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Background: Because value-based care is critical to the Affordable Care Act success, we forecasted inpatient costs and the potential impact of podiatric medical care on savings in the diabetic population through improved care quality and decreased resource use during implementation of the health reform initiatives in California.
Methods: We forecasted enrollment of diabetic adults into Medicaid and subsidized health benefit exchange programs using the California Simulation of Insurance Markets (CalSIM) base model. Amputations and admissions per 1,000 diabetic patients and inpatient costs were based on the California Office of Statewide Health Planning and Development 2009-2011 inpatient discharge files. We evaluated cost in three categories: uncomplicated admissions, amputations during admissions, and discharges to a skilled nursing facility. Total costs and projected savings were calculated by applying the metrics and cost to the projected enrollment.
Results: Diabetic patients accounted for 6.6% of those newly eligible for Medicaid or health benefit exchange subsidies, with a 60.8% take-up rate. We project costs to be $24.2 million in the diabetic take-up population from 2014 to 2019. Inpatient costs were 94.3% higher when amputations occurred during the admission and 46.7% higher when discharged to a skilled nursing facility. Meanwhile, 61.0% of costs were attributed to uncomplicated admissions. Podiatric medical services saved 4.1% with a 10% reduction in admissions and amputations and an additional 1% for every 10% improvement in access to podiatric medical care.
Conclusions: When implementing the Affordable Care Act, inclusion of podiatric medical services on multidisciplinary teams and in chronic-care models featuring prevention helps shift care to ambulatory settings to realize the greatest cost savings.
Hiking with Diabetes
Risks and Benefits
Background:
Exercise is highly beneficial for persons with diabetes. Similar to many other patients, those with diabetes may be reluctant to exercise given a lack of motivation and proper instruction regarding an exercise prescription. In general, medical providers are poorly equipped to develop an exercise prescription and furnish motivation. Attempts to find activities that not only provide effective aerobic challenges but also are enjoyable to participate in are fraught with difficulty. Hiking as a potential option for a safe and enjoyable activity is discussed, including the possible downsides.
Methods:
Multiple publications were reviewed using key words.
Results:
A review of the literature uncovered limited publications or controlled trials that discussed the use of hiking per se as an activity for the management of diabetes. Newer studies reviewing weightbearing exercise and diabetic polyneuropathy and those discussing the advantages of trekking poles for balance and proprioception are cited in support of the recommendation for hiking as an activity for those with diabetes.
Conclusions:
Exercise has been shown to substantially benefit individuals with diabetes, but convincing patients with diabetes to exercise is daunting. Hiking, unlike other, more tedious exercise programs, may be an exercise option that persons with diabetes might find enjoyable. Hiking may encourage balance training and reduced ground reaction forces. These benefits may be augmented by trekking poles, which may likewise counter the concerns of the uneven surfaces that present challenges to the hiker with diabetes.
The purpose of this article is to present reference guidelines to assist clinicians when treating diabetic patients with foot wounds. Diabetic patients with limb-threatening foot ulcers often have multiple coexisting medical conditions that frequently become impediments to the resolution of foot wounds. Each foot wound is unique and its etiology is multifactorial; therefore, each foot wound should be managed differently. The treatment algorithm presented in this article is divided into three categories: Algorithm I describes the treatment of septic foot wounds, which may be considered true podiatric surgical emergencies; Algorithm II describes the treatment of ischemic foot ulcers or gangrene with or without underlying osteomyelitis; and Algorithm III describes the treatment of neuropathic foot ulcers with or without underlying osteomyelitis. (J Am Podiatr Med Assoc 92(6): 336-349, 2002)
Background:
In this explorative study, we assessed the effect and feasibility of using motivational interviewing to improve footwear adherence in persons with diabetes who are at high risk for foot ulceration and show low adherence to wearing prescribed custom-made footwear.
Methods:
Thirteen individuals with diabetes, ulcer history, and low footwear adherence (ie, <80% of steps taken in prescription footwear) were randomly assigned to standard education (ie, verbal and written instructions) or to standard education plus two 45-min sessions of motivational interviewing. Adherence was objectively measured over 7 days using ankle- and shoe-worn sensors and was calculated as the percentage of total steps that prescribed footwear was worn. Adherence was assessed at home and away from home at baseline and 1 week and 3 months after the intervention. Feasibility was assessed for interviewer proficiency to apply motivational interviewing and for protocol executability.
