Tag Archives: diabetic foot

A new approach to quantifying the sustainability effects of healthcare: Applied to the diabetic foot

by Stefan Hellstrand1 and Ulla Hellstrand Tang2,3*

The Foot and Ankle Online Journal 12 (3): 5

A vital role for any society is to deliver health care considering: 1) the planetary boundaries, 2) the complexity of systems and 3) the 17 sustainable development goals (SDGs). The aim is to explore the feasibility of a method to quantify the sustainability effects in health-care services. A toolbox was explored in the prevention and care of foot complications in diabetes. People with diabetes run the risk of developing foot ulcers and undergoing amputations. Three relationships between ecosystems and human health and health-care systems were identified as: (i) The economic resources for health care have previously appropriated ecological resources in the economic process. (ii) Health-care systems consume natural resources. (iii) Ecosystems and the landscape affect human well-being. Some types of landscape support human well-being, while others do not. This category also includes the impact of emissions on human health. Diabetes is one of the non-communicable diseases with high mortality and foot complications. With health-promoting interventions, the risk of developing foot ulcers and undergoing amputations can be halved. The toolbox that was used could manage the complexity of systems. Several of the 17 SDGs can be calculated in the prevention of complications in diabetes: quality of life improves, while the costs of healthcare and the burden on the economy caused by people not being able to work decrease. The appropriation of natural resources and the wasted assimilated capacity for the same welfare level decreases, thereby offering an option to deliver health care within the planetary boundaries. 

Keywords: healthcare, sustainability, diabetes, diabetic foot, noncommunicable diseases, NCD, SDG, sustainable development goals

ISSN 1941-6806
doi: 10.3827/faoj.2018.1203.0005

1 – Nolby Ekostrategi, Tolita 8, SE-665 92 Kil, Sweden stefan@ekostrateg.se
2 – The Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
3 – The Department of Prosthetics and Orthotics, Sahlgrenska University Hospital, Gothenburg, Sweden.
* – Corresponding author: ulla.tang@vgregion.se


Achieving sustainable development from local to global level is challenging. One vital part is offering health care to patients in need. One unresolved question remains and that is how to ensure that healthcare is delivered within the planetary boundaries [1,2]. Health care should serve an increasing number of patients diagnosed with non-communicable diseases (NCD) and in need of prevention and care [3]. The intention is to minimise the negative consequences of the disease for the individual, society and the planet.

There is very little scientific research that presents approaches designed to measure the consequences of health care in the three dimensions of sustainability; ecological, economic and social. Tools such as analytical hierarchical processes have been used to manage and evaluate the complexity of the health-care system in relation to the social aspects using semi-quantitative measurements [4]. The authors Aljaberi et al encourage health-care professionals to collect data, in particular data on patient satisfaction, as a basis for further analysis of the sustainability dimension of health-care systems. However, two important dimensions, the ecological and the economic, were left out of their analysis. The definition of sustainability that the authors used was put forward in 1992 by the International Institute for Sustainable Development in conjunction with Deloitte & Touche and the World Business Council for Sustainable Development: “For the business enterprise, sustainable development means adopting business strategies and activities that meet the needs of the enterprise and its stakeholders today, while protecting, sustaining and enhancing the human and natural resources that will be needed in the future” [5]. Twenty-three years later, in 2015, the UN approved the 17 Sustainability Development Goals (SDG) to secure a life for future generations on our planet, not only limited to the business enterprise but also including all aspects of life [6]. 

A substantial percentage of Gross Domestic Product (GDP) funds health-care systems. With well-functioning health care, the benefits to the individual and to society are substantial. Dealing with sustainability means dealing with complex systems and complexity. The complexity is expressed in the 17 sustainable goals the UN approved in 2015 [6]. At national level, Sweden manages the 16 Swedish national environmental quality objectives [7]. The systems in which sustainability is an issue are typically complex. To a significant degree, their complexity stems from the fact that life, bios, is a vital system-defining element. No system of importance for ecological, economic or social sustainability is possible, if we assume life outside the borders of the system. This information is fairly general. Is it necessary? The OECD made an important contribution to the definition of sustainable development and how to achieve it [8]. Two of the main problems that were identified were the implementation gap and knowledge gap respectively. Despite knowing fairly well how policies supporting sustainable development should be designed, implementation is at a low and varying level [1]. In the 2000s, some authors [9-13] concluded that the implementation gap and the closely related knowledge gap were caused to a substantial degree by inappropriate analytical and management tools. 

With life as a crucial system element, it is clear that all processes are driven by a flux of energy by which quality is degraded. The sum of energy is constant, while the quality of energy is degraded. From an energy perspective, the system is a linear one. 

Cells, organs, individuals and ecosystems represent different system levels in biological and ecological systems. Feedback loops at each of these levels and between them are important for the efficient use of available resources [14, 15]. The linear flux of energy with quality drives loops of matter. These reinforcing loops may include a number of system levels, as well as all three sustainability dimensions. This results in systems with mutual dependence between system levels and the three sustainability dimensions. With the existence of thresholds, and the nature of interconnections, the system typically has features such as thresholds, irreversibility and resilience. The knowledge gap and demand for analytical tools that takes account of thresholds, irreversibility and resilience has been addressed by the Rockefeller Foundation-Lancet Commission on planetary health [1]. 

Within life sciences, irreversibility is easily understood. The process from living to dead cannot be reversed. Resilience is a phenomenon that requires some effort to understand. A resilient system is able to withstand stress from internal and external sources without changing its character. If the source of stress is removed, it returns to its original status. Systems that are not resilient are pushed away by internal and/or external sources from the domain of an operating balance space or point, into a phase of rapid, unpredictable change. Its system conditions then experience rapid, catastrophic changes. Some important considerations:

  1. A change in a well-defined part of a system may affect a hierarchy of sustainability goals from low to high system levels in the ecological, economic and social dimensions
  2. Instruments from mathematics, such as differential functions and linear and non-linear algebra, are of importance in analytical and management tools supporting sustainable health care. 

With a multitude of goals in different dimensions and system levels, there is a need for instruments that support the optimisation of utilised resources. With systems with reinforcing loops operating close to the borders of chaos, differential functions are tools that are able to extract order from chaos. 

As mentioned before, the OECD found that the understanding of what sustainable development is and how to achieve it was well understood [8]. In spite of this, policies for sustainable development that were in place were on a low, uneven level. The OECD expressed great concern about this and related it to two closely related obstacles they called the implementation gap and the knowledge gap. 

These gaps reflected a broken connection between 

  1. A general understanding of what sustainable development is and the policies needed to promote it, expressed in fields and policy contexts such as classic economic theory back to the 18th century, agricultural sciences as living knowledge until the Second World War, system ecology and ecological economics from around 1990, the UN Millennium Development Goals [6], the OECD [8], the Millennium Ecosystem Assessment [16] and the Economics of Ecosystems and Biodiversity [17], on the one hand, and
  2. Instruments and concepts in common practice with the aim of putting sustainable development in place, on the other hand [10]. 

Typical instruments and concepts in (2) are life cycle assessments, in accordance with the ISO 14 001 system, the Best Available Techniques (BAT) principle in the Integrated Pollution Prevention and Control Directive in the EU, the Integrated Production Policy from the EU Commission and a number of other policies from the same scientific ground, suffering from the same drawbacks [10]. As these concepts and tools are derived from engineering sciences, they do not express the competence relating to systems where life, bios, defines system characteristics. Their “default solution” when managing the complexity of life, e.g. in the understanding of the impact of the use of natural resources and the emissions in biological and ecological systems actually affected by production, is to assume that this complexity does not exist [9, 10, 12, 13].

Within agricultural and forestry science and practice, tools that are able to manage this complexity have emerged over hundreds of years of theoretical development and of trial and error in practice. A similar development has been seen in system ecology and economic theory during the last few decades. A combination of contributions from agricultural sciences, forestry sciences, system ecology, integrative assessments, applied environmental sciences and economic theory at micro and macro level offers a solution to the implementation gap by resolving the challenge, in everyday actions, of managing complex real-world systems, while being aware of and respecting their genuine complexity due to life as a defining system characteristic. A new approach to calculating the sustainability effects in health care is needed with criteria as mentioned above. An approach of this kind considers the planetary boundaries, the three dimensions of sustainability and the complexity of ecosystems. The aim of the article is to present a new approach to measuring sustainability in health care, applied to the prevention of foot complications in diabetes.

