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Prevention and Early Intervention for Diabetes Foot Problems

2. The Scope of the Problem continued...

The NHIS also provided information on the frequency of foot examinations made by health professionals. Almost 53 percent of patients with diabetes reported no foot exam by a health professional within the past six months. The frequency of having no foot exam was highest in patients not using insulin (59 percent)3. In a nationwide survey, primary care physicians reported performing semi-annual foot examinations for 66 percent of patients with type 1 diabetes and for 52 percent of patients with type 2 diabetes2. A 1992 review of Indian Health Service medical records showed that close to 50 percent of patients with diabetes had documentation of an annual foot examination7.

Personal and Financial Costs

Diabetes foot disease is a major burden for both the individual and the health care system and may increase as the population ages. Fifteen percent of all patients with diabetes in a population-based study experienced ulcers or sores on the foot or ankle. The prevalence increased with age, especially in patients who were age 30 or under at diagnosis of diabetes8.

Foot disease is the most common complication of diabetes leading to hospitalization. In 1995, foot disease accounted for 6 percent of hospital discharges listing diabetes and lower extremity ulcers, with an average hospital stay of 14.7 days. Cost of care estimates for lower limb amputations in 1992 ranged from $24,000 to $27,000 and from $14,500 to $21,500 for rehabilitation. The average length of hospital stay for these two diagnoses ranged from 18.4 to 20.3 and 16.0 to 23.9 days, respectively3. The total annual cost associated with diabetes foot disease is estimated to be more than $1 billion. This cost does not include surgeons' fees, rehabilitation costs, prostheses, time lost from work, and disability payments9.

After an amputation, the chance of another amputation of the same extremity or of the opposite extremity within 5 years is as high as 50 percent. The 5-year mortality rate after lower extremity amputation ranges from 39 to 68 percent3.

3. Causative Factors

Risk Factors for Lower Extremity Amputation (LEA)

Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer are independently associated with risk of LEA10. A 1996 study of Pima Indians with diabetes confirmed this finding and included the presence of foot deformity as another independent risk factor11. The presence of plantar callus also is highly predictive of subsequent ulceration in patients with diabetic neuropathy and is more predictive of ulceration than increased plantar foot pressures12. Hyperglycemia is an additional risk factor. In a 1996 study, Finnish researchers determined risk factors for amputation in 1,044 middle-aged patients with type 2 diabetes who were followed for up to 7 years. Because the incidence of amputation was similar in both sexes (5.6 percent men and 5.3 percent women), all statistical analyses were carried out combining men and women. This study found that high fasting plasma glucose levels at baseline, high HbA1c, and the duration of diabetes were independently associated with a twofold risk of amputation. Signs of peripheral neuropathy, bilateral absence of vibration sense, and bilateral absence of Achilles tendon reflexes were two times more frequent in patients with amputation than in patients without amputation13.

WebMD Public Information from the U.S. National Institutes of Health

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