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Diabetic foot care. Financial implications and practice guidelines.

Reiber GE.

Department of Health Services, University of Washington, Seattle 98195.

Foot problems are common in the 12 million diagnosed and undiagnosed United States diabetic subjects, and result

in extensive hospitalization, disfiguring surgery, lifetime disability, and a diminished quality of life. The unequivocal

nature of a lower-extremity amputation makes this the best-defined and monitored of the diabetic foot problems.

United States hospital discharge data from 1980 to 1987 indicated that amputation rates increased with advancing

age, and were higher in blacks than whites, and men than women. Foot pathology has been reported as the most

common complication of diabetes leading to hospitalization. Economic considerations extend beyond direct cost

estimates based on numbers of affected individuals, and the cost and duration of patient care. Indirect cost estimates

describing lost economic productivity because of related illness, disability, and premature death are needed.

Multidisciplinary team approaches to diabetic foot care have reported statistically significant pre-post program

reductions in morbidity and cost. Regardless of the care setting and the availability of foot care teams, diabetic foot

care guidelines should be viewed by providers as recommended minimum practice levels to be adapted according to

the patient's pathology, comorbidity, and abilities. Although guidelines specify minimum acceptable practice levels,

they are not intended to set a ceiling on professional excellence.

PMID: 1559416 [PubMed - indexed for MEDLINE]

The prevention of foot ulceration in diabetic patients.

Howard IM.

Department of Rehabilitation Medicine, University of Washington, Seattle, 98195, USA.

Diabetic foot ulcerations are a costly and common public health challenge. Although several organizations have

emphasized the need to increase awareness of this problem and called health care providers to action to decrease

the incidence of ulceration and amputation, there is limited evidence regarding what interventions are best suited to

accomplish this goal. This article reviews the pathogenesis, risk factors, and current interventions that have been
studied for the prevention of foot ulceration. Preventive measures with evidence for decreasing incidence of

ulceration include patient education, offloading abnormal pressures with foot orthotics, and thermal monitoring.

PMID: 19781501 [PubMed - indexed for MEDLINE]

Preventive care of the diabetic foot.

Fritschi C.

Department of Maternal Child Nursing, University of Illinois at Chicago College of Nursing, Chicago, Illinois 60612,


Lower extremity complications are a frequent occurrence in individuals with type 1 and type 2 diabetes. This article

discusses the etiologic pathway and risk factors associated with diabetic foot complications. Intervention strategies

including assessment, risk stratification, prevention, treatment, and patient education are discussed.

PMID: 11382565 [PubMed - indexed for MEDLINE]

Preventive foot care. A user-friendly system for patients and physicians.

Strauss MB, Hart JD, Winant DM.

Baromedical Department, Long Beach Memorial Medical Center, CA 90801-1428, USA.

Our user-friendly foot skin and toenail grading system is simple to understand for both patients and physicians.

Current medical practice dictates that primary care physicians deliver the most comprehensive care possible for their

patients. This includes preventive care and documentation of outcomes. Our approach simplifies evaluation and

management of the majority of foot skin and toenail conditions in compromised hosts. Reimbursement for the extra

care is justified, and authorized billing codes exist. Our system helps to prevent the physical, emotional, and financial
costs associated with severe foot wounds and nail disorders. We remind our patients that proper foot care is as

important in preventing foot complications as drug therapy is in preventing complications in other organs. Our

approach to foot skin and toenail care is largely prophylactic and can be easily instituted in a primary care practice.

Diabetic foot ulcers: A framework for prevention and care.

Boulton AJ, Meneses P, Ennis WJ.

Department of Medicine, University of Manchester, United Kingdom.

Complications secondary to diabetes, such as diabetic foot ulcers, continue to be a major worldwide health problem.