Method

Conceptual model

Tools and methods that considered the planetary boundaries, the three dimensions of sustainability and the complexity of ecosystems were chosen. The toolbox originates from a variety of fields. For example, they supported sustainable animal production systems; sustainable industrial production systems; effective policies to minimise health hazards associated with cadmium fluxes in food systems; milk consumption and the human health impact; physical planning for sustainable attractiveness at local and regional level; sustainable local, regional and national development; the development of certification schemes such as ISO 14 001 to contribute more effectively to improving the status of ecosystems actually affected by production and consumption; the development of public procurement in favour of growth, employment and a better environment in accordance with national environmental objectives [9, 10, 12, 13, 18-26]. 

In what follows, our approach that supports the management of health-care systems in a sustainable society is presented. The accuracy of these instruments is investigated and applied to the prevention of foot complications in diabetes. The effects on the individuals living with diabetes is dramatic, with a lifetime risk of 25% that a foot ulcer will develop, a threatening reality for the 425 million people living with diabetes [27]. Every thirty minutes, an amputation takes places on the planet due to diabetes [28]. People with a lower socioeconomic status are more likely to develop complications such as cardiovascular disease and/or foot ulcers and amputations [29-31]. This means that people already struggling for their lives and surveillance will be marginalised, more vulnerable in the presence of foot ulcers and amputations. Their health-related quality of life will decrease [32-34].

The article presents a new approach that includes a conceptual model, a map, of the economic system in its ecological and social context [13]. From this map of the sustainability landscape, we are able to define different pathways by which we can improve human health and meet the demands of society. One way of estimating the impact of health care on the appropriation of natural capital, man-made capital, human capital and social capital is suggested. We use the diabetic foot as a case in this exercise. The hypothesis is that a set of these instruments developed with the aim of supporting the effective management of natural resources, with the emphasis on acreage-dependent sectors, is able to significantly improve the efficiency of health-care systems in meeting the 17 SDGs. The toolkit has five internally consistent instruments:

  1. A conceptual model of the GDP part of the economy embedded in its ecological and social contexts where stocks of natural, man-made, human and social capital are located [11].
  2. From the conceptual model, Biophysically Anchored Production Functions (BAPFs) are constructed showing how the GDP economy is dependent on nature and delivers resources for the fulfilment of human needs [13].
  3. An application based on the general features of Impredicative Loop Analysis by which the impacts in a hierarchy of sustainability sub-goals of a specific change in a specific production process can be evaluated [20].
  4. From BAPFs, ecological economic accounts (EEA) can be derived by which the sustainability performance of any system can be evaluated [10-12]. 

In what follows, the conceptual model of the economic system in its ecological and social context is presented in some detail. This supports the understanding of health care in a broader sustainability context. The conceptual model of the economy in its ecological and social context is presented, Figure 1 [12].

The model consists of three compartments, where the first refers to nature, to ecosystems providing natural resources and taking care of emissions. The second is the traditional economy where goods and services are produced from natural resources and inputs of labour and (traditional) capital. GDP measures the size of the output. The third is the social dimensions where the economic resources that are created to meet human needs, including health care. In all parts of the economy, emissions and waste return to nature. 

With some simplification, Compartment I represents nature, the ecological dimension of the economy, Compartment II represents the economic system, in the narrower sense in which we often discuss it, and Compartment III represents the social dimension of our economy. In reality, they are three closely integrated parts of our economic system.

Compartment I defines ecological restrictions in society, Compartment II provides the means, while Compartment III contains the objective: human well-being. 

From the perspective presented in Figure 1, the challenge of health care is to use appropriated economic resources as efficiently as possible in order to improve the health of the population. It focuses on preventing and/or compensating for the functional loss of the individual. With the efficient use of economic resources, the needs of the people suffering from illnesses are met, while the economic burden on the rest of the economy is kept down. This increases the demand for goods and services from households, which stimulates the economy. At the same time, the competitiveness between enterprises is increased, while everything else is equal. The efficiency measurement referred to implicitly is the ratio between the level of health in the population as the numerator and the economic cost of providing it as the denominator. With efficient health care, the level of health in the numerator is increased, while everything else is equal, which improves the life quality of individuals, thereby improving the social capital. With improved health, the productivity of the same individuals increases and the stock of human capital is thereby also improved.

Relationships between nature and health care

There are three types of relationship between health and health care and NC (Natural Capital) and NR (Natural Resources), as shown in Figure 1. 

  1. The appropriate economic resources are produced in the GDP economy where NR are upgraded to goods and services through the input of labour and capital, while, on the output side, potentially harmful emissions are generated. Health care thus appropriates NR embedded in the economic resources that are used and indirectly cause emissions that can harm human health and ecosystem health. This is the indirect support to service sectors such as health care from nature [35, 36]. 
  2. The health-care system also directly consumes NR, by using the energy needed to build and heat/cool the buildings, fuel the equipment and transport personnel and patients to and from hospitals [35, 36].
  3. The third type of relationship relates to the way ecosystems and the landscape affect human well-being. Some landscapes support human well-being, others do not. This category also includes the impact of emissions on human health. The first two relationships are connected to the appropriation of ecological resources in the production of health. The third relationship relates to the demands on health care to the needs to be met.

Through emissions and changes in land use, the capacity and quality of the life-support system of ecosystems are affected. In maps of Europe [10, 11] the effect on (i) expected human life expectancy due to the emission of particles into the air is presented, as well as (ii) the deposits of nitrogen exceed the assimilative capacity of ecosystems. The congruence in the geography of these human health and ecosystem health impacts is profound. 

The United Nations Environment Programme (UNEP) [37], in collaboration with the World Health Organisation (WHO), estimated that, in 2012, 12.6 million deaths, or 23 per cent of the total, were due to deteriorating environmental conditions [38]. Air pollution which, according to the UNEP, kills seven million people across the world each year, dominates. Of these, 4.3 million are due to household air pollution, particularly among women and young children in developing countries. There is an uneven distribution of deaths due to environmental deterioration, with the highest proportion of deaths attributable to the environment in South-East Asia and in the Western Pacific (28 per cent and 27 per cent respectively). The percentage of deaths attributable to the environment is 23 per cent in sub-Saharan Africa, 22 per cent in the Eastern Mediterranean region, 11 percent and 15 per cent in OECD and non-OECD countries in the Americas region and 15 per cent in Europe.

In the case of the diabetic foot, the transport of personnel and patients to and from providers of health care consumes energy and causes a multitude of emissions, harming the health of ecosystems and of humans. The emissions from hospitals should be considered. Health-care services located in areas stressed by high emission rates have a greater negative impact on human health compared with health-care services localised in areas with forests and land. Forests and land assimilate emissions [10, 39]. 

Non-communicable diseases (NCDs) are a group of diseases with a substantial impact on health [3].They kill 41 million people each year. Cardiovascular diseases account for most NCD deaths, or 17.9 million people annually, followed by cancers (9.0 million) and respiratory diseases (3.9 million). Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from an NCD. The facts in the UNEP [37] and the WHO [38] imply that environmental issues are a substantial category of factors causing NCDs. This is supported by Lim et al. [40].

Health care and Agenda 2030 with 17 SDGs

Society can work through three major pathways to improve human health; traditional health care when illness is present, preventing illnesses by lifestyle changes within the population and by upgrading the quality of the environment and life-support systems. Odum [15] describes in detail the life-support systems of ecosystems, providing the physiological necessities for all life. In 2015, the UN [6] approved 17 SDGs. They form the basis of Agenda 2030. The overall objective of County Administrative Boards in Sweden, the regional representation of the national government, is to support the implementation of the 17 SDGs at regional level, in each county. The first paragraph in the task assigned to them is, at regional level, to contribute to sustainable, enduring solutions. The second is to contribute to the implementation of Agenda 2030 [41]. In Sweden, there is also a system of 16 environmental quality objectives [7]. Their role is to lay the environmental foundation for economic and social development within affected ecosystems carrying capacity limits. They agree well with the 17 SDGs from the UN with their foundation in the need for ecological sustainability as a prerequisite for economic and social sustainability. The recommendation from the UNEP [37] to reduce the number of deaths due to environmental deterioration reflects the purpose of the UN’s 17 SDGs. 

