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

Neal R Barshes, Meena Sigireddi, James S Wrobel, Archana Mahankali, Jeffrey M Robbins, Panos Kougias, David G Armstrong, Neal R Barshes, Meena Sigireddi, James S Wrobel, Archana Mahankali, Jeffrey M Robbins, Panos Kougias, David G Armstrong

Abstract

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.

Keywords: delivery of healthcare; diabetes; diabetic neuropathy; foot ulcer; peripheral vascular disease; physician's practice patterns.

Figures

Fig. 1
Fig. 1
The clinical states leading to limb loss among patients with diabetes mellitus and the risk factors that influence the transition between these states. DFU=diabetic foot ulcer.
Fig. 2
Fig. 2
The estimated annual direct costs of diabetic limb complications in comparison to the annual direct costs of the five most costly cancers in the United States.
Fig. 3
Fig. 3
The overlapping relationship of risk factors associated with non-traumatic limb loss in the United States. Estimates of total affected US population, US prevalence and annual incidence rates are shown.
Fig. 4
Fig. 4
Schematic diagram demonstrating (A) an example of a disordered, ad hoc pattern of patient referral and communication in among coalition of relevant specialty providers; and (B) an example of more structured patient referral and communication in a multidisciplinary care team.

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