Commentary by Kelly R. Reveles PharmD, PhD and Nere Onosode, DPM
“This study demonstrated a dramatic decline in the incidence of diabetic foot infections and lower extremity amputations among patients with diabetic foot infections over a 15-year period,” said senior author Kelly R. Reveles PharmD, PhD, Assistant Professor in the Pharmacotherapy Division at the University of Texas at Austin College of Pharmacy. “These findings are important because reduced diabetes complications result overall improved patient health and substantially reduced costs to the health care system. The findings might also signal that the improved efforts of health care providers to reduce these complications have been successful.”
“This critical study proves that a multidisciplinary team approach that includes a foot and ankle specialist or podiatrist is the most effective way to prevent complications of diabetes and reduce the risk for amputation,” commented Nere Onosode, DPM, Chairman of the Department of Podiatric Medicine and Surgery at Texas Health Presbyterian Hospital in Dallas.
The Incidence of Diabetic Foot Infection
Using ICD-9-CM codes from the U.S. National Hospital Discharge Survey from 1996 to 2010, the researchers identified 1,059,553 discharges with diabetic foot infection over the study period. The incidence of diabetic foot infection fell from 2.3 to 1.1 per 100 diabetes discharges between 1996 and 2010. In addition, the proportion of patients with a lower-extremity amputation decreased from 33.2% to 17.1% during the study period. The primary risk factors for diabetic foot infection were peripheral vascular disease (odds ratio [OR], 2.89), peripheral neuropathy (OR, 2.62), and male sex (OR, 1.67).
Possible Reasons For the Improved Outcome
The improved outcome is likely a result of enhanced efforts to both diagnose diabetes and prevent diabetes complications in the United States, the study authors noted.
“In recent years, there has been enhanced efforts to identify diabetes early and monitor the disease often, thus leading to reduced complications,” Dr. Reveles said. “Some of these efforts include increased annual foot examinations, dental examinations, and blood glucose monitoring.”
In addition, the diagnostic criteria for type 2 diabetes became more stringent during the study period, with revisions to the American Diabetes Association guidelines released in 1997, 2003, and 2010. In addition, previous studies have shown significant increases in annual foot examinations, dental examinations, and blood glucose monitoring over the last decade.
The results also may be linked to the nearly tripling number of diabetes discharges during the study period, which may result in larger diabetic foot infection incidence denominators over time, the authors noted.
“Despite the decline in diabetic foot infections and lower extremity amputations found in this study, these outcomes remain an important public health problem in the United States, and further efforts are needed to reduce these complications of diabetes,” Dr. Reveles emphasized. “This is especially important as the number of patients diagnosed with diabetes increases annually.”
Strategies for Preventing Diabetic Foot Ulcers
“This study is a good indicator that the risk of diabetic foot infections is decreasing; however, other studies show that the incidence of diabetes continued to rise over the last decade,” said Dr. Onosode, who also practices at OrthoCARE Institute in Dallas-Fort Worth, Texas. Given the rising rates of diabetes, many people with diabetes may still be undiagnosed and need education on the importance of diet and exercise and proper foot care. These patients also should be provided with access to health care, Dr. Onosode said.
In addition to patient education, physician education on preventing diabetic foot infections also is needed. In particular, Dr. Onosode said that educating emergency department staff on differentiating a diabetic foot infection from other complications of diabetes like Charcot joint disease is necessary. Early detection and a proper diagnosis, significantly improves the prognosis of these patients. He added that a multidisciplinary team approach to preventing diabetic foot infection and reducing the risk for lower-extremity amputation is best and should include a foot and ankle specialist, endocrinologist, vascular surgeon, and wound care specialists.
November 19, 2015
Duhon BM, Hand EO, Howell CK, Reveles KR. Retrospective cohort study evaluating the incidence of diabetic foot infections among hospitalized adults with diabetes in the United States from 1996-2010. Am J Infect Control. 2015 Nov 3. pii: S0196-6553(15)00985-2. doi: 10.1016/j.ajic.2015.09.012. [Epub ahead of print]