The presented toolbox supports policies that improve (i) health, by lowering the environmental burden on the ecosystem and human health, and (ii) diet patterns and physical activity, for example, to benefit both ecosystem health and human health, thus lowering NCDs. 

In what follows, an approach is presented in which the capacity of the toolbox to help health-care systems to comply with the 17 SDGs and the Swedish environmental quality objectives is tested. We do this using the case of diabetes and the prevention of diabetic foot ulcers (DFU).

Costs associated with diabetes and the diabetic foot

From 1980 to 2014, the prevalence of diabetes rose by a factor of 3.9, to 422 million people in 2014 [42]. In 1980, 4.7% of adults had diabetes and, in 2014, it was 8.5%. The rate of the increase in diabetes is highest in low-income and middle-income countries. If we add up the effect of diabetes and high blood glucose, 3.8 million deaths were related to these causes in 2012 [43]. The social and economic costs of diabetes to the individual and to society are therefore significant. Lowering the prevalence of diabetes will improve social and human capital (see Figure 1) and support a number of the 17 SDGs. 

A healthy diet, regular physical activity, maintaining a normal body weight and avoiding tobacco use are ways to prevent or delay the onset of diabetes type 2. For patients with diabetes it is important to maintain good function in the feet and in the lower extremities. 

The cost of the treatment of DFUs is substantial. In one study with data from Sweden, the span was 993-17,519 US$ [44, 45]. Table 1 presents estimates of treatment costs for diabetic foot ulcers at regional, national and global level [46]. 

Treatment costs US$ 2015
Patients, no Per patient Total, millions
Region Västra Götaland 3,000 5500 16.5
Sweden 20,000 5500 110
Global 20,000,000 5500 110000

Table 1 Estimated regional, national and global costs for treating DFUs in 2015. The equivalent of 5,525 US$ of 2015 converted from figures from 1990 per treatment of DFUs (5000 US$) was originally provided by Apelqvist et al. (1995) and refers to Sweden. Available 2018-07-12. http://www.historicalstatistics.org/Currencyconverter.html. 

Region Västra Götaland is one of the counties in Sweden. The estimated cost relates to the treatment of DFUs not infected or in need of intervention due to artery disease. The estimate is therefore conservative. We assume the same cost at regional level in Sweden (Västra Götaland) and global level as well. The estimate agrees well with the figures from Prompers et al [47], presenting estimates at European level, suggesting that the estimate is relevant at international level as well. 

The prevalence of DFUs is set at 5% among patients with diabetes [48]. The estimate is based on a population-based annual incidence of DFUs of 1.0-7.2% [49-53]. The number of patients with diabetes in Västra Götaland, in 2015, was approximately 60,000, in Sweden 400,000 [54] and globally 400 million people [55].

Results

By using the example of DFUs and the need for early prevention and treatment as an example, we shall now outline how the principles presented in previous parts can be considered in everyday practice in health care. We, therefore, present a proposal for ways of operationalising the UN’s 17 SDGs in health-care systems from the level of individual treatment to aggregated effects regionally, nationally and globally.

Of the population of people suffering from diabetes, it is estimated that 50% are in need of preventive foot care. This is based on the presence of the risk factor of loss of protective sensation, which can be as high as 50% in patients with diabetes [46]. Using early monitoring, patients at risk are identified, enabling intervention at an early stage [56]. Promising results show a reduction in the amputation rate of 40% to 60% [57] and DFUs of 50% [58]. Halving the presence of small DFUs leads to a reduction in ulcers that might develop into severely infected ulcers and amputations. 

One part of early treatment is the provision of insoles from a Department of Prosthetics & Orthotics (DPO) [59]. Insoles reduce the risk of pressure-induced DFUs [58, 60]. Insoles can be prefabricated or custom made or traditionally made [46]. Assume that we have custom-made insoles. Two visits to a health-care provider are needed. The costs associated with this solution are:

  • Time appropriated by
    1. The patient
    2. The staff at the health-care provider
  • Energy (with quality) consumed for
    1. Transportation to and from the health-care provider
    2. Heating of buildings and for the production of insoles 
  • Emissions from energy consumption potentially harming human and ecosystem health. 

The time appropriated by patients can be leisure time, or times when the patient would otherwise have worked, contributing to GDP.

The energy cost can be measured in both monetary and physical terms. Both are of interest. When measuring in physical terms, information is gathered that makes it possible to evaluate future risks and opportunities in relation to possible changes in the price of energy. The available amount of fossil fuels is limited. In 2015, fossil fuels provided 86% of the global energy budget [61]. 

The climate challenge calls for action which, in a fair number of decades, will eliminate the increase in greenhouse gases in the atmosphere [6, 7]. Energy consumption causes the emission of a spectrum of substances that affect the majority of the 16 environmental quality objectives in Sweden and those of the UN’s 17 SDGs that are related to emissions and their impact on ecosystems and human health. Regarding energy systems, we also have a range of aspects related to hydropower and nuclear power to consider, as well as contributions to climate change. Renewable fuels are of increasing importance for the supply of energy.

Taken together, the limitedness of non-renewable natural resources, fossil fuels, their dominance among energy sources in the economy from local to global level and the environmental and human health impacts of these energy sources and of hydropower and nuclear power all indicate a future, substantial transformation of the energy systems from local to global level. This transformation to future energy systems effectively supporting a sustainable society will cause a change in energy prices. 

Since 1998, there has been a substantial increase in the fixed level of global oil prices [10]. This may affect the outcome with regard to the rational localisation of future health care in the landscape. As a result, there are good economic reasons for health-care providers to be in control of their energy consumption in both economic and physical terms.

The time that each patient appropriates from the staff is time during which the staff are unable to support other groups of patients within budget restrictions. 

Figure 1 A conceptual model of the economy in its ecological and social contexts.

Assume that we have a solution where we can offer the same benefits to the patient with only one visit (the system with prefabricated insoles). If so, the above-mentioned costs can be cut by 50% per patient treated. On a regional, national and international scale, this would substantially improve the contribution to a number of ecological, economic and social sustainability goals.

So far, we have not dealt with the challenge of health-care systems that operate within affected ecosystems with capacity limits. The toolbox for sustainable development mentioned above [10] supports a solution to this challenge. It thus supports the emergence of health-care systems promoting Agenda 2030.

The production of ecosystem services from the life-support systems of ecosystems can be quantified. These systems are located in rural areas, in the so-called cultural and natural landscapes as defined within system ecology [15]. The contribution from Odum laid the scientific foundation for most of the work that has subsequently been devoted to the issue of ecosystem services and their importance for human well-being: the OECD [8], the Millennium Ecosystem Assessment [16] and the Economics of Ecosystems and Biodiversity [17].

Ecosystems are Compartment 1 in the model of the economic system in its ecological and social contexts in Figure 1. This is the ecological dimension of our economy and of our society. Using the same tools, the consumption of ecosystem services can also be quantified.

So, using the same tools deeply rooted in natural sciences, including agricultural sciences and system ecology, we are able to quantify the sustainable production of ecosystem services, as well as consumption. With this information related to the demand for and supply of ecosystem services, the human appropriation of ecosystem services can be adapted to affected ecosystems with capacity limits.

This suggests a way in which the appropriation of natural resources and the emissions related to the treatment of the diabetic foot are related to the area of ecosystems with the capacity to deliver natural resources and assimilate emissions. This suggests a methodological route to evaluate the pressure on nature from health-care systems and to adapt health-care systems and other socioeconomic systems to the carrying capacity of affected ecosystems.

Through this route, ecological and economic dependence between rural and urban areas can be visualised and policies that contribute to their mutual development in a sustainability context can be effectively implemented. 

Discussion

This paper presents a framework for measuring sustainability in health-care using a toolbox supporting the effective management of natural resources. Analytical tools evaluating the sustainability performance in health care in ecological, economic and social terms are a prerequisite for the management of health-care systems, in agreement with the UN’s 17 SDGs. Using a sustainability map, three types of relationship between ecosystems and human health and health-care systems were identified. 

