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Epidemiology and Health Care Costs of Diabetic Foot Problems

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The Diabetic Foot
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Abstract

The frequency of nontraumatic lower limb amputations in persons with diabetes has increased in the United States over the last decade. Currently two-thirds of all lower limb amputations occur in individuals with diagnosed diabetes. High geographic variation in age, sex, and race-adjusted amputation rates across U.S. populations suggest that important differences in practice patterns exist and that some patients may be receiving suboptimal care. Amputations reduce patient function and quality of life and place a heavy burden on individuals, families, and health care systems. In this chapter the epidemiology and risk factors for two major diabetic foot problems, ulcers and lower limb amputations, are described. Foot ulcer and amputation hospital discharge data are presented from two major U.S. surveys, the Nationwide Inpatient Sample (NIS), a database that also includes utilization and charge information, and the National Hospital Discharge Survey (NHDS) (1,2). Comparisons between persons with and without diabetes are clearly specified. Findings from analytic and experimental studies that used multivariable modeling techniques to determine risk factors are presented. The chapter concludes with information on the economic impact of diabetic foot problems.

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References

  1. AHRQ. Nationwide Inpatient Sample, 2000. http://www.ahrq.gov/data/hcup/nisintro.htm.

  2. Centers for Disease Control. Diabetes Surveillance. Atlanta, GA: U.S. Department of Health and Human Services, 1997.

    Google Scholar 

  3. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol 1994;130:489–493.

    Article  PubMed  CAS  Google Scholar 

  4. Borssen B, Bergenheim T, Lithner F. The epidemiology of foot lesions in diabetic patients aged 15–50 years. Diabet Med 1990;7:438–444.

    Article  PubMed  CAS  Google Scholar 

  5. Kumar S, Ashe HA, Fernando DJS, et al. The prevalence of foot ulceration and its correlates in type 2 diabetic patients: a population-based study. Diabet Med 1994; 11:480–484.

    Article  PubMed  CAS  Google Scholar 

  6. Moss SE, Klein R, Klein BEK. The prevalence and incidence of lower extremity amputation in a diabetic population. Arch Intern Med 1992;152:610–616.

    Article  PubMed  CAS  Google Scholar 

  7. Ramsey SD, Newton K, Blough D, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22:382–387.

    Article  PubMed  CAS  Google Scholar 

  8. Walters DP, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group. Diabet Med 1992;9: 354–358.

    Article  PubMed  CAS  Google Scholar 

  9. Palumbo PJ, Melton LJ, III. Peripheral vascular disease and diabetes. Diabetes in America (National Diabetes Data Group, ed.), DHHS, Washington, DC, 1995, pp. 401–407.

    Google Scholar 

  10. Apelqvist J, Castenfors J, Larsson J. Wound classification is more important than site of ulceration in the outcome of diabetic foot ulcers. Diabet Med 1989;6:526–530.

    Article  PubMed  CAS  Google Scholar 

  11. Reiber GE, Lipsky BA, Gibbons GW. The burden of diabetic foot ulcers. Am J Surg 1998; 176:5S-10S.

    Article  PubMed  CAS  Google Scholar 

  12. Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes, in Diabetes in America (National Diabetes Data Group, ed.), DHHS, Washington, DC, 1995, pp. 409–428.

    Google Scholar 

  13. Rith-Najarian S J, Stolusky T, Gohdes DM. Identifying diabetic patients at high risk for lower-extremity amputation in a primary health care setting. Diabetes Care 1992;15:1386–1389.

    Article  PubMed  CAS  Google Scholar 

  14. Abbott CA, Vileikyte L, Williamson S, Carrington AL, Boulton AJM. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 1998;21:1071–1075.

    Article  PubMed  CAS  Google Scholar 

  15. Boyko E, Ahroni JH, Stensel V, et al. A prospective study of risk factors for diabetic foot ulcer: the Seattle Diabetic Foot Study. Diabetes Care 1999;22:1036–1042.

    Article  PubMed  CAS  Google Scholar 

  16. Pham H, Armstrong DG, Harvey C, et al. Screening techniques to identify people at high risk for diabetic foot ulceration: a prospective multicenter trial. Diabetes Care 2000;23: 606–611.

    Article  PubMed  CAS  Google Scholar 

  17. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. Ann Intern Med 1993;119:36–41.

    PubMed  CAS  Google Scholar 

  18. Mantey I, Foster AVM, Spencer S, Edmonds ME. Why do foot ulcers recur in diabetic patients. Diabet Med 1999;16:245–249.

    Article  PubMed  CAS  Google Scholar 

  19. Humphrey A, Dowse G, Thoma K, Zimmet P. Diabetes and nontraumatic lower extremity amputation: incidence, risk factors and prevention—a 12 year follow-up study in Nauru. Diabetes Care 1996;19:710–714.

    Article  PubMed  CAS  Google Scholar 

  20. Humphrey L, Palumbo P, Butters M, et al. The contribution of non-insulin dependent diabetes to lower extremity amputation in the community. Arch Intern Med 1994;154:885–892.

