventing foot problems. This promotes patient adherence and accountability through self-management and unity of action. Patient self-management includes appropriate glycemic control as well as daily lower extremity self examination for early detection of pre-ulcerative lesions, blisters, erythema, swelling and callus development, as well as other potential problem areas.
In addition to self-management, community efforts may include the establishment of diabetes support group meetings — not unlike a support group for people who have had amputations — to allow high-risk patients to interact with one another and provide mutual support. Numerous studies have demonstrated the success of group support following amputation in patients with diabetes.14,15 These support groups commonly provide a sense of community and help patients come to terms with their amputation and its consequences.
A variation on this model can provide group interaction and support prior to the need for amputation, a sort of pre-amputation support group that empowers participating high-risk patients to take a more active role in the management of their diabetes.
Indeed, a recent study included the use of group activity in the development and implementation of a multifaceted program in an inner-city healthcare center designed to improve access to care.16 The Diabetes Rewards Issued Via Everyone (DRIVE) Day program included monthly group visits as well as patient selected activities including diabetes education, nutrition, exercise, group discussions and Q&A sessions. The program also entailed provider support including evidence-based medicine guidelines for glycemic, lipid and hypertension management as well as retinal screening, lower extremity exams and medication adjustment. In addition, DRIVE used a Web-based registry of participants for future reference.