  1. The economic resources needed to cover the cost of health care have previously appropriated ecological resources in the economic process, at the same time as good health care may reduce future economic costs and thereby the ecological resources that are appropriated. 
  2. Health-care systems consume natural resources.
  3. Ecosystems and the landscape affect human well-being. Some types of landscape support human well-being, while others do not. This category also includes the impact of emissions on human health. 

Diabetes, one of the NCDs, has a substantial impact on the health level of societies. In Sweden, around 20,000 patients with diabetes suffer from DFUs, while the global figure is 20 million people. With preventive interventions, the prevalence can be halved, saving 50 million USD in health-care costs in Sweden and 50 billion USD globally. 

Further research should preferably present details in ecological units, economic monetary terms and social terms from a real case for the two alternatives: the supply of insoles with one visit as compared with two visits to a DPO.

Effective, preventive interventions reduce the cost of health care, as well as the burden on the economy imposed by people who are not able to work. Life quality, i.e. social sustainability, is improved. The appropriation of natural resources and the waste of assimilative capacity for the same welfare level decrease. As a result, ecological, economic and social sustainability is improved – a prerequisite for development within the planetary boundaries.

Abbreviations

BAPF; Biophysically Anchored Production Functions, GDP; Gross Domestic Product, NC; natural capital, NCD; non-communicable diseases, NR; natural resources, SDG; Sustainable Development Goals, WHO; World Health Organisation, UNEP; United Nations Environment Programme

Acknowledgements

We are most grateful for the useful comments on the manuscript made by Professor Jon Karlsson, Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, Gothenburg. The Department of Prosthetics & Orthotics at Sahlgrenska University Hospital, Gothenburg, Sweden, encouraged the project. Thanks to all co-workers at the department and to graphic designer Pontus Andersson.

Availability of data and materials

Not applicable.

Authors’ contributions

S.H and U.H.T wrote the main manuscript text. S.H. prepared Figure 1. U.H.T prepared Table 1. All the authors reviewed the manuscript.

Funding

This research was supported by by Stiftelsen Promobilia, Stiftelsen Skobranschens Utvecklingsfond, the Research and Development Council of the County of Göteborg and Södra Bohuslän, the Health & Medical Care Committee of the Västra Götaland Region, Stiftelsen Felix Neubergh, Stiftelsen Gunnar Holmgrens Minne, IngaBritt & Arne Lundbergs Forskningsstiftelse, Adlerbertska forskningsstiftelsen, Diabetesfonden, the Gothenburg Diabetes Association (Inger Hultman med fleras fond and Utvecklingsfonden) and Sveriges Ortopedingenjörers Förening, Greta och Einar Askers Stiftelse and Hans Dahlbergs stiftelse för miljö och hälsa.

Competing interests

S.H. manages Nolby Ekostrategi but does not consider this to be a conflict of interest in this work. UT declares no competing interests.

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Conservative surgical management in an extreme diabetic foot case

by JM García-Sánchez1, A Ruiz-Valls1, A Sánchez-García1, A Pérez-García1

The Foot and Ankle Online Journal 11 (1): 2

Diabetes mellitus is one of the most prevalent diseases worldwide and an important cause of morbidity and mortality. Of relevance, due to its complicated management, morbidity and cost associated, is the diabetic foot. Here we present a case of a 51 year-old male diagnosed with  long-standing decompensated Diabetes mellitus with a 2 year history of a foot ulcer. After debridement of the ulcer, preservation of the bony structure was achieved by covering it with a fillet flap. The therapeutic management in patients with advanced diabetic foot should be individualized based on patient characteristics. Oftentimes, conservative amputations entail the need of complex surgical techniques, however, it allows the patient to retain their independence and an improved quality of life.

Keywords: diabetic foot, ulcer,  diabetes mellitus, fillet flap

ISSN 1941-6806
doi: 10.3827/faoj.2018.1101.0002

1 – Department of Plastic, Reconstructive and Aesthetic Surgery, Hospital Universitari i Politèctnic la Fe, Valencia, Spain.
* – Corresponding author: alejruvall@gmail.com


Diabetes mellitus (DM) is one of the most common diseases worldwide with a global prevalence of 8.5%, and increasing every year. Sustained hyperglycemia derives in numerous complications, mostly caused by macro and microangiopathy [1], of special importance are Diabetic Foot Ulcers (DFUs).

Diabetic Foot Ulcers represent an important healthcare issue due to the elevated morbidity, complexity of its management and elevated costs associated with this disease [2]. DFUs have a global prevalence of 6.3% and have a higher prevalence in DM type 2 and male patients [3]. Neuropathy is the most important risk factor for the development of DFUs. Moreover, the addition of different factors such as the of loss of skin integrity, existence of foot deformities (Hallux Valgus, Charcot’s arthropathy, etc.), and peripheral vascular disease ultimately lead to the formation of DFUs [4].  

The course of healing the DFU is arduous due to the impaired cicatrization and granulation processes in these patients, which is frequently complicated with superimposed infections.  Some cases, especially when osteomyelitis is present, require limb amputation as the sole therapeutic option. However, it is imperative to remain as conservative as possible, since amputations suppose a great psychological and functional impact that can pose a decrease in quality of life.

Here we present a case of a patient with a complicated DFU that was managed with conservative surgical treatment without undergoing amputation.

Case Report

A 51 year old male was first evaluated in the outpatient setting for a 1-year history of a DFU on the right foot. His medical history included a atrial fibrillation, dyslipidemia, hypertension, and a poorly controlled insulin-dependent DM with development of retinopathy, nephropathy and cardiac disease. The patient was also an active smoker with over 30 years of smoking history. A transmetatarsal amputation from the 2nd to the 5th toes on the right foot was previously carried out in a different hospital due to inadequate healing of a DFU. The surgical wound was complicated with a dehiscence, which remained as an ulcer that impeded the patient from ambulating.

The physical examination showed a lateral subluxation of the first metatarsophalangeal joint, an ulcer on the amputation stump, with granulation on the base and no inflammatory signs, proliferative signs, dermatosclerosis or hyperpigmentation of the skin edges (Figure 1). Additionally, the patient presented signs of chronic venous insufficiency, hence the induration hindered lower limb distal pulse examination. Plantar protective sensation was severely diminished.

An MRI was performed, which showed findings suggestive of osteomyelitis of the remnants of the 3rd, 4th and 5th toe, the anterior portion of the cuboid bone, and the navicular bone of the right foot. These findings were later confirmed with a gamma scan. The CTA scan showed bilateral permeability of the aortoiliac, femoropopliteal, and distal infrapopliteal trunks.

Given these findings a new surgical approach was conducted, with resection of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone (Figure 2), a fillet flap from the hallucis and the plantar skin was performed to provide coverage of the cutaneous defect (Figure 3).

The pathology report indicated the presence of a verrucous squamous cell carcinoma. However, no infiltrative component was seen in the specimen and the margins were disease free.

Figure 1 A 51 year old male with a lateral luxation of the metatarsophalangeal joint of the hallucis (Left). Ulcer presence on the amputation stump (Right). Frontal (Left) and plantar (Right) view.

Figure 2 Surgical excision of the remnants of the 2nd to 5th toes, cuboid bone, cuneiform bones, as well as the anterior portion of the navicular bone.

The postoperative course was uneventful with a favorable healing towards the resolution of the surgical wound, which was supported by a tight glucose control and a smoking cessation program. Two months after the intervention the patient has a healthy-appearing stump that allows ambulation (Figure 4).

Figure 3 Foot defect after resection (Left). Coverage with a fillet flap from the hallucis and the plantar skin (Right).

Figure 4 Postoperative result two months after the intervention. Frontal (Left) and posterior (Right) view.

Discussion

Complicated diabetic foot poses a risk of amputation and early mortality in diabetic patients. With a 10-fold increase in amputation rate of the lower limb for diabetic patients, according to WHO. Furthermore, the mortality rate is also increased 3-fold within a year of the amputation compared to non-amputated diabetic patients [6].

The course of DFUs is usually difficult owing to a deficient granulation and cicatrization, and commonly complicated with superimposed infections. DFUs that persist over time can sometimes lead to malignant transformation; most frequently squamous cell carcinoma [5]. All of these result in wide surgical excisions and, sometimes inevitably amputations.

There are different amputation levels of the lower limb, those that result in above-the-ankle amputation are considered major amputations, and those that spare the ankle are defined as minor amputations [7]. Regarding amputation-related-mortality, Evans et al, showed a mortality of 20% in the 2-year follow-up after a minor amputation compared to the 52% seen in patients who underwent a major amputation [8].

