The system of care for the diabetic foot: objectives, outcomes, and opportunities

Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.

[1]  J. Page,et al.  Barriers to podiatric care among diabetic patients in the San Francisco Bay area. , 2000, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[2]  P. Scuffham,et al.  The Health Care Costs of Diabetic Peripheral Neuropathy in the U.S. , 2003 .

[3]  Joe Feinglass,et al.  How ‘preventable’ are lower extremity amputations? A qualitative study of patient perceptions of precipitating factors , 2012, Disability and rehabilitation.

[4]  Matthew J. Thompson,et al.  Epidemiological study of lower limb amputation in England between 2003 and 2008 , 2010, The British journal of surgery.

[5]  David G Armstrong,et al.  Skin temperature monitoring reduces the risk for diabetic foot ulceration in high-risk patients. , 2007, The American journal of medicine.

[6]  G. Leese,et al.  Do patients with diabetes wear shoes of the correct size? , 2007, International journal of clinical practice.

[7]  C. M. Agrawal,et al.  Preventing Diabetic Foot Ulcer Recurrence in High-Risk Patients , 2007, Diabetes Care.

[8]  D. Margolis,et al.  Healing of diabetic neuropathic foot ulcers receiving standard treatment. A meta-analysis. , 1999, Diabetes care.

[9]  S. Lipsitz,et al.  Do Differences in Hospital and Surgeon Quality Explain Racial Disparities in Lower-Extremity Vascular Amputations? , 2009, Annals of surgery.

[10]  S. Albert,et al.  Effect of custom orthotics on plantar pressure distribution in the pronated diabetic foot. , 1994, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[11]  W. Katon,et al.  Depression and incident diabetic foot ulcers: a prospective cohort study. , 2010, The American journal of medicine.

[12]  J. Reekers,et al.  Specific guidelines for the diagnosis and treatment of peripheral arterial disease in a patient with diabetes and ulceration of the foot 2011 , 2012, Diabetes/metabolism research and reviews.

[13]  Donald R. Miller,et al.  Variation in antibiotic treatment for diabetic patients with serious foot infections: A retrospective observational study , 2010, BMC health services research.

[14]  D. Armstrong,et al.  A randomized trial of two irremovable off-loading devices in the management of plantar neuropathic diabetic foot ulcers. , 2005, Diabetes care.

[15]  R. Frykberg,et al.  Randomized Clinical Trial Comparing OASIS Wound Matrix to Regranex Gel for Diabetic Ulcers , 2005, Advances in skin & wound care.

[16]  D. Murdoch,et al.  Reevaluating the Way We Classify the Diabetic Foot , 2008, Diabetes Care.

[17]  D. Armstrong,et al.  Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. , 2000, Diabetes care.

[18]  W. Assendelft,et al.  Patient education for preventing diabetic foot ulceration. , 2014, The Cochrane database of systematic reviews.

[19]  Beth D Darnall,et al.  Depressive symptoms and mental health service utilization among persons with limb loss: results of a national survey. , 2005, Archives of physical medicine and rehabilitation.

[20]  David G Armstrong,et al.  2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections. , 2013, Journal of the American Podiatric Medical Association.

[21]  S. Liatis,et al.  Moisture Status of the Skin of the Feet Assessed by the Visual Test Neuropad Correlates With Foot Ulceration in Diabetes , 2010, Diabetes Care.

[22]  S. Genuth,et al.  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. , 1993, The New England journal of medicine.

[23]  James R Christina,et al.  The economic value of specialized lower-extremity medical care by podiatric physicians in the treatment of diabetic foot ulcers. , 2011, Journal of the American Podiatric Medical Association.

[24]  D. Murdoch,et al.  Validation of the Infectious Diseases Society of America's diabetic foot infection classification system. , 2007, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[25]  N. Tentolouris,et al.  Sudomotor dysfunction is associated with foot ulceration in diabetes , 2009, Diabetic medicine : a journal of the British Diabetic Association.

[26]  N. Hevelone,et al.  Socioeconomic and hospital-related predictors of amputation for critical limb ischemia. , 2010, Journal of vascular surgery.

[27]  Norman Fleischer,et al.  The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. , 1993 .

