Two Podiatrists and an Internist Talk About Saving Legs
I recently spoke with Drs. Lawrence Rubin and David Armstrong about reducing leg amputations in patients with diabetes. Dr. Rubin is a leader who has been advising Medicare on the topic for over 50 years. Dr. David Armstong is a professor at the University of Southern California who is a national academic leader in limb preservation. We all agree that there are real opportunities help diabetic patients keep healthier feet.
A policy statement from the American Heart Association calls for a 20% reduction in amputations by 2030. There are about 150,000 lower extremity amputations annually in the United States. Diabetes is the leading cause. Many of these procedures are caused by substandard care. Only about a quarter of Americans are aware of the problem of leg artery disease and nerve damage as contributors to a need for leg amputation.
While statins are recommended by guidelines for patients with peripheral arterial disease, only about 30% of patients with that condition are receiving the drug. Only a third receive counseling or medication aimed at stopping smoking and a third receive regular foot care. The implications of this inadequate care go far beyond our legs and feet. “Nearly half of the individuals who have an amputation due to vascular disease will die within 5 years. This is higher than the five-year mortality rates for breast cancer, colon cancer, and prostate cancer.”
These are not the only gaps in care. Diabetic patients with nerve damage often have severely diminished sensation. I saw a diabetic patient with a tack in the sole of his foot who had no idea it was there. Poor circulation also increases the risk. Pressure from poorly fitting shoes can cause ulcers and blisters which greatly increase the risk of amputation. Diabetic shoes reduce the risk of ulcers and blisters. When diabetic shoes are part of a structured program to reduce amputation, those procedures are 70% less frequent. There are extensive barriers to more consistent use of diabetic shoes. Podiatrists have the most training and skill in managing diabetic foot ulcer, but they are not allowed to prescribe diabetic shoes without the approval of a physician. They are capable of making this decision and more people would get appropriate footwear if podiatrists could prescribe it independently.
Even though the most recent data shows an increasing rate of amputation, we could far exceed the 20% reduction goal from the AHA. Patients with type 2 diabetes and small amounts of protein in their urine have a much higher risk of vascular complications. Optimal medical therapy (OMT)—control of blood pressure, blood sugar, and cholesterol along with aspirin treatment and stopping smoking—reduces the risk of amputation very dramatically. There were 80 patients in the usual care group who received the care that most patients receive. There were 80 patients who received optimal medical therapy. There were 33 amputations over 13 years in the usual care group and 10 in the OMT group over the same period. Deaths and other arterial complications were much higher in the usual care group as well.
Amputations are reduced three-fold by OMT. They are also reduced 70% by a structured program that includes reducing pressure on the wound. If systematically combined we could greatly exceed the 20% amputation reduction goal of the American Heart Association. There is a similar OMT program for heart artery disease at Kaiser Permanente in Colorado with 12,000 patients enrolled. Over 4 and a half years, OMT lowered cardiovascular and all-cause mortality by 90% and saved tens of thousands of dollars per patient annually. An outpatient primary care team could provide OMT for patients with leg artery disease, heart artery disease, hypertension and diabetes. A path to better health at lower cost is available now. Let’s use it!
. Let’s use it!