Numerous studies support the need to be as surgically conservative as possible, with limb conservation procedures, since energetic output is increased progressively as an amputation becomes more proximal [9]. Moreover, several patients present with several comorbidities, as in the case presented, and are non-candidates for rehabilitation after major amputations. Hence, preservation of the majority of the limb with partial minor amputations can result in an improved functional status [10]. Likewise, minor amputations may confer the possibility to ambulate for short distances without the need of prosthesis, allowing the patient to perform many daily-living activities, and thus, having a major impact on quality of life [8].  In some cases, in order to achieve minor amputations, the complexity of the surgical techniques is considerably higher and are often unconventional procedures that surgeons might not be familiarized with. In the case presented, due to patient conditions, impaired sensibility, presence of osteomyelitis, and the condition of the foot soft tissues, initially the decision was to perform a major amputation. Nevertheless, the scarce possibilities for adaptation to a prosthetic device and ambulation after amputation, a more conservative approach was planned. Therefore, preservation of the non-osteomyelitic bone and coverage of the skin defect with an adipocutaneous fillet flap from the hallux and the plantar surface provided a stable coverage without any added morbidity.

The fillet flap is well described in the literature as an alternative for large defects that require coverage without sacrificing the length of the extremity [11].  It provides superb mechanical stability plus an added quasi-normal sensitivity to the stump. Additionally, utilizing plantar tissue also provides an excellent, and long-lasting, surface for the stump [12].

Conclusion

Diabetic patients with DFUs should undergo individualized treatment based on their characteristics. In certain cases, a more conservative amputation, despite being more technically challenging, allows the patient to have a better quality of life as well as more independence.

Conflict of interest declaration

No conflict of interest to disclose.

References

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  2. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. Ann Med. 2017 Mar;49(2):106–16.
  3. Al-Rubeaan K, Al Derwish M, Ouizi S, Youssef AM, Subhani SN, Ibrahim HM, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PloS One. 2015;10(5):e0124446.
  4. Allen L, Powell-Cope G, Mbah A, Bulat T, Njoh E. A Retrospective Review of Adverse Events Related to Diabetic Foot Ulcers. Ostomy Wound Manage. 2017 Jun;63(6):30–3.
  5. Scatena A, Zampa V, Fanelli G, Iacopi E, Piaggesi A. A Metastatic Squamous Cell Carcinoma in a Diabetic Foot: Case Report. Int J Low Extrem Wounds. 2016 Jun;15(2):155–7.
  6. Hoffstad O, Mitra N, Walsh J, Margolis DJ. Diabetes, Lower-Extremity Amputation, and Death. Diabetes Care. 2015 Oct;38(10):1852–7.
  7. Wukich DK, Hobizal KB, Brooks MM. Severity of Diabetic Foot Infection and Rate of Limb Salvage. Foot Ankle Int. 2013 Mar;34(3):351–8.
  8. Evans KK, Attinger CE, Al-Attar A, Salgado C, Chu CK, Mardini S, et al. The importance of limb preservation in the diabetic population. J Diabetes Complications. 2011 Jul;25(4):227–31.
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  11. Chung S-R, Wong KL, Cheah AEJ. The lateral lesser toe fillet flap for diabetic foot soft tissue closure: surgical technique and case report. Diabetic Foot Ankle. 2014 Jan;5(1):25732.
  12. Janssen D, Adolfsson T, Mani M, Rodriguez-Lorenzo A. Use of a pedicled fillet foot flap for knee preservation in severe lower extremity trauma: A case report and literature review. Case Rep Plast Surg Hand Surg. 2015 Dec 23;2(3–4):73–6.

Bilateral Charcot neuroarthropathy, a challenge for diagnosis and treatment

by Nathalie Denecker1*, Dimitri Aerden2, Michel De Maeseneer3pdflrg

The Foot and Ankle Online Journal 9 (1): 6

Charcot neuroarthropathy is a devastating foot disorder whose differential diagnosis with infectious, bone or articular disease is difficult. We report a rare case of a woman with diabetes who developed bilateral Charcot neuroarthropathy after erysipelas of her left leg and subsequent trauma, which complicated diagnosis as well as efficient off-loading.

Key words: bilateral Charcot foot, diabetic foot, diabetic neuropathy, off-loading

ISSN 1941-6806
doi: 10.3827/faoj.2016.0901.0006

1,2 – UZ Brussel, Diabetic foot clinic, Laarbeeklaan, 101, 1090 Brussel, BELGIE
3 – UZ Brussel, Radiology department Laarbeeklaan, 101, 1090 Brussel, BELGIE
* – Correspondence: Nathalie Denecker nathalie.denecker@uzbrussel.be


Charcot neuroarthropathy (CN) of the foot is a rare but debilitating disorder that affects bones, joints and soft tissues and leads to significant deformity unless diagnosis is established early. We report a case of bilateral synchronous CN that proved particularly challenging because diagnosis was obfuscated 1) by bilateral symptomatology and 2) a preceding erysipelas. In addition, we had no prior experience in off-loading both limbs simultaneously.

Case report

A 58-year old woman with insulin dependent type 2 diabetes and lower limb neuropathy presented to the emergency department with fever and erythema of the left leg. The limb was erythematous and warm with a plantar neuropathic ulcer on the left hallux. Distal pulses were detected bilaterally. Blood sampling showed overt inflammation. The diagnosis of erysipelas was established with the toe ulcer as entry point. A wound smear revealed Pseudomonas aeruginosa for which intravenous antibiotics were administered for 8 days. She returned with increased oedema and pain of her leg two weeks later, although inflammatory blood parameters had normalised.

Ten days later inflammatory symptoms had persisted and spread to the contralateral foot and ankle: both feet now were swollen, red and warm, and some bruises from a recent trauma were detected. X-rays of both feet were normal. A bone scintigraphy with SPECT-CT (Single Photon Emission Computed Tomography) was suggestive for CN of both feet, with tracer uptake in the midfoot (Figure 1a) and small bony fragments on CT (Figure 1b). Hotspots over the 2nd metatarsal heads bilaterally raised the possibility of underlying osteomyelitis.

Bilateral immobilization with total contact casts (TCC) was deemed impracticable. Hence, the left foot was treated with a removable air-cushioned cast (Aircast®) but this required the patient to be hospitalized. Oedema of the tarsus and metatarsal bases shown on magnetic resonance imaging (MRI) confirmed bilateral CN (Figure 2a) but osteomyelitis of the 2nd metatarsal head was rejected by leucocyte scan with SPECT-CT. Transfer to a rehabilitation centre and regular ambulatory appointments to renew the TCC were initiated. Three months later clinical inflammatory signs and oedema of the midfoot on control MRI had decreased, although increased oedema was observed at the talar bone bilaterally (Figure 2b). Off-loading was continued with bilateral Aircast® walkers for another 3 months until orthopaedic shoes became available. Final ambulatory rehabilitation was satisfactory.

1a1b

Figure 1 (a) Bone scintigraphy shows tracer uptake in the midfoot and 2nd metatarsal heads bilaterally. (b) Irregular margins and bone fragments in the midfoot are seen on SPECT-CT.

Discussion

Charcot neuroarthropathy or Charcot foot is a devastating complication of neuropathy which is mostly seen as a rare complication of longstanding diabetes [1-5]. Men and women are equally affected [2,6]. Until recently, the prevailing hypothesis for pathogenesis was neurotraumatic or neurovascular [2,7,8]. Authors have observed however that CN is also associated with an enhanced inflammatory response, presumably triggered by minor trauma, prior infection, ulceration or foot surgery. Pro-inflammatory cytokines (TNF-α, IL-1ß) are released and lead to increased expression of receptor activator of nuclear factor-κB (RANK) ligand, thereby activating NF-κB (Nuclear Factor κB), a potent promotor of osteoclastic activity which promotes osteolysis and fractures [1,2,8,9].

The prevalence of CN is underestimated but affects less than 1% of all patients with diabetes [6,8-10]. Moreover, local inflammation is inhibited by limited arterial inflow, a frequent occurrence in patients prone to macrovascular disease [9]. Ipsilateral recurrence of CN is rare [10]. Over several years, contralateral CN may occur in 20% to 30% [6,7,11]. Off-loading of the index foot has been suggested as the initiating event that may develop CN at the contralateral foot [11].