    Article  PubMed  CAS  Google Scholar 

  21. Lehto S, Pyorala K, Ronnemaa T, Laakso M. Risk factors predicting lower extremity amputations in patients with NIDDM. Diabetes Care 1996;19:607–612.

    Article  PubMed  CAS  Google Scholar 

  22. Morris AD, McAlpine R, Steinke D, et al. Diabetes and lower-limb amputations in the community. Diabetes Care 1998;21:738–743.

    Article  PubMed  CAS  Google Scholar 

  23. Nelson R, Gohdes D, Everhart J, et al. Lower-extremity amputations in NIDDM: 12-yr follow-up study in Pima Indians. Diabetes Care 1988;11:8–16.

    Article  PubMed  CAS  Google Scholar 

  24. Siitonen OL, Niskanen LK, Laakso M, Tiitonen J, Pyorala K. Lower extremity amputations in diabetic and nondiabetic patients. Diabetes Care 1993;16:16–20.

    Article  PubMed  CAS  Google Scholar 

  25. Trautner C, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care 1996;19:1006–1009.

    Article  PubMed  CAS  Google Scholar 

  26. Van Houtum W, Lavery LA. Outcomes associated with diabetes-related amputations in the Netherlands and in the state of California. J Intern Med 1996;240:227–231.

    Article  PubMed  Google Scholar 

  27. Geiss LS. Personal communication. 1999.

    Google Scholar 

  28. Resnick HE, Valsania P, Phillips CL. Diabetes mellitus and nontraumatic lower extremity amputation in black and white Americans: The National Health and Nutrition Examination Survey epidemiologic follow-up study, 1971–1992. Arch Intern Med 1999;159:2470–2475.

    Article  PubMed  CAS  Google Scholar 

  29. Wróbel JS, Mayfield JA, Reiber GE. Geographic variation of lower-extremity major amputation in individuals with and without diabetes in the Medicare population. Diabetes Care 2001;24:1–5.

    Article  Google Scholar 

  30. Birkmeyer JD, Sharp SM, Finlayson SRG, Fisher ES, Wennberg JE. Variation profiles of common surgical procedures. Surgery 1998;124:917–923.

    Article  PubMed  CAS  Google Scholar 

  31. Ford EJ, Remington PL, Sonnenberg GE. The burden of diabetes in Wisconsin: diabetes-related amputations, 1994. Wis Med J 1996;643.

    Google Scholar 

  32. Lavery LA, Ashry HR, van Houtum W, et al. Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 1996;19:48–52.

    Article  PubMed  CAS  Google Scholar 

  33. Lavery LA, van Houtum WH, Armstrong DG, et al. Mortality following lower extremity amputation in minorities with diabetes mellitus. Diabetes Res Clin Pract 1997;37:41–47.

    Article  PubMed  CAS  Google Scholar 

  34. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus. Ann Intern Med 1992;117:97–105.

    PubMed  CAS  Google Scholar 

  35. Selby JV, Zhang D. Risk factors for lower extremity amputation in persons with diabetes. Diabetes Care 1995;18:509–516.

    Article  PubMed  CAS  Google Scholar 

  36. Adler AL, Boyko EJ, Ahroni JH, Smith DG. Lower-extremity amputation in diabetes: the independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers. Diabetes Care 1999;22:1029–1035.

    Article  PubMed  CAS  Google Scholar 

  37. Hamalainen H, Ronnemma T, Halonen JP, Toikka T. Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mellitus: a population-based 7-year follow-up study. J Intern Med 1999;246:97–103.

    Article  PubMed  CAS  Google Scholar 

  38. Lee J, Lu M, Lee V, et al. Lower extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study. Diabetes 1993;42:876–882.

    Article  PubMed  CAS  Google Scholar 

  39. Mayfield JA, Reiber GE, Nelson R, Greene T. A foot risk classification system to predict diabetic amputation in Pima Indians. Diabetes Care 1996;19:704–709.

    Article  PubMed  CAS  Google Scholar 

  40. Moss SE, Klein R, Klein BEK. The 14-year incidence of lower-extremity amputations in a diabetic population. Diabetes Care 1999;22:951–959.

    Article  PubMed  CAS  Google Scholar 

  41. Boulton AJM. Diabetic neuropathy. Marius Press, Carnforth, Lanshire, UK, 1997.

    Google Scholar 

  42. Kannel WB, McGee DL. Diabetes and cardiovascular disease: The Framingham Study. JAMA 1979;241:2035–2038.

    Article  PubMed  CAS  Google Scholar 

  43. Feinglass J, Brown JL, LoSasso A, et al. Rates of lower extremity amputation and arterial reconstruction in the United States, 1979 to 1996. Am J Public Health 1999;89:1222–1227.

    Article  PubMed  CAS  Google Scholar 

  44. Larsson J, Agardh CD, Apelqvist J, Stenstrom A. Long term prognosis after healed amputations in patients with diabetes. Clin Orthop 1998;350:149–158.

    PubMed  Google Scholar 

  45. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990;13:513–521.

