Incidence, outcomes, and cost of foot ulcers in patients with diabetes.
TL;DR: The results appear to support the value of foot-ulcer prevention programs for patients with diabetes and the attributable cost of care compared with that in patients without foot ulcers.
Abstract: OBJECTIVE: To determine the incidence of foot ulcers in a large cohort of patients with diabetes, the risk of developing serious complications after diagnosis, and the attributable cost of care compared with that in patients without foot ulcers. RESEARCH DESIGN AND METHODS: Retrospective cohort study of patients with diabetes in a large staff-model health maintenance organization from 1993 to 1995. Patients with diabetes were identified by algorithm using administrative, laboratory, and pharmacy records. The data were used to calculate incidence of foot ulcers, risk of osteomyelitis, amputation, and death after diagnosis of foot ulcer, and attributable costs in foot ulcer patients compared with patients without foot ulcers. RESULTS: Among 8,905 patients identified with type 1 or type 2 diabetes, 514 developed a foot ulcer over 3 years of observation (cumulative incidence 5.8%). On or after the time of diagnosis, 77 (15%) patients developed osteomyelitis and 80 (15.6%) required amputation. Survival at 3 years was 72% for the foot ulcer patients versus 87% for a group of age- and sex-matched diabetic patients without foot ulcers (P
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TL;DR: Substantial evidence supports screening all patients with diabetes to identify those at risk for foot ulceration and recommending certain prophylactic interventions, including patient education, prescription footwear, intensive podiatric care, and evaluation for surgical interventions.
Abstract: ContextAmong persons diagnosed as having diabetes mellitus, the prevalence
of foot ulcers is 4% to 10%, the annual population-based incidence is 1.0%
to 4.1%, and the lifetime incidence may be as high as 25%. These ulcers frequently
become infected, cause great morbidity, engender considerable financial costs,
and are the usual first step to lower extremity amputation.ObjectiveTo systematically review the evidence on the efficacy of methods advocated
for preventing diabetic foot ulcers in the primary care setting.Data Sources, Study Selection, and Data ExtractionThe EBSCO, MEDLINE, and the National Guideline Clearinghouse databases
were searched for articles published between January 1980 and April 2004 using
database-specific keywords. Bibliographies of retrieved articles were also
searched, along with the Cochrane Library and relevant Web sites. We reviewed
the retrieved literature for pertinent information, paying particular attention
to prospective cohort studies and randomized clinical trials.Data SynthesisPrevention of diabetic foot ulcers begins with screening for loss of
protective sensation, which is best accomplished in the primary care setting
with a brief history and the Semmes-Weinstein monofilament. Specialist clinics
may quantify neuropathy with biothesiometry, measure plantar foot pressure,
and assess lower extremity vascular status with Doppler ultrasound and ankle-brachial
blood pressure indices. These measurements, in conjunction with other findings
from the history and physical examination, enable clinicians to stratify patients
based on risk and to determine the type of intervention. Educating patients
about proper foot care and periodic foot examinations are effective interventions
to prevent ulceration. Other possibly effective clinical interventions include
optimizing glycemic control, smoking cessation, intensive podiatric care,
debridement of calluses, and certain types of prophylactic foot surgery. The
value of various types of prescription footwear for ulcer prevention is not
clear.ConclusionsSubstantial evidence supports screening all patients with diabetes to
identify those at risk for foot ulceration. These patients might benefit from
certain prophylactic interventions, including patient education, prescription
footwear, intensive podiatric care, and evaluation for surgical interventions.
2,469 citations
TL;DR: When assessing the economic effects of diabetic foot disease, it is important to remember that rates of recurrence of foot ulcers are very high, being greater than 50% after 3 years.
2,081 citations
TL;DR: In this Review, amplicon and shotgun metagenomic DNA sequencing studies that have been used to assess the taxonomic diversity of microorganisms that are associated with skin from the kingdom to the strain level are described.