2a2b

Figure 2 (a) MRI of the right foot initially shows bone marrow oedema of the tarsus and metatarsal bases. (b) Three months later oedema in the original regions has improved but is now more prominent in the talar bone.

Diagnosis of acute Charcot foot is primarily established clinically because no specific laboratory tests are available: a unilateral red, warm, swollen foot that is remarkably painless due to neuropathy. Differential diagnosis should be made with infection (cellulitis, osteomyelitis, arthritis, abscess), acute gout, deep venous thrombosis and trauma (sprain, fracture) [1-4,11,12]. Imaging techniques are helpful but X-rays lack sensitivity during the first weeks. The sensitivity of bone scintigraphy is superior and its low specificity is improved by SPECT-CT. MRI has diagnostic accuracy in the early stages and allows differentiation from osteomyelitis [1-3,11]. According to literature, the diagnosis of CN may be missed in 79% and delayed up to 29 weeks [11]. Unfortunately, early recognition of CN and prompt treatment is mandatory to prevent foot deformation.

Rapid immobilisation of the affected foot is paramount and accomplished best by TCC, the gold standard for off-loading [1,13]. A removable pneumatic walker achieves comparable off-loading but non-compliance remains a problem [4,10]. Immobilisation is advised until clinical signs have resolved and a temperature difference of <2°C between feet is recorded [1,9,14]. In general, this occurs after 3-12 months, with 6 months being most common [10,11,14]. Bisphosphonates which inhibit bone resorption have been suggested as adjunctive therapy but current data do not support their routine use [5].

Bilateral synchronous CN as reported in the presented case is not only an extremely rare occurrence, but also greatly complicates diagnosis and subsequent immobilisation/off-loading. To our knowledge, only one similar case has previously been reported: a man in which contralateral CN presumably was elicited two weeks after off-loading his index foot with a TCC [12]. In our case, a skin infection probably triggered CN on the index side which unfortunately also delayed diagnosis. On the contralateral side both the overloading of the right foot due to pain on the left side, or trauma may have been the trigger for CN. The number of radiological exams that had to be performed, and their conflicting findings demonstrate how difficult a diagnosis can be. Long-term immobilisation and off-loading of both limbs was extremely debilitating to our patient and justified hospitalisation in a rehabilitation centre.

In summary, diagnosis of acute Charcot foot is challenging, especially when triggered by prior infection or trauma. Bilateral CN, although extremely rare, further complicates the diagnosis as well as efficient off-loading and immobilisation.

References

  1. Rogers LC, Frykberg RG, Armstrong DG, Boulton AJM, Edmonds M, Van Ha et al. The Charcot Foot in Diabetes. Diabetes Care 2011; 34(9): 2123–2129. (PubMed)
  2. Gouveri E, Papanas N. Charcot osteoarthropathy in diabetes: A brief review with an emphasis on clinical practice. World J Diabetes 2011; 2(5): 59–65. (PubMed)
  3. Botek G, Anderson MA, Taylor R. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleve Clin J Med 2010; 77(9): 593-599. (PubMed)
  4. Pinzur MS. Current concepts review: Charcot arthropathy of the foot and ankle. Foot Ankle Int 2007; 28(8):952-9. (PubMed)
  5. Richard JL, Almasri M, Schuldiner S. Treatment of acute Charcot foot with bisphosphonates: a systematic review of the literature. Diabetologia 2012; 55: 1258–1264. (PubMed)
  6. Hartemann-Heurtier A, Van GH, Grimaldi A. The Charcot foot. Lancet 2002; 360: 1776-1779. (PubMed)
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  10. Christensen TM, Gade-Rasmussen B, Pedersen LW, Hommel E, Holstein PE, Svendsen OL. Duration of off-loading and recurrence rate in Charcot osteo-arthropathy treated with less restrictive regimen with removable walker. J Diabetes Complications 2012; 26(5): 430-434. (PubMed)
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Foot Infections in the Veterans Health Administration

by Priya P. Sundararajan DPM, FACFAS1, Barbara M. Porter DPM2, Keith A. Grant Ph.D3, Jeffrey M. Robbins DPM4pdflrg

The Foot and Ankle Online Journal 8 (3): 1

BACKGROUND: Foot infections represent a major health concern in the Veterans Health Administration as they often may lead to limb loss. A majority of these infections are associated with diabetes in the form of diabetic foot ulcers. The diabetic foot infection is associated with a substantial mortality rate and often requires amputation to fully address the nidus of infection.
METHODS: A retrospective chart analysis of all surgeries to treat foot infections in an 18-month period was conducted. Multiple variables- patient location, preventative primary care diabetic foot screenings, routine follow-up by a foot-care specialist, and pre-operative hospital admission- were reviewed and recorded. The data was analyzed using a one-tailed z-test and chi-squared tests. The one-tailed z-test provided a facility-specific data analysis highlighting areas which may benefit from education or assistance in terms of resource allocation. The chi-squared tests reveal generalizable findings regarding the association among primary care diabetic foot screenings, routine follow-up by a foot-care specialist, and the need for pre-operative admission.
RESULTS: Results show an absence of routine follow-up by a foot-care specialist is associated with a statistically higher rate of patients requiring pre-operative admission. Conversely, those patients with routine follow-up required fewer admissions. Though not significant at conventional levels, a higher percentage of patients without the primary care diabetic foot exams also lacked specialty follow-up and necessitated pre-operative hospital admission when compared to patients with the screenings.
CONCLUSION: This study provides an example of methodology reviewing pedal infection-related surgical data to perform effective limb loss prevention in the VHA setting. The generalizable results elucidate the role of the primary care and foot-care specialists in preventative medicine thereby avoiding a hospital admission. The current study suggests that a close, collaborative, patient-centered approach between primary care and podiatry results in better outcomes for patients.

Key words infection, ulcer, diabetic foot, veteran, amputation

ISSN 1941-6806
doi: 10.3827/faoj.2015.0803.0001

Address correspondence to: Priya P. Sundararajan DPM, FACFAS
[1] Director of Podiatry, Wilmington VA Medical Center, Department of Surgery, 302-994-2511, 1601 Kirkwood Highway Wilmington, DE 19805, Priya.Sundararajan@va.gov
[2] Podiatric Surgeon, Wilmington VA Medical Center, Department of Surgery,  302-994-2511, 1601 Kirkwood Highway Wilmington, DE 19805, Barbara.Porter3@va.gov
[3] Assistant Professor, James Madison University Department of Political Science, 540-568-4336, 91 E Grace St., MSC 7705 Harrisonburg, VA 22807, GrantKA@jmu.edu
[4] Director, Podiatry Service Veterans Affairs Central Office; Professor of Podiatric Medicine, Kent State University College of Podiatric Medicine; Clinical Assistant Professor, Case Western Reserve University School of Medicine; 216-791-3800, Louis Stokes VA Medical Center, 10701 East Boulevard Cleveland, OH 44106, Jeffrey.Robbins@va.gov


Foot infections are a major health issue in the Veterans Health Administration as they often jeopardize limb preservation and shorten the patient’s lifespan. A majority of these infections are associated with diabetes in the form of diabetic foot ulcers (DFU). The excessively high 5-year mortality rate associated with patients with diabetic ulcers reaches upwards of 55% [1]. With chronicity, the DFU transitions to bone infection. A festering oste-omyelitis further propagates the pedal nidus of infec-tion resulting in a statistically higher rate of fatal sys-temic disease such as heart attack or stroke [2,3,4]. Consequently, 45% of all patients with a diabetic ulcer require surgery, often times a pedal amputation, to address the nidus of infection and reach resolution of symptoms [5]. Effective preventative care can maximize limb preservation and improve life expectancy.