Results:
Median (range) baseline, 1-week, and 3-month adherence at home was 49% (6%–63%), 84% (5%–98%), and 40% (4%–80%), respectively, in the motivational interviewing group and 35% (13%–64%), 33% (15%–55%), and 31% (3%–66%), respectively, in the standard education group. Baseline, 1-week, and 3-month adherence away from home was 91% (79%–100%), 97% (62%–99%) and 92% (86%–98%), respectively, in the motivational interviewing group and 78% (32%–97%), 91% (28%–98%), and 93% (57%–100%), respectively, in the standard education group. None of the differences were statistically significant. Interviewer proficiency was good, and the protocol could be successfully executed in the given time frame.
Conclusions:
Footwear adherence at home increases 1 week after motivational interviewing to clinically relevant but not statistically significant levels (ie, 80%) but then returns over time to baseline levels. Away from home, adherence is already sufficient at baseline and remains so over time. The use of motivational interviewing seems feasible for the given purpose and patient group. These findings provide input to larger trials and provisionally suggest that additional or adjunctive therapy may be needed to better preserve adherence.
Background: Diabetic neuropathy leads to progressive loss of sensation, lower-limb distal muscle atrophy, autonomic impairment, and gait alterations that overload feet. This overload has been associated with plantar ulcers even with consistent daily use of shoes. We sought to investigate and compare the influence of diabetic neuropathy and plantar ulcers in the clinical history of diabetic neuropathic patients on plantar sensitivity, symptoms, and plantar pressure distribution during gait while patients wore their everyday shoes.
Methods: Patients were categorized into three groups: a control group (CG; n = 15), diabetic patients with a history of neuropathic ulceration (DUG; n = 8), and diabetic patients without a history of ulceration (DG; n = 10). Plantar pressure variables were measured by Pedar System shoe insoles in five plantar regions during gait while patients wore their own shoes.
Results: No statistical difference between neuropathic patients with and without a history of plantar ulcers was found in relation to symptoms, tactile sensitivity, and duration of diabetes. Diabetic patients without ulceration presented the lowest pressure–time integral under the heel (72.1 ± 16.1 kPa × sec; P = .0456). Diabetic patients with a history of ulceration presented a higher pressure–time integral at the midfoot compared to patients in the control group (59.6 ± 23.6 kPa × sec × 45.8 ± 10.4 kPa × sec; P = .099), and at the lateral forefoot compared to diabetic patients without ulceration (70.9 ± 17.7 kPa sec × 113.2 ± 61.1 kPa × sec, P = .0193). Diabetic patients with ulceration also presented the lowest weight load under the hallux (0.06 ± 0.02%, P = .0042).
Conclusions: Although presenting a larger midfoot area, diabetic neuropathic patients presented greater pressure–time integrals and relative loads over this region. Diabetic patients with ulceration presented an altered dynamic plantar pressure pattern characterized by overload even when wearing daily shoes. Overload associated with a clinical history of plantar ulcers indicates future appearance of plantar ulcers. (J Am Podiatr Med Assoc 99(4): 285–294, 2009)
Background
Although there are several different concepts of hindfoot relief footwear, there are no studies on the extent of pressure reduction to be achieved by this footwear. Therefore, we sought to evaluate the reduction in plantar pressure to be achieved with two different hindfoot relief shoes.
Methods
Ten healthy volunteers performed three trials at a self-selected speed. Peak pressure values in mass-produced shoes (normal gait) were considered as 100% and were compared with measurements in two differently designed hindfoot relief shoes. Foot portions were defined as heel (0%–15% of total insole length), hindfoot (16%–30%), midfoot (31%–60%), and forefoot (61%–100%).
Results
Heel and hindfoot peak pressures were significantly reduced in both shoes compared with normal gait (P < .05), but the extent of peak pressure reduction under the heel and hindfoot varied significantly between the tested shoes. Midfoot peak pressure was not significantly reduced in tested shoes compared with baseline (P > .05) but differed significantly between the two shoes. Forefoot peak pressure was significantly reduced with one of the tested shoes (to a median 73% baseline; P = .004) but not with the other (median, 88% baseline).
Conclusions
Hindfoot relief shoes leave a considerable amount of peak pressure, predominantly under the hindfoot. The extent of peak pressure reduction for the heel and the hindfoot varies between different hindfoot relief shoes. Depending on the affected foot area, the kind of hindfoot relief shoe should be carefully chosen.
Background
Charcot's arthropathy (CA) is a destructive rare complication of diabetes, and its diagnosis remains challenging for foot specialists and surgeons. We aimed to assess the clinical presentation and characteristics of CA and the frequencies of its various types.
Methods
This cross-sectional study was conducted from January 1, 2007, to December 31, 2016, and included 149 adults with diabetes diagnosed as having CA. Cases of CA were classified based on the Brodsky anatomical classification into five types according to location and involved joints.