    Article  PubMed  CAS  Google Scholar 

  46. Apelqvist J, Larsson J, Agard C. Long term prognosis for diabetic patients with foot ulcers. J. Int. Med. 1993;233:485–491.

    Article  CAS  Google Scholar 

  47. Edmonds M, Blundell M, Morris M, et al. Improved survival of the diabetic foot. QJ Med 1986;60:763–771.

    CAS  Google Scholar 

  48. Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376–1378.

    Article  PubMed  CAS  Google Scholar 

  49. Malone JM, Snyder M, Anderson G, et al. Prevention of amputation by diabetic education. Am J Surg 1989;158:520–524.

    Article  PubMed  CAS  Google Scholar 

  50. Davidson JK, Alogna M, Goldsmith M. Assessment of program effectiveness at Grady Memorial Hospital, Atlanta, in Educating Diabetic Patients (Steiner G, Lawrence PA, eds.), Springer-Verlag, New York, 1981, pp. 329–350.

    Google Scholar 

  51. Miller LV. Evaluation of patient education: Los Angeles County Hospital experience: Report of National Commission on Diabetes, Volume 3, 1975: Part V.

    Google Scholar 

  52. Runyon J. The Memphis diabetes continuing care program. JAMA 1975;3:231–264.

    Google Scholar 

  53. Miller AE, Van Buskirk A, Verhoek W, Miller ER. Diabetes related lower extremity amputations in New Jersey, 1979–1981. J Med Soc NJ 1985;82:723–726.

    CAS  Google Scholar 

  54. Wright WE, Kaplan GA. Trends in lower extremity amputations, California, 1983–1987. Sacremento, CA: California Department of Health Services, 1989.

    Google Scholar 

  55. Ebskov B, Josephsen P. Incidence of reamputation and death after gangrene of the lower extremity. Prosthet Orthot Int 1980;4:77–80.

    PubMed  CAS  Google Scholar 

  56. Braddeley RM, Fulford JC. A trial of conservative amputations for lesions of the feet in diabetes mellitus. Br J Surg 1965;52:38–43.

    Article  Google Scholar 

  57. Larsson J. Lower extremity amputation in diabetic patients: Lund University, 1994.

    Google Scholar 

  58. Silbert S. Amputation of the lower extremity in diabetes mellitus. Diabetes 1952;1:297–299.

    PubMed  CAS  Google Scholar 

  59. Deerochanawong C, Home PD, Alberti KGMM. A survey of lower limb amputation in diabetic patients. Diabet Med 1992;9:942–946.

    Article  PubMed  CAS  Google Scholar 

  60. Preston SD, Reiber GE, Koepsell TD. Lower extremity amputations and inpatient mortality in hospitalized persons with diabetes: national population risk factors and associations. University of Washington Thesis, 1993.

    Google Scholar 

  61. Mayfield J, Reiber G, Maynard C, Caps M, Sangeorzan B. Trends in lower extremity amputation in the Veterans Affairs Hospitals, 1989–1998. J Rehabil Res Dev 2000;37:23–30.

    PubMed  CAS  Google Scholar 

  62. Pohjolainen T, Alaranta H. Ten-year survival of Finnish lower limb amputees. Prosthet Orthotlnt 1998;22:10–16.

    CAS  Google Scholar 

  63. Apelqvist J, Ragnarson-Tennvall G, Persson U, Larson J. Diabetic foot ulcers in a multi-disciplinary setting: an economic analysis of primary healing and healing with amputation. J Intern Med 1994;235:463–471.

    Article  PubMed  CAS  Google Scholar 

  64. Hölzer SES, Camerota A, Martens L, et al. Costs and duration of care for lower extremity ulcers in patients with diabetes. Clin Ther 1998;20:169–181.

    Article  PubMed  Google Scholar 

  65. HCFA. DRG Inpatient Billing Data, 1998: Health Care Finance Administration, Bureau of Data Strategy and Management, 2000.

    Google Scholar 

  66. MEDSTAT. DRG Guide Descriptions and Normative Values. Ann Arbor, MI, 2000.

    Google Scholar 

  67. Gibbons GW, Marcaccio EJ Jr, Burgess AM, et al. Improved quality of diabetic foot care, 1984 vs 1990. Arch Surg 1993;128:576–581.

    Article  PubMed  CAS  Google Scholar 

  68. Colorado State Department of Health. Diabetes Prevalence and Morbidity in Colorado Residents, 1980–1991. 1993:119–136.

    Google Scholar 

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Reiber, G.E. (2002). Epidemiology and Health Care Costs of Diabetic Foot Problems. In: Veves, A., Giurini, J.M., LoGerfo, F.W. (eds) The Diabetic Foot. Humana Press, Totowa, NJ. https://doi.org/10.1007/978-1-59259-168-8_2

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  • DOI: https://doi.org/10.1007/978-1-59259-168-8_2

  • Publisher Name: Humana Press, Totowa, NJ

  • Print ISBN: 978-1-61737-253-7

  • Online ISBN: 978-1-59259-168-8

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