At the same time, health care systems are changing rapidly, causing concern about the quality of patient care. While

the ultimate effect of current changes on health care professionals and patient outcomes remain uncertain, measures

commonly used to reduce costs, e.g., disease and multi- disciplinary management strategies, have been shown to

help prevent the occurrence of diabetic ulcers. In addition, utilizing a multi- disciplinary approach, the principles of off-

loading and optimal wound care, the vast majority of diabetic foot ulcers can be expected to heal within 12 weeks of

treatment. Education of primary care providers and patients is paramount.

PMID: 10231501 [PubMed - indexed for MEDLINE]

Duodecim. 2009;125(17):1907-9.

[Diabetes-related foot problems]

[Article in Finnish]

Käypä hoito -suosituksen tiivistelmä.

Collaborators (13)
Ebeling T, Heikkilä E, Hiltunen L, Juutilainen V, Kanerva M, Laine HJ, Lepäntalo M, Saarikoski H, Sane T, Toivonen
J, Tukiainen E, Vaalasti A, Valve K.

Foot ulcers due to neuropathy and/or ischemia, often complicated by infection, are a leading cause of hospitalisation

and amputation in diabetic patients. Sensory neuropathy, foot abnormality, missing pulses and previous history of

ulcers or amputation are risk factors for ulceration. Regular examination of feet and protective footwear reduce this

risk. Off-loading the ulcer area promotes healing. Revascularisation improves the blood supply in cases where it has

been compromised. Systemic antibiotics are only required in the case of acute foot infections and osteomyelitis with

an underlying ulcer. Prevention and treatment of foot ulceration by multidisciplinary teams, including podiatric

services, decreases amputations by up to 85%.

PMID: 19860093 [PubMed - indexed for MEDLINE]

[The diabetic foot. Optimal prevention and treatment can halve the risk of

[Article in Swedish]

Apelqvist J, Bergqvist D, Eneroth M, Larsson J.

Diabetes-endokrinologisektionen, medicinska kliniken, Universitetssjukhuset i Lund.

Almost half of all lower leg amputations are performed in patients with diabetes. In over 70 per cent of these cases,

amputation is precipitated by progression of foot ulceration to deep gangrenous infection. Most foot ulcers are

preceded by trauma, usually due to ill-fitting shoes, and are precipitated by sensory motor neuropathy with varying

degrees of peripheral vascular disease. The Swedish Medical Research Council and the Swedish Institute for Health

Services Development arranged a conference on diabetic foot problems in April 1998, the purpose of which was to

arrive at a consensus regarding the prevention and management of diabetic foot. It was concluded that a satisfactory

multidisciplinary approach should include regular control of feet and footwear, preventive foot care (education,

footwear, chiropody), continuous follow-up of high-risk feet, and early recognition of revascularisation. Continuous
registration of amputation, irrespective of type, cause and site, might substantially reduce the amputation rate among

diabetics. Were such an approach to reduce the incidence of diabetes-related amputation by 50 per cent, annual

costs for the management of diabetic foot in Sweden would be reduce by SEK 400 million (the value of improved

quality of life not taken into consideration).

PMID: 9951247 [PubMed - indexed for MEDLINE]

Curr Diab Rep. 2004 Dec;4(6):413-8.

Reducing the incidence of foot ulceration and amputation in diabetes.

Bartus CL, Margolis DJ.

Department of Dermatology, University of Pennsylvania, 815 Blockley Hall, 423 Guardian Drive, Philadelphia, PA

19104, USA.

Diabetes is a common disease that is associated with numerous complications, including foot ulceration and

amputation. In diabetic patients, the incidence of foot ulcers ranges from 1.0% to 4.1%, and the incidence of lower-

extremity amputations ranges from 2.1 to 13.7 per 1000. Risk factors for developing foot ulcers and subsequent

amputation include neuropathy, peripheral vascular disease, and trauma. To reduce these complications, several

preventive strategies have been devised, from reducing risk factors to improving treatment and management.

PMID: 15539004 [PubMed - indexed for MEDLINE]

Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007610.

Complex interventions for preventing diabetic foot ulceration.

Dorresteijn JA, Kriegsman DM, Valk GD.

