Amputation can be prevented when patients are treated by podiatric physicians: Study

Amputation, one of the most devastating and costly consequences of diabetes, can be prevented when patients are treated by podiatric physicians.

That's the finding of a national, large-scale study co-authored by Dr. James Wrobel, DPM, MS, Associate Professor of Medicine at Rosalind Franklin University of Medicine and Science.

"More than half of all amputations in the U.S. are related to diabetes," said Dr. Wrobel, Director of CLEAR, the Center for Lower Extremity Ambulatory Research at the University's Dr. William M. Scholl College of Podiatric Medicine. "Podiatrists are detecting conditions that can lead to amputation. That's just what we do."

The first of its kind, the study examined records for almost 29,000 patients with diabetes, ages 18-64, and compared health and risk factors for those who had seen podiatrists to those who had not. Researchers found that care by a podiatric physician - defined as at least one visit before a foot ulcer was diagnosed - was associated with a nearly 15 percent lower risk of amputation and 17 percent lower risk of hospitalization.

The study, funded by the American Podiatric Medical Association, was conducted using Thomson Reuters' MarketScan Research Databases, which contain de-identified health-care claims data.

MarketScan data is used by researchers to understand health economics and outcomes. Studies based on MarketScan data have been published in more than 130 peer-reviewed articles in the past five years.

"We statistically matched patients with diabetes and foot ulcers who had visited a podiatrist with like patients who had not," said lead researcher Teresa Gibson, PhD, Director of Health Outcomes research at Thomson Reuters. "Patients who had seen a podiatrist in the year prior to the onset of a foot ulcer had significantly lower rates of any amputation and hospitalization than those who had not."

The volume of data with the precise level of matching make the study findings much more robust.

"We found people who looked very similar to each other and we were able to observe the outcomes were due to podiatric care rather than something else distorting the data," Dr. Wrobel said. "This is a very strong study as it was conducted in patients already having a foot ulcer and it highlights the podiatrist's role in preventing hospitalizations due to infection and in preventing amputations if a foot ulcer develops."

Diabetic foot complications are the leading cause of non-traumatic lower limb amputation in the U.S., a lapse in prevention that costs an estimated $3 billion per year, according to the Amputee Coalition of America. The Centers for Disease Control estimates that 24 million Americans have diabetes, and 86,000 undergo amputations each year.

Podiatrists, who must complete four years of medical school and a postdoctoral residency program, are trained to diagnose and treat problems with the feet, which may be the first area to show symptoms of serious conditions like diabetes, arthritis and heart disease. People with diabetes are prone to foot infections and ulcers because of poor circulation and neuropathy, or loss of physical sensation, and podiatrists can spot problems like calluses, blisters or ill-fitting shoes before a hard-to-heal sore develops.

Dr. Wrobel points to the conclusion of the Thomson Reuters study and numerous smaller studies that preceded it that show expert podiatric care cannot only save limbs but possibly save lives, given that after an amputation the five-year survival rate is poorer than with many cancers.

Such studies are also important in designing clinical practice guidelines. In a 2003 paper published in the journal Diabetes Care, Dr. Wrobel looked at diabetes-related foot outcomes at 10 Veterans Affairs medical centers and found a correlation between coordination of preventative foot care and lower amputation rates. In a 2001 study that also appeared in Diabetes Care, he previously found sizeable geographic variations in lower-limb amputation rates among Medicare patients and concluded that keeping or losing a toe, foot or leg depended on "systematic differences in preventative care and treatment decision making."

Dr. Wrobel emphasizes the need for coordinated patient care and communication among health care providers.

"The delivery of health care in this country happens too often in isolated pods - insurance companies, managed care providers, fee-based care," Dr. Wrobel said. "There has been very little patient advocacy. Problems with diabetes are too pervasive for care not to be more coordinated. We're beginning to see it now, bubbling up from patient frustration."

But in 10 states, according to Chad Appel, APMA state advocacy associate, Medicaid programs do not reimburse for podiatric care, including California, Michigan and, effective Oct. 1, Arizona, where indigenous populations suffer higher rates of diabetes and related complications.

"Budgets are hurting and they have to look for somewhere to cut and right now, podiatric are is an optional service under Medicaid," Appel said.

The Thomson Reuters study, which was presented July 17 during the APMA's annual Scientific Meeting in Seattle, adds to the body of evidence that shows that including podiatry in a multidisciplinary, coordinated effort to treat diabetes could prevent up to 50 percent of related amputations and the pain, depression and loss of quality of life that often follow.