How Can I Maintain My Patient With Diabetes and History of Foot Ulcer in Remission?

Abstract

Patients with diabetes and previous history of ulceration occupy the highest category of risk for reulceration and amputation. Annual recurrence rates of diabetic ulcerations have been reported as high as 34%, 61%, and 70% at 1, 3, and 5 years, respectively, with studies reporting 20% to 58% recurrence rate within 1 year. As the ever growing epidemic of diabetes expands globally, this sequelae of diabetic complication will continue to require increasing resources from the healthcare community to effectively manage. Recent data suggest that removal of preventative podiatric care from statewide reimbursement systems lead to significant and sustained increases in hospital admission (37%), charges (38%), length of stay (23%), and severe aggregate outcomes including amputation, sepsis and death (49%). The addition of comorbidities such as peripheral artery disease, poor nutrition, and non-adherence to preventive therapies not only increase a patient's likelihood for ulcer recurrence, but also cost of care and certainty of hospital admission. Currently, numerous efforts, guidelines, and industry generated products exist to prolong remission from ulceration; however, the clinical science for treating this patient population calls for much more effort. Despite this, data continue to suggest to demonstrate that appropriate follow-up care, shoe and insole modification, and patient education play a central role in reducing reulceration and amputation. Novel modalities for offloading and wearable sensor technologies offer the advantage of round-the-clock, patient specific and active response healthcare. These have the potential to detect, or even prevent, many wounds before they begin.

Implementation of foot thermometry plus mHealth to prevent diabetic foot ulcers: study protocol for a randomized controlled trial

“…These tools have the potential to replace conventional diabetic care approaches in LMICs and to provide wide coverage in both urban and rural areas. We strongly believe that interventions such as the one proposed in this study may be able to extend “ulcer-free days” in patients in diabetic foot remission [ 34 – 36 ].…”

Illustration of Cost Saving Implications of Lower Extremity Nerve Decompression to Prevent Recurrence of Diabetic Foot Ulceration

“…Neuropathic DFU then might be seen once again as potentially "cured" rather than only "in remission." 61…”

Offloading the diabetic foot: toward healing wounds and extending ulcer-free days in remission

“…Figure 2 shows a TCC, the gold standard in offloading neuropathic wounds, which is quite cumbersome for patients and requires significant time and expertise to apply properly. 8 Although effective in patients with moderate ischemia or infection, TCCs are strongly contraindicated in patients with significant peripheral arterial disease. 19 When …”

“…This has the added benefit of preventing patients from being lost to follow-up or prudent at-home care as patients are now tasked with increasing their own "ulcer-free days" and reducing the severity of recurrences rather than simply "remaining healed". [6][7][8] Reducing peak plantar pressures The use of custom footwear for offloading…”