Department of Internal Medicine, University Medical Center Utrecht, Oudenoord 465, Utrecht, Netherlands, 3513 EP.

BACKGROUND: Ulceration of the feet, which can lead to the amputation of feet and legs, is a major problem for

people with diabetes mellitus, and can cause substantial economic burden. Single preventive strategies have not

been shown to reduce the incidence of foot ulceration to a significant extent. Therefore, in clinical practice, preventive

interventions directed at patients, health care providers and/or the structure of health care are often combined

(complex interventions). OBJECTIVES: To assess the effectiveness of complex interventions on the prevention of

foot ulcers in people with diabetes mellitus compared with single interventions, usual care or alternative complex

interventions. A complex intervention is defined as an integrated care approach, combining two or more prevention

strategies on at least two different levels of care: the patient, the healthcare provider and/or the structure of

healthcare. SEARCH STRATEGY: Eligible studies were identified by searching the Cochrane Wounds Group

Specialised Register (28/05/09), the Cochrane Central Register of Controlled Trials (CENTRAL, 28 May 2009), Ovid

MEDLINE (1950 to May Week 3 2009), Ovid EMBASE (1980 to 2009 Week 21) and EBSCO CINAHL (1982 to May

Week 4 2009). SELECTION CRITERIA: Prospective randomised controlled trials (RCTs) which compared the

effectiveness of combinations of preventive strategies, not solely patient education, for the prevention of foot ulcers in

people with diabetes mellitus, with single interventions, usual care or alternative complex interventions. DATA

COLLECTION AND ANALYSIS: Two review authors were assigned to independently select studies, to extract study

data and to assess risk of bias of included studies, using predefined criteria. MAIN RESULTS: Only five RCTs met

the criteria for inclusion. The study characteristics differed substantially in terms of health care settings, the nature of

the interventions studied and outcome measures reported. In three studies that compared the effect of an education

centred complex intervention with usual care or written instructions only, little evidence of benefit was found. Two

studies compared the effect of more intensive and comprehensive complex interventions with usual care. One of

these reported improvement of patients' self care behaviour. In the other study a significant and cost-effective

reduction of lower extremity amputations (RR 0.30 (95% CI 0.13 to 0.71)) was achieved. All five included RCTs were

at high risk of bias; with hardly any of the predefined quality assessment criteria met. AUTHORS' CONCLUSIONS:

There is no high quality research evidence evaluating complex interventions for preventing diabetic foot ulceration

and insufficient evidence of benefit.

PMID: 20091642 [PubMed - in process]

Br J Community Nurs. 2008 Mar;13(3):S16, S18, S20 passim.

Management of the diabetic foot ulcer: exercising control.

Bentley J, Foster A.

Kings College London, Florence Nightingale School of Nursing and Midwifery.

The incidence of diabetes is increasing and therefore patients with diabetic foot ulcers will become increasingly

common in the community. The NHS model of Health and Social Care (Department of Health (DH), 2005) places a

high emphasis on self care and disease management, and, as a long-term condition, diabetes mellitus requires

efficient and effective management. The supervision and organization of the care of diabetic patients is multi-factorial

and for this reason, a multi-disciplinary approach is essential for effective care, without which patients with diabetic

foot ulcers are at high risk of complications. Diabetic wounds present differently to other chronic wounds; unless

these are adequately assessed and treated, there may be devastating consequences for the patient--the most

serious being major amputation and/or death. In the first article, accurate assessment was discussed; in this second

article, the management of diabetic foot ulcers is explored.

PMID: 18557570 [PubMed - indexed for MEDLINE]

Ostomy Wound Manage. 1995 May;41(4):28-30, 32-4.

Preventive foot care program: a nursing perspective.

Bryant JL.