[28]  Patrick J. Heagerty,et al.  Prediction of Diabetic Foot Ulcer Occurrence Using Commonly Available Clinical Information , 2006, Diabetes Care.

[29]  B. Rovner,et al.  Randomized clinical trial: a pilot study investigating the safety and effectiveness of an escalating dose of peginterferon &agr;-2a monotherapy for 48 weeks compared with standard clinical care in patients with hepatitis C cirrhosis , 2012, European journal of gastroenterology & hepatology.

[30]  Donald R. Miller,et al.  Evaluation of regional variation in total, major, and minor amputation rates in a national health-care system. , 2007, International journal for quality in health care : journal of the International Society for Quality in Health Care.

[31]  L. Lavery,et al.  The Development of Foot Deformities and Ulcers After Great Toe Amputation in Diabetes , 1996, Diabetes Care.

[32]  Shoshannah A. Pearlman.  The Patient Protection and Affordable Care Act , 2013, Journal of the American Psychiatric Nurses Association.

[33]  Donald R. Miller,et al.  Depression and incident lower limb amputations in veterans with diabetes. , 2011, Journal of diabetes and its complications.

[34]  B. Pentland,et al.  Depression and anxiety symptoms after lower limb amputation: the rise and fall , 2009, Clinical rehabilitation.

[35]  W. Hiatt,et al.  Patterns of artery disease in 450 patients undergoing revascularization for critical limb ischemia: implications for clinical trial design. , 2008, Journal of vascular surgery.

[36]  Charles E. Leonard,et al.  Location, Location, Location: Geographic Clustering of Lower-Extremity Amputation Among Medicare Beneficiaries With Diabetes , 2011, Diabetes Care.

[37]  N. Barshes,et al.  A framework for the evaluation of "value" and cost-effectiveness in the management of critical limb ischemia. , 2011, Journal of the American College of Surgeons.

[38]  K Kluge,et al.  Effects of preventative footwear on foot pressure as determined by pedobarography in diabetic patients: a prospective study , 2001, Diabetic medicine : a journal of the British Diabetic Association.

[39]  R. Frykberg,et al.  Surgical off-loading of the diabetic foot. , 2010, Journal of vascular surgery.

[40]  Donald R. Miller,et al.  Trends in Initial Lower Extremity Amputation Rates Among Veterans Health Administration Health Care System Users From 2000 to 2004 , 2011, Diabetes Care.

[41]  Spence M. Taylor.  Current status of heroic limb salvage for critical limb ischemia. , 2008, The American surgeon.

[42]  C. Grunfeld,et al.  Prevalence of foot pathology and lower extremity complications in a diabetic outpatient clinic. , 1989, Journal of rehabilitation research and development.

[43]  D. Armstrong,et al.  Variability in activity may precede diabetic foot ulceration. , 2004, Diabetes care.

[44]  E. Bass,et al.  Variation in utilization of procedures for treatment of peripheral arterial disease. A look at patient characteristics. , 1993, Archives of internal medicine.

[45]  G. A. Holloway,et al.  Prevention of amputation by diabetic education. , 1989, American journal of surgery.

[46]  Anthony Delitto,et al.  Total Contact Casting in Treatment of Diabetic Plantar Ulcers: Controlled Clinical Trial , 1989, Diabetes Care.

[47]  C. Corbett.  A Randomized Pilot Study of improving Foot Care in Home Health Patients With Diabetes , 2003, The Diabetes educator.

[48]  S. Ingman,et al.  Reliability of Palpation of Pedal Pulses As Ascertained by the Kappa Statistic , 1980, Journal of the American Geriatrics Society.

[49]  A. A. Hellingman,et al.  Efficacy and efficiency of a streamlined multidisciplinary foot ulcer service. , 2008, Journal of wound care.

[50]  David G Armstrong,et al.  It's not what you put on, but what you take off: techniques for debriding and off-loading the diabetic foot wound. , 2004, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[51]  N. Schaper,et al.  International consensus and practical guidelines on the management and the prevention of the diabetic foot. International Working Group on the Diabetic Foot. , 2000, Diabetes/metabolism research and reviews.

[52]  G. Reiber,et al.  Pathways to Diabetic Limb Amputation: Basis for Prevention , 1990, Diabetes Care.

[53]  F. Logerfo,et al.  Current concepts. Vascular and microvascular disease of the foot in diabetes. Implications for foot care. , 1984, The New England journal of medicine.

