Disease management for the diabetic foot: Effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations

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Abstract

Objective:

To demonstrate the effectiveness of a diabetic foot disease management program in a managed care organization.

Methods:

We implemented a lower extremity disease management program consisting of screening and treatment protocols for diabetic members in a managed care organization. Screening consisted of evaluation of neuropathy, peripheral vascular disease, deformities, foot pressures, and history of lower extremity pathology. We stratified patients into low and high-risk groups, and implemented preventive or acute care protocols. Utilization was tracked for 28 months and compared to 12 months of historic data prior to implementation of the disease management program.

Results:

After we implemented the disease management program, the incidence of amputations decreased 47.4% from 12.89 per 1000 diabetics per year to 6.18 (p < 0.05). The number of foot-related hospital admissions decreased 37.8% from 22.86 per 1000 members per year to 14.23 (37.8%). The average inpatient length-of-stay (LOS) was reduced 21.7% from 4.75 to 3.72 days (p < 0.05). In addition, there was a 69.8% reduction in the number of skilled nursing facility (SNF) admissions per 1000 members per year (Table 1) and a 38.2% reduction in the average SNF LOS from 8.72 to 6.52 days (p < 0.05).

Conclusion:

A population-based screening and treatment program for the diabetic foot can dramatically reduce hospitalizations and clinical outcomes.

Introduction

Despite many recent advances in medical therapies, the prevalence of diabetes and diabetes related complications continues to increase. There is estimated to be more than 17 million people with diabetes in the United States. Half of these patients have been diagnosed, and half do not yet know that they have the disease [1], [2]. There has been a steady increase in the prevalence of diabetes over the past 35 years with higher prevalence and complication rates in Mexican Americans, African Americans and Native Americans [3]. For instance, the average prevalence of diagnosed diabetes was three times higher in 1991–1993 compared to 1960. Projections of the impact of diabetes for 2010 and 2020 suggest that this trend is expected to increase at an accelerated rate [3]. Trends in diabetes related complications such as retinopathy, kidney disease and heart disease have also increased significantly. Likewise, the incidence of amputations appears to be steadily increasing. Among persons with diabetes, the number of lower extremity amputations was about 30% higher in 1990 compared to 1980 [4], [5].

Several clinical and financial models have indicated that there is the potential for significant reduction in morbid events [6], [7], [8], [9], [10], [11], [12], [13] and costs [14], [15], [16] when prevention programs are implemented. Multispecialty clinical programs have reported a decrease in amputation, re-amputation, ulceration, hospitalization, length of stay, and missed work days. Much of the existing literature focuses on relatively small groups of high-risk patients. The objective of this study was to evaluate the impact of a disease management program in a large cohort of persons with diabetes in a health maintenance organization (HMO). The goal of the program was to prevent diabetes related lower extremity complications and was based on the implementation of systematic protocols for foot screening, prevention, and treatment of complications. We hypothesized that early identification of risk factors for foot ulcers and amputations, aggressive prevention practices, and standardized wound care protocols would decrease the incidence of foot complications and thereby reduce hospitalizations and lower extremity amputations among persons with diabetes.

Section snippets

Materials and methods

We implemented a lower extremity screening and treatment program in San Antonio, Texas. At the beginning of the disease management program 1708 persons with diabetes mellitus were identified. Members with diabetes were identified from inpatient and outpatient administrative databases to identify patients with any 250 ICD-9-CM code [17]. As part of the program a database was established to track clinic events, hospitalizations, procedures and referrals. In addition, these events were verified

Results

The average age of subjects screened in the disease management program was 67.2 ± 8.5 years with a range of 23–90. The population reflected the racial and ethnic demographics of the San Antonio metropolitan area; 42.8% of participants were Mexican–American, 53.2% were non-hispanic white and 4.0% were African American. The average duration of diabetes was 11.2 ± 9.5 years with a range of 0–32 years.

There was a significant reduction in the incidence of amputations, diabetic foot related admissions,

Effectiveness of prevention programs

Several studies in Europe and the U.S. have reported reduction in lower extremity complications when prevention and treatment programs were instituted [6], [7], [8], [9], [10], [11], [12], [13]. The results of the XLHealth disease management model are similar to several of these studies that have reported reduction of amputations of 48–78% [6], [7], [8], [9], [10], [11], [12], [13], reduction of re-ulceration of 48% [6] and reduction in hospitalizations of 47–49%. [10], [12] The baseline

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