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Study Suggests Remote Patient Monitoring Decreases DFU Recurrence And Health-Care Costs

Could daily remote monitoring of patient foot temperatures mitigate the risk of diabetic foot ulcers and reduce overall utilization of health-care resources? 

A recent study in BMJ Open Diabetes Research and Care says this may be the case. Researchers enrolled 80 patients with healed diabetic foot ulcers (DFUs) in a year-long prevention-focused program including daily foot temperature monitoring with a foot temperature monitoring mat (Podimetrics SmartMat, Podimetrics). They then extracted and analyzed electronic health record (EHR) data retrospectively to determine rates of resource utilization, DFU recurrence and lower extremity amputation. 

Adam L. Isaac, DPM, FACFAS, the lead author on the study, explains that the data showed a complete elimination of major amputations and a 52 percent decrease in all-cause hospital admissions for patients participating in the study. 

“Remarkably, for every three study participants, they avoided one hospital admission,” says Dr. Isaac, the Director of Research at Foot and Ankle Specialists of the Mid-Atlantic (FASMA). “In addition, we noted significant reductions in emergency department and outpatient visits as well as a decreased rate of ulcer recurrence. Put together, these findings demonstrate that use of foot temperature monitoring, in conjunction with a prevention program for patients at high risk for diabetic foot complications, represents a golden opportunity to decrease health-care costs and improve patient outcomes.” 

Windy Cole, DPM says this study reflects newer trends in patient care. 

“Remote patient monitoring (RPM) is a health-care delivery method that utilizes technology to monitor patients outside of the traditional hospital or clinic setting,” notes Dr. Cole, an Adjunct Professor and Director of Wound Care Research at the Kent State University School of Podiatric Medicine. “This is an emerging industry of advancing technological devices with the ability to collect and interpret various physiologic data.” 

Dr. Cole sees the potential utility of remote patient monitoring devices in the management of all phases of diabetes with benefits to patients, physicians and health-care systems alike. 

“From simple alarms to remind patients to take their insulin … and temperature monitors like the device used in this study, remote patient monitoring can be a valuable tool to prevent the many known complications of long-standing diabetes,” maintains Dr. Cole. 

Dr. Isaac agrees. He says providers may one day prescribe a foot temperature monitoring device to patients with diabetes in much the same way as glucometers. 

Both doctors feel that the COVID-19 pandemic emphasizes the importance of the use of such technology. 

“Obviously, the current pandemic magnifies the key findings of this study,” says Dr. Isaac. “Keeping vulnerable patients out of the hospital and trying to mitigate virus exposure are paramount. At the very least, by incorporating foot temperature monitoring into the patients’ daily routine, they can pause and reflect for 20 seconds about the condition of their feet, something they may not do otherwise.” 

Given the high prevalence of neuropathy in patients with diabetes, Dr. Isaac says these patients may lack the “gift of pain” and every second counts in this high-risk population. 

“We often talk about diabetes and amputations in the context of time, and we know that seconds count,” maintains Dr. Isaac. “Every 1.2 seconds, someone develops a diabetic foot ulcer. Every 7 seconds around the world, someone dies from diabetes. Every 20 seconds, someone has an amputation.1 Taken from a different perspective, with the results of our study, look at what is possible in just 20 seconds per day.” 

Do Patients With Gout And Diabetes Face A Higher Risk Of Amputation? 

By Jennifer Spector, DPM, FACFAS, Associate Editor

Most are familiar with the amputation risk associated with diabetes mellitus but a recent abstract presented at the American College of Rheumatology Convergence 2020 Virtual Conference suggests that gout is an independent risk factor for amputation as well. Even more concerning was the finding of an apparent additive risk for patients with both gout and diabetes. 

Researchers identified over four million patients with gout and over 25 million patients with diabetes in a large U.S. claims database. Analysis of the data on these patients revealed that patients with gout only, diabetes only and those with diabetes and gout were 4.6, 13.2 and 22 times more likely respectively to have an amputation than those with neither condition. The study authors relate that there is significant clinical challenge in differentiating infected gouty tophi, osteomyelitis and diabetic foot ulcers (DFUs), which further complicates the risk. Amputations in the study population included feet, toes, fingers and hands. 