[54]  A. Veves,et al.  A randomized, controlled trial of Promogran (a collagen/oxidized regenerated cellulose dressing) vs standard treatment in the management of diabetic foot ulcers. , 2002, Archives of surgery.

[55]  V. Bertone,et al.  Vascular involvement in diabetic subjects with ischemic foot ulcer: a new morphologic categorization of disease severity. , 2007, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[56]  M. Huijberts,et al.  Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study , 2008, Diabetic medicine : a journal of the British Diabetic Association.

[57]  R. Galiano,et al.  Diabetic foot ulcers treated with becaplermin and TheraGauze, a moisture-controlling smart dressing: a randomized, multicenter, prospective analysis. , 2010, Journal of the American Podiatric Medical Association.

[58]  V. Driver,et al.  Reducing amputation rates in patients with diabetes at a military medical center: the limb preservation service model. , 2005, Diabetes care.

[59]  M. Porter,et al.  Redefining Health Care: Creating Value-based Competition on Results , 2006 .

[60]  C. Basch,et al.  Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics. , 1995, Archives of family medicine.

[61]  D G Smith,et al.  A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. , 1999, Diabetes care.

[62]  N. Schaper,et al.  International consensus and practical guidelines on the management and the prevention of the diabetic foot , 2000, Current diabetes reports.

[63]  Stephanie Wu,et al.  Evaluation of removable and irremovable cast walkers in the healing of diabetic foot wounds: a randomized controlled trial. , 2005, Diabetes care.

[64]  C. M. Agrawal,et al.  Home monitoring of foot skin temperatures to prevent ulceration. , 2004, Diabetes care.

[65]  D. Armstrong,et al.  Do US veterans wear appropriately sized shoes?: the Veterans Affairs shoe size selection study. , 2006, Journal of the American Podiatric Medical Association.

[66]  D. Margolis,et al.  Association Between Renal Failure and Foot Ulcer or Lower-Extremity Amputation in Patients With Diabetes , 2008, Diabetes Care.

[67]  C. Kalbaugh,et al.  Preoperative clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive patients. , 2005, Journal of vascular surgery.

[68]  Joshua T. Cohen,et al.  Cost-effectiveness in the contemporary management of critical limb ischemia with tissue loss. , 2012, Journal of vascular surgery.

[69]  G. Seghieri,et al.  Improvement of diabetic foot care after the Implementation of the International Consensus on the Diabetic Foot (ICDF): results of a 5-year prospective study. , 2007, Diabetes research and clinical practice.

[70]  Martin P Charns,et al.  The relationship between provider coordination and diabetes-related foot outcomes. , 2003, Diabetes care.

[71]  N. Schaper,et al.  Diabetic foot disease: impact of ulcer location on ulcer healing , 2013, Diabetes/metabolism research and reviews.

[72]  M. Huijberts,et al.  Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation , 2011, Diabetic medicine : a journal of the British Diabetic Association.

[73]  F. Ghiasi,et al.  Effects of vacuum-compression therapy on healing of diabetic foot ulcers: randomized controlled trial. , 2007, Journal of rehabilitation research and development.

[74]  Alastair Gray,et al.  Estimating Utility Values for Health States of Type 2 Diabetic Patients Using the EQ-5D (UKPDS 62) , 2002, Medical decision making : an international journal of the Society for Medical Decision Making.

[75]  J. Regensteiner,et al.  Functional outcome in a contemporary series of major lower extremity amputations. , 2003, Journal of vascular surgery.

[76]  P. Hogan,et al.  Economic Costs of Diabetes in the U , 2013 .

[77]  L. Geiss,et al.  Declining Rates of Hospitalization for Nontraumatic Lower-Extremity Amputation in the Diabetic Population Aged 40 Years or Older: U.S., 1988–2008 , 2012, Diabetes Care.

[78]  J. Leahy.  Economic Costs of Diabetes in the U.S. in 2007 , 2008 .

[79]  Mangala Rajan,et al.  Foot care education and self management behaviors in diverse veterans with diabetes , 2009, Patient preference and adherence.

[80]  David G Armstrong,et al.  Resource utilization and economic costs of care based on a randomized trial of vacuum-assisted closure therapy in the treatment of diabetic foot wounds. , 2008, American journal of surgery.

