12/19/2018    Allen Jacobs, DPM

Reported Increase in Non-traumatic Amputations in People with Diabetes will Challenge Podiatric Medicine (Leonard Levy, DPM, MPH)

This was predictable. I have been watching this
evolve and for one am not surprised. Study after
study has demonstrated an inverse relationship
between access to foot care and amputation rates
in the patient with diabetes. The relationship
between podiatry and interventional cardiology
and vascular surgery has grown exponentially.
Wound care centers have populated cities like
hamburger franchises. Wound care products are
multitudinous. Wound care books, seminars,
certifications, journals, are everywhere.

Why then the increased amputation rates reported
in this and other recent articles?

1. Access to foot care - Many diabetic patients
remain poorly educated on the need for
comprehensive risk factor assessment and
intervention. Many do not receive referrals to
Podiatry for early evaluation and preventive
care. With all the talk and interdisciplinary
education, early referrals are not being made.
See the most recent issue of JAPMA.

2. Lack of podiatric care - Every podiatric
physician knows the etiology of ulceration and
risk to the diabetic lower limbs is
multifactorial. The unarguable truth is that
only a podiatrist has the capability of
multifactorial risk evaluation and provision of
multilevel intervention. Other healthcare
providers may have the license to do what a
podiatrist can do, but they do not have the
requisite knowledge to do it as well. Not even
close.

3. High cost of medical care - High deductibles
and copays discourage patients from seeking
early care for problems which they perceive are
not limb-threatening. The high cost of many
preventive therapies or lack of overage eg- shoe
therapy, orthotic or brace off-loading,
emollients, antifungal therapies) increased the
probability that such therapies will not be
followed.
4. Care by alternative providers - Simply
stated, primary care providers, NPs, PAs, urgent
care centers, vascular surgeons, and other non-
podiatric healthcare providers do not know what
they do not know. Common examples are failure to
diagnose Charcot’s joint disease. Failure to
offload, failure to provide adequate ulcer care,
failure to diagnose PAD.

5. Reliance on technology rather than the
basics. - Increased amputation rates? What
about HBO, what about all the miracle
biologicals, dressings, advanced debridement
methods, genetic testing. The basic principles
of wound evaluation and wound care save the day:
Recognition of and intervention for PAD. Off-
loading. Debridement when necessary. Good
control of diabetes. Correction of nutritional
factors. Local wound care. Reduction of
bioburden. Patient adherence. Preventive care.

Allen Jacobs, DPM, St. Louis, MO

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