• 1

    Centers for Disease Control and Prevention: National diabetes statistics report, 2017: estimates of diabetes and its burden in the United States. Available at: https://dev.diabetes.org/sites/default/files/2019-06/cdc-statistics-report-2017.pdf.

    • Search Google Scholar
    • Export Citation
  • 2

    Boulton AJ, Armstrong DG, Albert SF, et al.: Comprehensive foot examination and risk assessment: a report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists. Phys Ther 88: 1436, 2008.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3

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

  • 4

    Rice JB, Desai U, Cummings AK, et al.: Burden of diabetic foot ulcers for medicare and private insurers. Diabetes Care 37: 651, 2014.

  • 5

    Game FL, Attinger C, Hartemann A, et al.: IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes. Diabetes Metab Res Rev 32(suppl 1): 75, 2016.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Lipsky BA, Berendt AR, Cornia PB, et al.: Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 54: 1679, 2012.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 7

    Bus SA, van Netten JJ, Lavery LA, et al.: IWGDF guidance on the prevention of foot ulcers in at-risk patients with diabetes. Diabetes Metab Res Rev 32(suppl 1): 16, 2016.

  • 8

    Isei T, Abe M, Nakanishi T, et al.: The wound/burn guidelines - 3: guidelines for the diagnosis and treatment for diabetic ulcer/gangrene. J Dermatol 43: 591, 2016.

  • 9

    Bus SA, Armstrong DG, van Deursen RW, et al.: IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev 32(suppl 1): 25, 2016.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Snyder RJ, Frykberg RG, Rogers LC, et al.: The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. JAPMA 104: 555, 2014.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 11

    Hingorani A: The management of diabetic foot: a clinical practice guideline by the Society for Vascular Surgery in Collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg 63(suppl): 3S, 2016.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 12

    Lipsky BA, Aragón-Sánchez J, Diggle M, et al.: IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 32: 45, 2016.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Lavery LA, Davis KE, Berriman SJ, et al.: WHS guidelines update: diabetic foot ulcer treatment guidelines. Wound Repair Regen 24: 112, 2016.

  • 14

    Hinchliffe RJ, Brownrigg JR, Apelqvist J, et al.: IWGDF guidance on the diagnosis, prognosis and management of peripheral artery disease in patients with foot ulcers in diabetes. Diabetes Metab Res Rev 32(suppl 1): 37, 2016.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    American Diabetes Association: 10. Microvascular complications and foot care: Standards of Medical Care in Diabetes-2018. Diabetes Care 41(suppl 1): S105, 2018.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    2018 Guidelines on the management of diabetic patients: a position of Diabetes Poland. Clin Diabetol 7: 1, 2018.

  • 17

    American College of Cardiology Foundation and American Heart Association Inc: Methodology manual and policies from the ACCF/AHA Task Force on Practice Guidelines. Available at: https://professional.heart.org/-/media/phd-files/guidelines-and-statements/methodology_manual_and_policies_ucm_319826.pdf.PublishedJune2010.

    • Search Google Scholar
    • Export Citation
  • 18

    Alseiari M, Meyer KB, Wong JB: Evidence underlying KDIGO (Kidney Disease: Improving Global Outcomes) guideline recommendations: a systematic review. Am J Kidney Dis 67: 417, 2016.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Tricoci P, Allen JM, Kramer JM, et al.: Scientific evidence underlying the ACC/AHA clinical practice guidelines. JAMA 301: 831, 2009.

An Analysis of Guideline Consensus for the Prevention, Diagnosis, and Management of Diabetic Foot Ulcers

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  • 1 Department of Infectious diseases, Hawthorn Medical Associates, Dartmouth, MA.
  • | 2 Department of Anesthesiology, St. Elizabeth Hospital, Brighton, MA.
  • | 3 Department of Vascular Surgery, Tufts Medical Center, Boston, MA. Dr. Suarez is now with Department of Vascular Surgery, Massachusetts General Hospital, Boston, MA. Dr. Iafrati is now with Department of Vascular Surgery, Vanderbilt University Medical Center, Nashville, TN.
  • | 4 Department of Geographic Medicine and Infectious Diseases, Tufts Medical Center, Boston, MA.
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Background: Multiple organizations have issued guidelines to address the prevention, diagnosis, and management of diabetic foot ulcers (DFUs) based on evidence review and expert opinion. We reviewed these guidelines to identify consensus (or lack thereof) on the nature of these recommendations, the strength of the recommendations, and the level of evidence.

Methods: Ovid, PubMed, Web of Science, Cochrane Library, and Embase were searched in October 2018 using the MESH term diabetic foot, the key word diabetic foot, and the filters guideline or practice guideline. To minimize recommendations based on older literature, guidelines published before 2012 were excluded. Articles without recommendations characterized by strength of recommendation and level of evidence related specifically to DFU were also excluded. A manual search for societal recommendations yielded no further documents. Recommendations were ultimately extracted from 12 articles. Strength of evidence and strength of recommendation were noted for each guideline recommendation using the Grading of Recommendations Assessment, Development, and Evaluation system or the Centre for Evidence-Based Medicine system. To address disparate grading systems, we mapped the perceived level of evidence and strength of recommendations onto the American Heart Association guideline classification schema.

Results: Recommendations found in two or more guidelines were collected into a clinical checklist characterized by strength of evidence and strength of recommendation. Areas for future research were identified among recommendations based on minimal evidence, areas of controversy, or areas of clinical care without recommendations.

Conclusions: Through this work we developed a multidisciplinary set of DFU guidelines stratified by strength of recommendation and quality of evidence, created a clinical checklist for busy practitioners, and identified areas for future focused research. This work should be of value to clinicians, guideline-issuing bodies, and researchers. We also formulated a method for the review and integration of guidelines issued by multiple professional bodies.

Corresponding author: Geneve M. Allison, MD, MSc, Geographic Medicine and Infectious Diseases, Tufts Medical Center, 800 Washington St, Box 238, Boston, MA 02111. (E-mail: gallison@tuftsmedicalcenter.org)