[81]  C. Agardh,et al.  Decreasing Incidence of Major Amputation in Diabetic Patients: a Consequence of a Multidisciplinary Foot Care Team Approach? , 1995, Diabetic medicine : a journal of the British Diabetic Association.

[82]  Sarah Calhoun,et al.  Temporal trends and geographic variation of lower-extremity amputation in patients with peripheral artery disease: results from U.S. Medicare 2000-2008. , 2012, Journal of the American College of Cardiology.

[83]  G. Reiber,et al.  Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery. , 2004, The American journal of managed care.

[84]  W. Jeffcoate,et al.  Education for secondary prevention of foot ulcers in people with diabetes: a randomised controlled trial , 2008, Diabetologia.

[85]  T. Koepsell,et al.  How Does Provider and Patient Awareness of High-Risk Status for Lower-Extremity Amputation Influence Foot-Care Practice? , 1994, Diabetes Care.

[86]  D. Blumenthal,et al.  Patient Protection and Affordable Care Act , 2010 .

[87]  Annemarie A. Edwards,et al.  Diabetic foot disorders: A clinical practice guideline , 2000 .

[88]  L. Norgren,et al.  Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). , 2007, Journal of vascular surgery.

[89]  D. Armstrong,et al.  A Supplement to : Foot & Ankle Surgery , 2006 .

[90]  Terry Kemple,et al.  Patients' perspectives on foot complications in type 2 diabetes: a qualitative study. , 2008, The British journal of general practice : the journal of the Royal College of General Practitioners.

[91]  Plamen Nikolov,et al.  Economic Costs of Diabetes in the U.S. in 2002 , 2003, Diabetes care.

[92]  J. Mills,et al.  The Diabetic Foot: Consequences of Delayed Treatment and Referral , 1991, Southern medical journal.

[93]  R. Rubin,et al.  Depression predicts first but not recurrent diabetic foot ulcers , 2010, Diabetologia.

[94]  D. Armstrong,et al.  Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial , 2005, The Lancet.

[95]  M. Rutter,et al.  Dialysis Treatment Is an Independent Risk Factor for Foot Ulceration in Patients With Diabetes and Stage 4 or 5 Chronic Kidney Disease , 2010, Diabetes Care.

[96]  W. Assendelft,et al.  Patient education for preventing diabetic foot ulceration (Review) , 2012 .

[97]  L. Uccioli,et al.  Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study , 2008, Diabetologia.

[98]  Jennifer Y. Liu,et al.  Correlates of Quality of Life in Older Adults With Diabetes , 2011, Diabetes Care.

[99]  W. Hiatt,et al.  Peripheral arterial disease in patients with diabetes. , 2006, Journal of the American College of Cardiology.

[100]  A. Morabito,et al.  Predictive values of transcutaneous oxygen tension for above-the-ankle amputation in diabetic patients with critical limb ischemia. , 2007, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[101]  D. Armstrong,et al.  Off-loading the diabetic foot wound: a randomized clinical trial. , 2001, Diabetes care.

[102]  A. Ainsworth,et al.  Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 3. Podiatry services and related foot care issues , 2002, Diabetic medicine : a journal of the British Diabetic Association.

[103]  W. Rathmann,et al.  Older Subjects With Diabetes and Prediabetes Are Frequently Unaware of Having Distal Sensorimotor Polyneuropathy , 2013, Diabetes Care.

[104]  G. Gill,et al.  Amputation and mortality in new-onset diabetic foot ulcers stratified by etiology. , 2003, Diabetes care.

[105]  D. Armstrong,et al.  Toward a change in syntax in diabetic foot care: prevention equals remission. , 2013, Journal of the American Podiatric Medical Association.

[106]  F. Vinicor,et al.  Independent Physiological Predictors of Foot Lesions in Patients With NIDDM , 1997, Diabetes Care.

[107]  D. Armstrong,et al.  Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. , 2000, The Journal of foot and ankle surgery : official publication of the American College of Foot and Ankle Surgeons.

[108]  A. Bradbury.  Bypass versus Angioplasty in Severe Ischaemia of the Leg (BASIL) trial in perspective. , 2010, Journal of vascular surgery.