As the single largest health care system in the United States, the Veterans Health Administration (VHA) is working to meet the complex needs of this dramatically increasing pathology [6]. Primary care providers, podiatric surgeons, general surgeons, vascular surgeons, infectious disease physicians, and wound care nurses are integrated in the treatment of the diabetic foot infection.  In the enormity of the VHA system, providers can be oblivious to the amputation-related statistics that may improve patient outcomes.  A facility-specific assessment allows providers to better understand the events leading up to the amputation and prevent long-term loss of follow-up. Such evidence can inform future strategies to effect better prevention and management of the DFU pathology. The aim of this study is two-fold: 1) to provide an example of a retrospective statistical analysis assessing facility-specific data regarding preventative care and patient outcomes for the benefit of other VHA facilities and 2) to understand the associations among preventative primary care diabetic (PC DM) foot exams, routine follow-up by a foot-care specialist, and pre-operative hospital admission in the VHA setting.

Methods

A retrospective analysis of all surgeries to address pedal ulceration infections between January 1, 2013 and June 30, 2014 were analyzed using one-tailed z-tests and chi-squared tests. The following data was collected for each infection-related pedal surgery: chronological surgery number, chronological patient number, location following the patient, whether a preventative PC DM foot exam was performed, whether the patient’s condition required pre-operative hospital admission, if so the date of admission and the reason necessitating admission, dates of podiatric/surgical/wound care follow-ups the patient had prior to admission or surgery (in the case of no admission), whether the patient was routinely followed or not followed by a foot-care specialist prior to surgery, the date of surgery, and an update regarding the patient’s condition.  Patients who went on to have further limb amputation or endured further complication related to the pedal infection were classified as “poor prognosis.” On the contrary, patients who healed the surgical sites were classified as “healed surgical site.” A description of the data collected is detailed and summarized in Table 1 (see supplement within PDF). Table 1 was analyzed using both one-tailed z-tests (Table 2) to understand facility-specific trends and chi-squared tests (Table 3-5) to examine the association between PC DM foot screenings, routine follow-up by a foot-care specialist, and pre-operative hospital admissions.

The locations from which the patient was referred included the main medical center: Wilmington, surrounding community based outpatient clinics (CBOC) A, B, C, and D, and a nursing home: Community Living Center (CLC). The CBOC facility location was withheld for this publication. Some patients were also referred from the neighboring Coatesville VA medical center.  Patient follow-up data was not readily available from this facility, leading to the exclusion of patients originating from this location from the analysis. The variables (PC DM foot screening, specialty follow-up, admission, and surgery) measured in each facility were compared against each location’s outpatient population share as the base value (Table 2). Additional analysis was also performed to test for dependencies between the variables: preventative PC DM foot exams, specialty follow-up prior to surgery, and pre-operative hospital admissions (Tables 3-5).

The PC DM foot exam is a clinical reminder to be completed by the primary care provider as required by “VA/DoD Clinical Practice Guidelines for the Management of Diabetes Mellitus in Primary Care“ [7]. This reminder ensures that DFU prevention is performed in the primary care sector. This alert is only activated at the anniversary of the patient’s last exam. The alert remains active until the test is performed by the provider at which point the test is de-activated for another calendar year.  If the PC DM foot exam was either not performed or performed within a week of admission or surgery, the exam was considered non-preventative as it served no preventative use once the patient required surgical intervention.

table2

Table 2 One-tailed test comparing the variables measured in each location. Statistical significant findings are in bold.  Down-arrow: Findings are statistically lower than expected. Up-arrow: Findings are statistically higher than expected.

table3

Table 3 Χ2 = 9.9676, p = 0.008.  A statistically significant relationship was found between patients who were not followed by a foot-care specialist and those who were admitted.

The specialty follow-up dates, (as listed in column 5 in Table 1), dictated if the patient was adequately followed by a foot-care specialist (as noted in the adjacent column, column 6). By recording the patients’ last 3 podiatry, surgery, or wound care visits, the investigators were able to assess if the patient had regular follow-ups prior to surgery.  At these visits, all components of the diabetic foot exam were assessed. ADA guidelines suggest that a high-risk patient with a history of amputation or ulceration be seen by a specialist every 1-2 months [8]. To give the patients and providers some leeway, the patient was considered “not followed” if he/she was not seen within 3 months preceding admission or surgery.

table4

Table 4 Χ2 = 2.0563, p=0.152. No statistically significant association was found between patients who did not have a PC DM foot screening and those who were not followed by a foot-care specialist. However a higher percentage of patients who had a PC DM foot exam were also followed by a foot-care specialist. The converse also held true.

 table5

Table 5 Χ2 = 1.6067, p=0.205. No statistically significant association was found between patients who did not have a PC DM foot screening and those who were admitted. However a higher percentage of patients with no PC DM foot exam were admitted compared to patients with a PC DM foot exam. Similarly, most of the patients who were not admitted had a prior PC DM foot screening.

Results

Over the 18-month period, 53 surgeries were performed to treat foot infections on 44 patients. Of these surgeries, 92% were amputations (n=49). Fifty-six percent of the surgeries (n=30) required pre-operative admission. Of the admissions, 95.8% occurred secondary to a foot infection. Only 3.7% of the surgeries were performed on non-diabetic patients (n=2). Forty-four percent of the surgeries were performed on patients who were not followed regularly (<3 months). As a result of foot infection, 7.5% of the pedal surgeries (n=4) were associated with further limb amputation. Five of the surgeries were classified as “poor prognosis”, i.e. the patient was expected to or did lose limb or life and was associated with an unresolved pedal infection. One of these patients, healed the surgical site but subsequently developed severe hypotension, multiple bodily pressure lesions, and died from septic shock.

The one-tailed z-test was used to identify patterns within the variables that were disproportionate to that facility’s population share.  For example, a CBOC serving 15% of the population would be expected to account for 15% of the performed surgeries.  This location-specific analysis demonstrates significantly fewer infection-related pedal surgeries, missing PC DM foot exams, and pre-operative admissions out of the Wilmington facility than would be expected relative to its population share alone (table 1).  In contrast, CBOC A has a significantly higher rate of surgeries, missing PC DM foot exams, and admissions than its population share would suggest.  CBOC C also has more admissions than would be expected, but the number of surgeries and missing PC DM foot exams are not overly disproportionate to its population. Additionally, a higher than expected number of patients were regularly followed in CBOC C prior to surgery. As expected with the typical nursing home population, the CLC has a higher rate of surgery, specialty follow-up, pre-operative admissions, and poor prognosis (60%).  No significant findings were noted in CBOC B and D.

Although the above results are idiosyncratic to the Wilmington medical center and surrounding CBOCs, patterns identified in the aggregate data are generalizable to other VHA systems. Chi-squared tests were used to assess bivariate statistical dependencies in which the presence or absence of one factor influences the rate with which another factor occurs. Analysis confirmed a significant relationship (p=0.008) between patients who were not followed by a foot-care specialist to those who necessitate pre-operative admission (table 2). The observed relationship suggests that high-risk patients who are not routinely followed by a foot-care specialist are more likely to require admission than those who are routinely followed. In fact, the odds of a patient without routine specialty follow-up requiring pre-operative admission is roughly 7.5 times higher than for a followed patient.  No statistically significant relationship was found between patients without PC DM foot screenings and those followed (p=0.152) and admitted (p=0.205) at conventional levels (table 3, 4). However based on percentages, certain trends among these variables seem apparent.  Patients without the preventative PC DM foot screenings tended to also lack follow-up by a foot-care specialist (table 3). The converse also held true. Similarly, a higher percentage of the patients without the PC DM foot exam required pre-operative hospital admission when compared to patients with the screening (Table 4).

The Wilmington facility was associated with statistically fewer infection-related pedal surgeries, fewer missing PC DM foot exams, and fewer admissions than its population share would suggest. This site had fewer adverse events preceding the patient’s surgery and overall fared better in the preventative arena than its CBOC counterparts. These comparatively better outcomes coincided with the most resource-intensive location. As a result, the Wilmington facility assisted in the evaluation in slow or non-healing ulcer patients from the CBOC facilities.

The overlap between CBOC C patients who required surgery and those were admitted was 100%. Moreover, 85% of these surgeries were associated with routine follow-up prior to surgery. These clinical outcomes are suggestive of a lack of efficacy in preventative care in this location.  In CBOC A, 87.5% of surgeries required pre-operative admission, which is significantly higher than would be expected based on its population share. Our solution was to request the foot-care specialists in both CBOC A and C to send all non-healing ulcers with a duration greater than 3 months to Wilmington for evaluation and possible treatment.  In terms of resource allocation, funds for part-time nail technician were requested for CBOC A and C to allow the providers to focus on the higher risk patient population. Additionally, 75% of surgeries out of CBOC A did not have preventative PC DM foot evaluations in the year prior to surgery. Our remedy was to present a facility-wide educational lecture discussing these results and the importance of preventative care in the treatment of DFU.