Abstract: Functioning as the exterior interface of the human body with the environment, skin acts as a physical barrier to prevent the invasion of foreign pathogens while providing a home to the commensal microbiota. The harsh physical landscape of skin, particularly the desiccated, nutrient-poor, acidic environment, also contributes to the adversity that pathogens face when colonizing human skin. Despite this, the skin is colonized by a diverse microbiota. In this Review, we describe amplicon and shotgun metagenomic DNA sequencing studies that have been used to assess the taxonomic diversity of microorganisms that are associated with skin from the kingdom to the strain level. We discuss recent insights into skin microbial communities, including their composition in health and disease, the dynamics between species and interactions with the immune system, with a focus on Propionibacterium acnes, Staphylococcus epidermidis and Staphylococcus aureus.
1,284 citations
TL;DR: Foot infections in patients with diabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity and, thus, the urgency and venue of management.
Abstract: Benjamin A. Lipsky, Anthony R. Berendt, H. Gunner Deery, John M. Embil, Warren S. Joseph, Adolf W. Karchmer, Jack L. LeFrock, Daniel P. Lew, Jon T. Mader, Carl Norden, and James S. Tan Medical Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington; Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom; Northern Michigan Infectious Diseases, Petoskey, Michigan; Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; Section of Podiatry, Department of Primary Care, Veterans Affairs Medical Center, Coatesville, Pennsylvania; Division of Infectious Diseases, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; Dimensional Dosing Systems, Sarasota, Florida; Department of Medicine, Service of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; Department of Internal Medicine, The Marine Biomedical Institute, and Department of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, Texas; Department of Medicine, New Jersey School of Medicine and Dentistry, and Cooper Hospital, Camden, New Jersey; and Department of Internal Medicine, Summa Health System, and Northeastern Ohio Universities College of Medicine, Akron, Ohio
991 citations
Cites background from "Incidence, outcomes, and cost of fo..."
...Foot infections in persons with diabetes are a common, complex, and costly problem [1–4]....
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...M os t st ud ie s [4 1, 42 , 84 , 85 ] in di ca te th at th e la tt er yi el d a...
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TL;DR: This large cohort study aims to determine the incidence of, and clinically relevant risk factors for, new foot ulceration in a large cohort of diabetic patients in the community healthcare setting.
Abstract: Aims To determine the incidence of, and clinically relevant risk factors for, new foot ulceration in a large cohort of diabetic patients in the community healthcare setting.
Methods Diabetic patients (n = 9710) underwent foot screening in six districts of North-west England in various healthcare settings. All were assessed at baseline for demographic information, medical and social history, neuropathy symptom score, neuropathy disability score, cutaneous pressure perception (insensitivity to the 10 g monofilament), foot deformities, and peripheral pulses. Two years later, patients were followed up via postal questionnaire to determine the incidence of new foot ulcers. Cox’s proportional hazards regression analysis was used to determine the independent, relative risk of baseline variables for new foot ulceration.
Results New foot ulcers occurred in 291/6613 patients who completed and returned their 2-year follow-up questionnaire (2.2% average annual incidence). The following factors were independently related to new foot ulcer risk: ulcer present at baseline (relative risk (95% confidence interval)) 5.32 (3.71–7.64), past history of ulcer 3.05 (2.16–4.31), abnormal neuropathy disability score (≥ 6/10) 2.32 (1.61–3.35), any previous podiatry attendance 2.19 (1.50–3.20), insensitivity to the 10 g monofilament 1.80 (1.36–2.39), reduced pulses 1.80 (1.40–2.32), foot deformities 1.57 (1.22–2.02), abnormal ankle reflexes 1.55 (1.01–2.36) and age 0.99 (0.98–1.00).
Conclusions More than 2% of community-based diabetic patients develop new foot ulcers each year. The neuropathy disability score, 10 g monofilament and palpation of foot pulses are recommended as screening tools in general practice.
939 citations
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TL;DR: It is concluded that scoring automated pharmacy data can provide a stable measure of chronic disease status that, after controlling for health care utilization, is associated with physician-rated disease severity, patient-rated health status, and predicts subsequent mortality and hospitalization rates.