Scott M. Neville, DPM, FACFAS, a co-author of the study, shares that although doctors often focus on gout flares, the intercritical periods between these flares where total body urate increases also warrant treatment. He cites the findings of the study as strong supporting evidence to reevaluate one’s outlook on the ramifications of gout outside of acute episodes. 

“It is well-documented that patients with diabetes are at increased risk for an amputation but this is the first research to document the increase in risk for patients with gout and a synergistic increase in amputation risk for patients with both gout and diabetes,” points out Dr. Neville, a Diplomate of the American Board of Foot and Ankle Surgery. 

He relates that there is mounting evidence that gout is not a disease of flares alone. 

“By the time gout symptoms occur, there is a total body urate deposition problem. With the increased amputation rate associated with gout and especially with gout and concomitant diabetes, DPMs must act to treat the total body urate deposition problem by decreasing serum uric acid to a level below six mg/dL,” says Dr. Neville, who is in private practice in Mooresville, Ind. 

Are Octogenarians Reasonable Candidates For Total Ankle Arthroplasty? 

By Jennifer Spector, DPM, FACFAS, Associate Editor 

A recent total ankle arthroplasty study in Foot and Ankle Specialist found that octogenarians were not more likely than younger patients to experience any postoperative complications within the first 30 days, nor did they experience an increased number of complications. 

Drawing upon data from a national database of patients who had a total ankle arthroplasty, researchers assessed 1,059 patients under the age of 80 and a group of 54 patients over the age of 80. While there were no differences between the groups in regard to complications, the study authors noted the older patients did spend more time in the hospital (2.5 versus 1.9 days) and had an increased risk of discharge to a rehabilitation or skilled nursing center postoperatively. 

Lawrence DiDomenico, DPM, FACFAS states that important considerations for candidacy for total ankle arthroplasty in this age range include medical condition, activity level, quality of life and deformity. He says surgeons must go through the appropriate steps to be sure the patient is a “good octogenarian” prior to total ankle arthroplasty surgery and discuss the options with the patient. 

“This needs to be a joint decision between the patient and foot and ankle surgeon,” notes Dr. DiDomenico, the Director of Fellowship Training for the Reconstructive Foot and Ankle Surgical Fellowship at NOMS Ankle and Foot Care Centers in Youngstown, Ohio. “Once one decides to proceed with surgery, then the surgeon must also evaluate the vascularity, the health of the soft tissue envelope, the bone stock and the alignment, or necessary concurrent procedures/surgeries.” 

Ashim Wadehra, DPM, AACFAS relates that he does not typically perform total ankle arthropasty in patients younger than age 50. However, he strongly considers patient goals and activity levels as well. 

“High physical demand at any age is a contraindication for total ankle arthroplasty in my practice,” maintains Dr. Wadehra, a fellowship-trained foot and ankle surgeon. “A healthy octogenarian, who aims to manage end-stage ankle arthrosis with surgical intervention, can very well be a candidate for total ankle arthroplasty. Most of my octogenarian patients do fairly well with simple bracing, however.” 

Based on the results of this article, this population may benefit from an ankle joint prosthesis to improve function and decrease pain, says Dr. DiDomenico, who is in private practice in Youngstown, Ohio. 

Dr. Wadehra feels that with newer implants coming to the market, total ankle arthroplasty is becoming the gold standard for management of end-stage ankle arthritis. However, he says age and functional demand are key factors in assessing treatment options. 

“Ankle fusion is still a very viable procedure that one should consider in those younger patients who may live more physically demanding lifestyles,” says Dr. Wadehra. 

News and Trends
By Jennifer Spector, DPM, FACFAS, Associate Editor

1. Armstrong DG, Kanda VA, Lavery LA, Marston W, Mills JL, Boulton AJ. Mind the gap: disparity between research funding and costs of care for diabetic foot ulcers. Diabetes Care. 2013;36(7):1815-1817. 

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