[109]  J. Cromwell,et al.  The cost of cancer , 1979, The Laryngoscope.

[110]  G. Rayman,et al.  Reduction in Diabetic Amputations Over 11 Years in a Defined U.K. Population , 2008, Diabetes Care.

[111]  D. A. Nelson,et al.  Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting , 2003, Journal of General Internal Medicine.

[112]  P. Cavanagh,et al.  Off-loading the diabetic foot for ulcer prevention and healing. , 2010, Journal of vascular surgery.

[113]  D. Armstrong,et al.  Practical criteria for screening patients at high risk for diabetic foot ulceration. , 1998, Archives of internal medicine.

[114]  P. Scuffham,et al.  The health care costs of diabetic peripheral neuropathy in the US. , 2003, Diabetes care.

[115]  Michaël Lauer,et al.  Book Review Redefining Health Care: Creating Value-Based Competition on Results By Michael E. Porter and Elizabeth Olmsted Teisberg. 506 pp. Boston, Harvard Business School Press, 2006. $35. 978-1-59139-778-6 , 2006 .

[116]  J. Smith,et al.  Debridement of diabetic foot ulcers. , 2002, The Cochrane database of systematic reviews.

[117]  J. Wrobel,et al.  Does Open Access Improve the Process and Outcome of Podiatric Care? , 2011, Journal of clinical medicine research.

[118]  R. Roussel,et al.  Use and utility of ankle brachial index in patients with diabetes. , 2011, European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery.

[119]  Michael J. Mueller,et al.  Effect of Achilles tendon lengthening on neuropathic plantar ulcers. A randomized clinical trial. , 2003, The Journal of bone and joint surgery. American volume.

[120]  David G. Armstrong,et al.  Mind the Gap: Disparity Between Research Funding and Costs of Care for Diabetic Foot Ulcers , 2013, Diabetes Care.

[121]  F. Logerfo,et al.  Vascular and Microvascular Disease of the Foot in Diabetes , 2010 .

[122]  R. Jiménez-García,et al.  Trends in Lower-Extremity Amputations in People With and Without Diabetes in Spain, 2001–2008 , 2011, Diabetes Care.

[123]  David G Armstrong,et al.  Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. , 2001, Diabetes care.

[124]  L. Uccioli,et al.  Manufactured Shoes in the Prevention of Diabetic Foot Ulcers , 1995, Diabetes Care.

[125]  P. Sönksen,et al.  A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population , 1993, Diabetologia.

[126]  W. J. Litchy,et al.  The prevalence by staged severity of various types of diabetic neuropathy, retinopathy, and nephropathy in a population‐based cohort , 1993, Neurology.

[127]  Lee C. Rogers,et al.  Toe and flow: essential components and structure of the amputation prevention team. , 2010, Journal of vascular surgery.

[128]  Z. Mulla,et al.  Health Insurance and the Development of Diabetic Complications , 2009, Southern medical journal.

[129]  D. G. Armstrong,et al.  The impact and outcomes of establishing an integrated interdisciplinary surgical team to care for the diabetic foot , 2012, Diabetes/metabolism research and reviews.

[130]  David G. Armstrong,et al.  Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa , 2012 .

[131]  P. Holt,et al.  Volume–Outcome Relationships in Lower Extremity Arterial Bypass Surgery , 2012, Annals of surgery.

[132]  Jeffrey A. Cohen,et al.  Static magnetic field therapy for symptomatic diabetic neuropathy: a randomized, double-blind, placebo-controlled trial. , 2003, Archives of physical medicine and rehabilitation.

[133]  T. File,et al.  Can aggressive treatment of diabetic foot infections reduce the need for above-ankle amputation? , 1996, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[134]  V. Driver,et al.  The impact of a podiatric lead limb preservation team on disease outcomes and risk prediction in the diabetic lower extremity: a retrospective cohort study. , 2010, Journal of the American Podiatric Medical Association.

[135]  C. D. Owens,et al.  Inferior outcomes of autogenous infrainguinal bypass in Hispanics: an analysis of ethnicity, graft function, and limb salvage. , 2009, Journal of vascular surgery.

[136]  M. Airey,et al.  Variation in clinical decision making is a partial explanation for geographical variation in lower extremity amputation rates , 2001, The British journal of surgery.