Results
The mean ± SD age of the studied cohort was 56.7 ± 11 years, with a mean ± SD diabetes duration of 21.2 ± 7.0 years. The CA cohort had poorly controlled diabetes and a high rate of neuropathy and retinopathy. The most frequent type of CA was type 4, with multiple regions involved at a rate of 56.4%, followed by type 1, with midfoot involvement at 34.5%. A total of 47.7% of the patients had bilateral CA. Complications affected 220 limbs, of which 67.7% had foot ulceration. With respect to foot deformity, hammertoe affected all of the patients; hallux valgus, 59.5%; and flatfoot, 21.8%.
Conclusions
There is a high rate of bilateral CA, mainly type 4, which could be attributed to cultural habits in Saudi Arabia, including footwear. This finding warrants increasing awareness of the importance of maintaining proper footwear to avoid such complications. Implementation of preventive measures for CA is urgently needed.
Background
The preferred primary treatment of toe osteomyelitis in diabetic patients is controversial. We compared the outcome of primary nonoperative antibiotic treatment versus digital amputation in patients with diabetes-related chronic digital osteomyelitis.
Methods
We conducted a retrospective medical record review of patients treated for digital osteomyelitis at a single center. Patients were divided into two groups according to initial treatment: 1) nonoperative treatment with intravenous antibiotics and 2) amputation of the involved toe or ray. Duration of hospitalization, number of rehospitalizations, and rate of below- or above-the-knee major amputations were evaluated.
Results
The nonoperative group comprised 39 patients and the operative group included 21 patients. The mean ± SD total duration of hospitalization was 24.05 ± 15.43 and 20.67 ± 15.97 days, respectively (P = .43). The mean ± SD number of rehospitalizations after infection recurrence was 2.62 ± 1.63 and 1.67 ± 1.24, respectively (P = .02). During follow-up, the involved digit was eventually amputated in 13 of the 39 nonoperatively treated patients (33.3%). The rate of major amputation (above- or below-knee amputation was four of 39 (10.3%) and three of 21 (14.3%), respectively (P = .69).
Conclusions
Despite a higher rate of rehospitalizations and a high failure rate, in patients with mild and limited digital foot osteomyelitis in the absence of sepsis it may be reasonable to offer a primary nonoperative treatment for digital osteomyelitis of the foot.
Background: We sought to determine the frequency of toenail onychomycosis in diabetic patients, to identify the causative agents, and to evaluate the epidemiologic risk factors.
Methods: Data regarding patients’ diabetic characteristics were recorded by the attending internal medicine clinician. Clinical examinations of patients’ toenails were performed by a dermatologist, and specimens were collected from the nails to establish the onycomycotic abnormality. All of the specimens were analyzed by direct microscopy and culture.
Results: Of 321 patients with type 2 diabetes mellitus, clinical onychomycosis was diagnosed in 162; 41 of those diagnoses were confirmed mycologically. Of the isolated fungi, 23 were yeasts and 18 were dermatophytes. Significant correlations were found between the frequency of onychomycosis and retinopathy, neuropathy, obesity, family history, and duration of diabetes. However, no correlation was found with sex, age, educational level, occupation, area of residence, levels of hemoglobin A1c and fasting blood glucose, and nephropathy. The most frequently isolated agents from clinical specimens were yeasts.
Conclusions: Long-term control of glycemia to prevent chronic complications and obesity and to promote education about the importance of foot and nail care should be essential components in preventing onychomycosis and its potential complications, such as secondary foot lesions, in patients with diabetes mellitus. (J Am Podiatr Med Assoc 101(1): 49–54, 2011)
Background: We evaluated 35% urea in a water-lipid–based foam delivery system containing lactic acid in participants with mild-to-moderate xerosis of the foot.
Methods: This 4-week open-label study enrolled 12 participants with xerosis of the foot; six participants were diabetic and six were nondiabetic. Study medication was applied to the affected area twice daily. All adverse events were recorded. Disease severity was measured at baseline and at the end of treatment by Investigator’s Global Assessment, and investigator’s and participant’s signs and symptoms scores. At 4 weeks, compliance and participant satisfaction were determined from participant diaries and a 16-item survey instrument, respectively.
Results: Ten participants completed the study. No adverse reactions were noted with application of the foam. All of the participants who completed the study experienced an improvement in xerosis. The median Investigator’s Global Assessment score decreased significantly from baseline to the end of treatment (P = .005). The investigator and participants observed significant improvement (P < .05) in redness, scaling, and cracking from baseline to the end of treatment. Compliance with the regimen was good, and participants expressed satisfaction with the product.
Conclusions: Thirty-five percent urea in a water-lipid–based foam delivery system containing lactic acid can be an appropriate treatment option for mild-to-moderate xerosis of the foot. (J Am Podiatr Med Assoc 101(2): 153–158, 2011)