975 citations
TL;DR: With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
Abstract: Limb- or life-threatening complications in patients with diabetes can be prevented with an integrated, multidisciplinary approach. Most patients seen in clinical practice are in the early stages of the disease process. Glycemic control retards the progression of neuropathy, which is the most important risk factor for ulceration. Early detection of the loss of protective sensation and implementation of strategies to prevent ulceration will reduce the rates of limb-threatening complications. Clinicians should routinely examine the feet of diabetic patients. Education in foot care, proper footwear, and close follow-up are required to prevent or promptly detect neuropathic injury. If ulceration occurs, removal of pressure from the site of the ulcer and careful management of the wound will allow healing in most cases. The failure to heal despite these measures should prompt a search for associated arterial insufficiency. If infection is present, appropriate antimicrobial therapy combined with immediate surgical intervention, including revascularization when necessary, will increase the chances of saving the limb. With this comprehensive approach, it is possible to achieve the goal of a 40 percent decrease in amputation rates among diabetic patients by the year 2000.
613 citations
TL;DR: The results suggest that the revised chronic disease score and ambulatory care groups with empirically derived weights provide improved prediction of health care utilization and costs, as well as hospitalization and mortality, over age and sex alone.
Abstract: Different types of medication prescribed during a 6-month period for the treatment and management of chronic conditions were utilized in the refinement and validation of a chronic disease score Prescription data, in addition to age and sex, were utilized to develop a chronic disease score based on empirically derived weights for each of three outcomes: total cost, outpatient cost, and primary care visits The ability of the revised chronic disease score to predict health care utilization, costs, hospitalization, and mortality was compared to an earlier version of the chronic disease score (original) that was derived through clinical judgments of disease severity The predictive validity of the chronic disease score is also compared to ambulatory care groups, which utilize outpatient diagnoses to form mutually exclusive diagnostic categories Models based on a concurrent 6-month period and a 6-month prospective period (ie, the 6-month period after the chronic disease score or ambulatory care group derivation period) were estimated using a random one half sample of 250,000 managed-care enrollees aged 18 and older The remaining one half of the enrollee population was used as a validation sample The revised chronic disease score showed improved estimation and prediction over the original chronic disease score The difference in variance explained prospectively by the revised chronic disease score versus the ambulatory care groups, conversely, was small The revised chronic disease score was a better predictor of mortality than the ambulatory care groups The combination of revised chronic disease score and ambulatory care groups showed only marginally greater predictive power than either one alone These results suggest that the revised chronic disease score and ambulatory care groups with empirically derived weights provide improved prediction of health care utilization and costs, as well as hospitalization and mortality, over age and sex alone We recommend the revised chronic disease score with total cost weights for general use as a severity measure because of its relative advantage in predicting mortality compared to the outpatient cost and primary care visit weights
571 citations
TL;DR: Programs to reduce amputations among people with diabetes in primarycare settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and follow-up; and, when necessary, refer patients to specialists.
Abstract: The age-adjusted rate of lower-extremity amputation (LEA) in the diabetic population is approximately 15 times that of the nondiabetic population. Over 50,000 LEAs were performed on individuals with diabetes in the United States in 1985. Among individuals with diabetes, peripheral neuropathy and peripheral vascular disease (PVD) are major predisposing factors for LEA. Lack of adequate foot care and infection are additional risk factors. Several large clinical centers have experienced a 44-85% reduction in the rate of amputations among individuals with diabetes after the implementation of improved foot-care programs. Programs to reduce amputations among people with diabetes in primary-care settings should identify those at high risk; clinically evaluate individuals to determine specific risk status; ensure appropriate preventive therapy, treatment for foot problems, and follow-up; provide patient education; and, when necessary, refer patients to specialists, including health-care professionals for diagnostic and therapeutic interventions and shoe fitters for proper footwear. Programs should monitor and evaluate their activities and outcomes. Many issues related to the etiology and prevention of LEAs require further research.
502 citations
Journal Article•
TL;DR: In this article, the authors identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus, and design a case-control study to evaluate the risk factors.
Abstract: ▪Objective:To identify and quantify risk factors for lower extremity amputation in persons with diabetes mellitus. ▪Design:Case-control study. ▪Setting:A Veterans Affairs medical center. ▪...
433 citations