As expected, patients residing in the CLC were associated with a higher rate of pedal surgery with subsequent limb amputation. With its census of patients who are elderly, immobilized, poorly-vascularized, non-responsive, or systemically complicated, a proper treatment addressing the nidus of infection is often not accomplished. We advised the dedicated CLC wound care nurse who performs weekly wound assessments to consult podiatric or general surgery for new wounds in a timely manner. In addition, the Wilmington wound care nurses have assisted in CLC management and prevention of ulcers.

Discussion

The current study demonstrates the value of collaboration between primary care and specialty care for the treatment of diabetic foot infections in the VHA setting. It is the first in its class to present an example of methodology reviewing pedal amputation and infection-related surgical data for limb loss prevention in the integrated VHA system. This facility-specific research focusing on the circumstances surrounding surgery was conducted to assess the efficacy of preventative measures and effect change to better patient outcomes. As it stands today, data collection and analysis for the purpose of limb preservation is not a routine occurrence in the VHA. The present study uses the data collected to highlight areas of concern and allow implementation of minor changes to effectively manage high-risk diabetic patients.  This methodology can be applied in any facility and may directly impact departmental reorganization, resource allocation, and provider or patient education. The present research is also suggestive of a collaborative relationship between of primary care and foot-care specialists in the management and mitigation of diabetic pedal infections. Prior to this study, the associations of these variables and the need for pre-operative hospital admission were not evident. Our results encourage a partnership between primary care providers and foot-care specialists, including podiatrists, general surgeons, and wound care specialists for early detection of pedal infections, thereby minimizing the need for pre-operative hospital admissions in VHA facilities.

Results indicate CBOC A was associated with a higher rate of surgical interventions for foot infections as well as a lower rate of completed preventative PC DM foot exams. One explanation suggests that fewer providers examining the diabetic foot may lead to undetected foot ulcers, propagate the infection, and result in an amputation. Previous studies have indicated that an increased number of providers examining the diabetic foot resulted in fewer infection-related surgeries [9,10]. A study originating in Sweden demonstrates a lower amputation rate in a region in which patients were referred by a variety of providers in contrast to only referrals from general practitioners, suggesting that the more providers examine the diabetic foot, the earlier infection is treated [9]. Another analysis documents the reduced rate of amputation with early detection of DFU [11]. With the addition of nail technicians, we increase the number of providers examining the diabetic foot. Along with the current study, these investigations illustrate the importance of cross-collaboration between specialties for the early detection and subsequent referral to a specialized diabetic wound care team.

Patients originating from CBOC C were routinely followed prior to surgery but nonetheless required admission prior to surgical intervention. This finding questions the efficacy of preventative treatment received in this facility and is suggestive of the need for education, resources, or further referral to a more specialized team. Similarly, CBOC A was associated with a significantly higher than expected rate of surgeries and admissions. As a hospital admission rather than an outpatient consult usually confers a more serious infection, the presumption that superficial infections are permitted to devolve into deeper more consequential infections is suggested. One plausible hypothesis to explain the higher rate of amputations is that care may not be adequately appropriated for the higher risk patients. Often times, VA podiatric providers are inundated with the lower risk routine nail patients leaving limited resources available for the higher risk patients with ulcers.  The American Diabetes Association task force recommends that high-risk patients (history of ulceration/amputation) be evaluated by a foot-care specialist every 1-2 months, whereas low risk diabetic patients may be evaluated annually by a primary care provider or specialist when necessary [8,12-14]. The addition of a nail technician in CBOC A and C could offload the low-risk patients allowing the providers to focus on the patients at a higher risk for amputation. Moreover, the request for the CBOC facilities to refer their long-standing DFU (> 3months) to the Wilmington facility benefits the CBOC patients. With the Wilmington facility having statistically lower rates of infection-related surgeries and admissions, the patients in the lesser performing facilities are likely to have more positive clinical outcomes with an earlier referral.

The purpose of the study was not necessarily to avoid pedal amputation but to maintain optimal compliance in the events preceding the surgery. Many providers have associated the word “amputation” with a negative connotation as in the case of “amputation prevention.” However evidence-based medicine suggests that patients who avoid amputation and live with chronic osteomyelitis generate a chronic inflammatory response by triggering vascular atherosclerosis [3,15]. A population-based study in a cohort of 23 million studied the relationship between chronic osteomyelitis and coronary heart disease [15]. Once the researchers controlled for age, gender, hypertension, diabetes, hyperlipidemia, and stroke between the control and chronic osteomyelitis cohorts, they found a significantly elevated risk of heart disease- a 95% increase- as compared to the control population [15]. Similar findings were supported in a meta-analysis study evaluating the association of the DFU and cardiovascular mortality [3]. Results showed a substantially increased risk of all-cause mortality, fatal myocardial infarction, and fatal stroke in patients with DFU [3]. These studies are among the growing number of studies that support a timely resolution of the DFU thereby preventing limb loss and increasing life expectancy [3,15-20]. The 30-day mortality rate, cardiovascular outcomes, and pulmonary events associated with a pedal amputation is substantially lower (4x) than below-knee or above knee amputations [17-20]. The goal is not simply to avoid amputation but to recognize the time-sensitivity of reaching a permanent resolution, thereby broadening our perspective to prioritize limb and life preservation.

Results derived from the full dataset suggest that the more high risk patients are followed by foot-care specialists, the less likely the infection will progress to a degree that necessitates admission (table 2). On the patient-level, routine follow-up generally translates to earlier detection of infection or vascular impairment, fewer systemic complications, and lower potential for nosocomial infections. From the facility standpoint, a substantial financial and economic burden can be obviated for each avoidable hospitalization.  Studies show that on average each hospital admission for a pedal amputation costs the facility is approximately $32,000 [21]. This confirms the role of foot-care specialists in the treatment of diabetic foot infection and limb loss prevention as documented in previous studies [22,23]. The present study also demonstrates a positive trend between PC DM foot screenings and follow-up by a foot-care specialist in the VHA setting (table 3). Thus the domino effect between the absence of PC DM foot screening and patients necessitating pre-operative admission is evident. The direct impact of fewer PC DM foot screenings and a higher rate of admission follows a negative trend, though not statistically significant at a conventional level (table 4). The current study, specific to the VHA system, is among the increasing evidence supporting the interdepartmental collaboration to improve patient outcomes and reduce complications [23-25].

Limitations to this study are inherent to any retrospective analysis in that all variables cannot be examined. Regarding the one-tailed z-test, extraneous variables such a provider methodology, patient non-compliance, reason for lacking specialty follow-up, or location-specific resources such as casts, grafts, or personnel assistance were not assessed. However, these extrinsic factors do not diminish current results highlighting areas that may benefit from assistance or modification. This study provides perspective in regards to the number of surgeries rather than the number of patients. Therefore, some patients had repeat infection-related surgeries; this variable was not assessed.  In regards to the chi-squared tests, the variables studied (specialty follow-up, PC DM foot assessments, and pre-operative admission) are generalizable among the VHA facilities nationwide. However, small sample size biases against statistically significant results. For example, the findings regarding PC DM foot screenings and specialty follow-up or admissions are likely to be significant by conventional standards with a larger sample following the current trends. Future research specific to the treatment of pedal infections or DFU may help determine which strategies and wound therapies will improve amputation prevention in this high-risk population. We encourage all VHA facilities to retrospectively assess the variables affecting patient outcomes and study the associations between these variables to better patient outcomes.

In summary, by focusing on the situations surrounding the surgical treatment of pedal infections or amputation, each facility is able to perform self-assessments to improve patient care. We believe that only with a self-investigative approach can limb preservation be legitimately pursued. By assessing relevant variables we demonstrate the value of foot-care specialists and primary care providers in the treatment of diabetic foot infections in a VHA facility. This patient-centered approach facilitates earlier detection of infection, mitigates systemic complications, decreases the economic burden to the facility, and ultimately minimizes limb loss.  With interdepartmental collaboration, we are able to prioritize limb preservation for veterans who have already sacrificed so much.

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