Severe foot problems often develop from minor abnormalities that are preventable. It is crucial for nurses to

understand and practice the principles of preventive foot care for elderly patients, both diabetic and non-diabetic. It is

also important for nurses to distinguish between lesser foot problems that can easily be treated and more serious
conditions that require referral to a specialist. This article includes practical applications for a foot care program from

a nursing perspective and discusses pathophysiology of foot injuries, foot assessment using a screening tool and the

Semmes-Weinstein monofilaments test, procedural techniques for nail and callus care using a cordless rotary tool,

and nurses' qualification for providing nail care.

PMID: 7598781 [PubMed - indexed for MEDLINE]

Clin Nurse Spec. 1999 Mar;13(2):57-65; quiz 66-8.

Diabetic neuropathy: pathophysiology and prevention of foot ulcers.

Zangaro GA, Hull MM.

United States Navy, Puerto Rico.

Diabetic neuropathy, which affects 60% to 70% of those with diabetes mellitus, is one of the most troubling

complications for persons with diabetes, often leading to foot ulcers and potentially to lower limb amputations, both of

which are preventable. The physiologic, structural, and functional changes associated with diabetic neuropathy and

foot ulcers are discussed. Advanced practice nurses are in a unique position to implement strategies for the

prevention of serious and debilitating complications from diabetic neuropathy, including foot assessment, education,

and specialist referrals. Research evidence is given to support the use of the Semmes-Weinstein monofilaments to

evaluate decreased plantar sensation, a common precursor to ulceration. Ongoing patient and family education can

emphasize the importance of preventive self-care measures. Referrals for specialist care and therapeutic footwear

can be made by advanced practice nurses. If begun early, these interventions can prevent foot ulcers from diabetic

neuropathy, thereby improving the quality of life and reducing healthcare costs for this chronic disease.

PMID: 10382400 [PubMed - indexed for MEDLINE]
Volume 64, Issue 2, Pages 77-83 (May 2004)
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Diabetes care and complications in a remote primary health care setting

yes platform+medline author author

L.J Maple-Browna, J Brimblecombea, D Chisholmb, K O’Deaa

Accepted 20 October 2003.


Prevalence of complications of type 2 diabetes in a remote Australian Indigenous community was measured as
part of a population survey of risk factors for diabetes and cardiovascular disease. Information was obtained
from history, clinical examination, blood sample and medical records. Forty-three diabetic participants (six
newly diagnosed) were assessed from a sample of 339 (12% diabetes prevalence); mean age 50 (range 31–
67), duration of diabetes 5.6 (0–15) years, 40% male. Risk factors/complications: 70% with BMI≥25, 50%
cigarette smokers, HbA1c 8.5 (S.D. 2.9)%, cholesterol 4.8 (0.8) mmol/l, triglycerides 2.7 (1.6) mmol/l, HDL 0.83
(0.2) mmol/l; 60% had albuminuria (micro 38%, macro 22%), 47% were hypertensive, 7% (n=2) had
retinopathy, 24% had peripheral neuropathy, none had peripheral vascular disease, 14% had documented
coronary vascular and one participant cerebrovascular disease. Of 37 with previously diagnosed diabetes: 43%
were on aspirin, 65% on metformin, 80% with albuminuria on ACE inhibitors. Four additional diabetic
participants (not studied) were receiving renal dialysis elsewhere. The results demonstrate on the one hand,
very high indices of cardiovascular risk (smoking, hypertension, dyslipidaemia and albuminuria) and on the
other, good quality primary health care providing good detection and follow up management of type 2 diabetic

Keywords: Type 2 diabetes, Albuminuria, Peripheral neuropathy, Retinopathy, Aboriginal, Primary health care

a Menzies School of Health Research, P.O. Box 41096, Casuarina, NT 0811, Australia

b Diabetes and Obesity Research Program, Garvan Institute of Medical Research, 384 Victoria St., Darlinghurst, NSW 2010 and
University of New South Wales, Australia

Corresponding author. Tel.: +61-8-8922-8605; fax: +61-8-8922-8999.

PII: S0168-8227(03)00267-5


© 2003 Elsevier Ireland Ltd. All rights reserved.

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