Connecting The Dots Between Diabetic Foot Ulcers, PAD And Dangerous Complications

Author(s): 
Desmond Bell, DPM, CWS, FACCWS

   Part of the initiative was to increase diabetic foot screenings as a method to ultimately reduce amputation. During the five-year period, assessment rates rose from 29 percent in 2003-2004 to 83 percent in 2008-2009.4,5 However, no requirement to act on findings existed within the initiative and no evidence exists to demonstrate the screenings had any impact on amputation reduction. When screening was combined with referrals as part of a multidisciplinary approach, researchers observed a positive impact.

   The creation of “Integrated Multidisciplinary Specialist Diabetes Foot Teams” has been associated with markedly improved outcomes. In Ipswich, a town in England, the rate of lower extremity amputation decreased from 36.4 to 6.7 major amputations per 10,000 people with diabetes per year over an 11-year period.4,6

   The National Institute for Health and Clinical Excellence in Great Britain advises that inpatients who are diagnosed with a diabetic foot ulcer should get a referral to a multidisciplinary team within 24 hours of initial examination of the feet.4,7

   Awareness of diabetic foot ulcers and complications is important but even more critical is action in the form of timely referral to providers dedicated to limb preservation. Various authors further support not only the creation of dedicated teams but equally validate the efficacy of the multidisciplinary approach.

   In light of these findings, perhaps further research could illuminate how many referrals to a vascular or endovascular service, aside from amputation prevention, result in life saving procedures such a cardiac or carotid intervention in the presence of discovered blockages in respective arteries.

Emphasizing The Importance Of Vascular Testing And Timely Referrals

As I alluded to earlier, breast cancer awareness has created an indelible impact in our society. Most women are aware of the importance of being proactive by performing regular self-examinations. In those unfortunate instances when a patient or provider may discover a lump, the request for a referral to an oncologist or other cancer specialist is a foregone action step.

   Unfortunately, the same scenario is not associated with the discovery of a diabetic foot ulcer, whether it is complicated by PAD or not. More often than not, a diabetic foot ulcer discovered by a primary care provider meets with a tempered level of urgency and precious time is lost over ensuing weeks. When patients discover an ulcer, they often attempt self-treatment.

   Instead of immediate referrals to wound specialists and/or vascular-endovascular specialists, self-treatment by the patient or limited engagement by the provider is more likely.

   Allie and colleagues found that more than 50 percent of lower extremity amputations occur without prior vascular testing of any type.8 They noted that tests that were not performed included non-invasive types of testing, such as segmental Doppler, pulse volume recording or ankle-brachial index.

   This statistic further illustrates the concept of the lower extremity amputation lottery. Patients with diabetic foot ulcers and wounds related to PAD have their legs and lives in the hands of the provider they happen to be seeing for care. If that provider is not an advocate of limb preservation but views such wounds as an impending indication for amputation, then the patient is certainly in for further complicating issues.

   Understanding that a diabetic foot ulcer is a symptom of far more serious underlying conditions is understanding that cardiac artery disease, peripheral arterial disease, heart attack, stroke and diabetic foot ulcers, among the list of diabetes-related complications, all share common factors.

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