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Diabetic foot problems are one of the most serious complications of the disease


Pittsburgh Post-Gazette (PA)

05-21-13

May 20--More than a decade of type 2 diabetes has left George Weber without feeling in the bottoms of his feet.

"My biggest problem is at night, when I take the weight off my feet," said the 67-year-old Green Tree man who said his weight tops 300 pounds. "When I'm lying down, they ache."

The good news? Mr. Weber still has his feet and he's anxious to keep them.

In the past three years, circulatory problems in his lower extremities led to neuropathy -- diabetic nerve damage caused by restricted blood flow in the small vessels of the feet. It brought on feelings of pins and needles and numbness. Now Mr. Weber knows that foot inspection and cleaning techniques five days a week are key to preventing wounds that might require a long hospital stay and even an amputation.

"I feel it is very important to care for your feet," Mr. Weber said. "I clean and dry them and make sure there are no ulcers, which are extremely hard to heal when you have diabetes."

Poor circulation and lack of sensation represent a biological conspiracy -- a medical double whammy -- making foot problems one of the most serious diabetes complications and most expensive to treat. When a person cannot feel his or her feet, wounds and ulcers can worsen without the person's knowledge and advance to grotesque levels, which are difficult to treat due to lack of blood circulation. About 100,000 diabetes-related amputations occur in the United States each year.

This all happens at great cost and human toll.

The total annual direct and indirect costs of diabetes health care in the United States are $245 billion and climbing at a rate of 25 percent to 40 percent every four years, the American Diabetes Association states. The annual direct and indirect costs of diabetes foot care, including loss of productivity, increased absenteeism and other social welfare costs, top $80 billion, or a third of the total annual health care cost of diabetes.

Major diabetes complications include heart disease, kidney failure, eye problems and foot problems, "but of all the things that can go wrong with diabetes, what puts you in the hospital most often is a foot infection," said Peter Joseph, chairman of the Allegheny General Hospital podiatry department.

Treating a foot ulcer -- beginning with seeing a podiatrist, then proceeding to a lengthy hospital stay and ultimately ending with amputation -- averages about $300,000, with additional costs for sophisticated and costly prosthetic devices, Dr. Joseph said. Eighty percent of amputations start with a foot ulcer.

But health experts say 90 percent of the hospitalizations and amputations are preventable with daily inspection and cleansing of the feet, along with quick action if problems emerge. Properly fitted shoes are also recommended.

"You want to stop the little red spot before it becomes an ulcer. I treat ulcers all day long. I look at them and shake my head. Did this need to happen?" Dr. Joseph said. "Self-management is key to prevention and key components are daily inspection, daily hygiene and regular sensory testing."

Campaigns for prevention

Dr. Joseph actively advocates the prevention of diabetes foot problems, having traveled over the years to meet with government, hospital and health insurance officials with his message.

In 1989, he and Thomas Michalek, a lawyer and his business partner since they met in Rotary Club, created Dr. Joseph's Self-Management System for the Diabetic Foot that includes a long-handled tool with a brush to clean the top and sides of the feet with attachments including a plastic mirror to inspect the bottoms of the feet, an edged sponge to clean between the toes and a fiber to test for sensation in the foot.

At about $30 per kit, he said, the $300,000 spent on one amputation could instead purchase his kit or another foot management kit for 10,000 patients, reduce the national price tag of diabetes foot care and improve outcomes for patients.

"What moves me the most is that after all these years I enjoy stopping people from losing a foot," Dr. Joseph said.

In his own practice, he said, two or three patients a week have limb-threatening problems requiring hospitalization. He doesn't try selling his product to his patients because many of them cannot afford the cost.

But Medicare and Medicaid, along with health insurance providers, he said, could reduce total diabetes costs by providing a foot-maintenance tool for people with the problem.

In the Diabetes Report Card 2012, issued by the U.S. Centers for Disease Control and Prevention, only 67.5 percent of all U.S. adults with diabetes reported receiving an annual foot exam in 2009-10. The foot exam is only one recommended preventive care practice for patients with diabetes. Others include annual eye exams and daily monitoring of blood glucose.

When doctors and their patients ignore prevention measures, the prognosis becomes more dire.

"Fifty percent of patients have a second amputation within three years of the first amputation, and within five years following the first amputation, 50 percent are dead for whatever reason," he said.

About a decade ago, he and Mr. Michalek met with Medicare officials in Washington, D.C., to advocate efforts to prevent ulcers but left discouraged that such a change in emphasis on prevention would require congressional action.

In December, Dr. Joseph met with Vincent Gordon, deputy secretary for the Office of Medical Assistance Programs in the state Department of Public Welfare. The office administers the Medicaid program in Pennsylvania through managed care organizations.

"In a nutshell, what Dr. Joseph was about was to advocate prevention, good health and for those with diabetes to have access to a tool kit or some form of foot-care management," Mr. Gordon said.

He has arranged for Dr. Joseph to speak at a June meeting of medical directors and community outreach officials for the Medicaid health management organizations in Mechanicsburg, where he will emphasize the low cost of prevention to counter the high cost of treatment.

"I personally was impressed with his passion and commitment to the care of diabetes," Mr. Gordon said of Dr. Joseph. "I'm not sure what drives his passion, but some people are wired to really care, and he seems to be that type of individual.

"We also had another conversation about prevention in general. He is a supporter of eating healthy and making better food choices. The more we talk about diabetes, providers like Dr. Joseph and the tools available, I think it is a good thing not just for Medicaid but for health care in general."

Calculating costs

Gary Gibbons, medical director for the South Shore Hospital Center for Wound Healing in Weymouth, Mass., was part of a research team that published a report on the cost of diabetic foot care.

"Diabetic foot problems impose a major economic burden, and costs increase disproportionately to the severity of the condition," Dr. Gibbons said. "Compared with diabetic patients without foot ulcers, the cost of care for those with foot ulcers is 5.4 times higher in the year after the first ulcer episode and 2.8 times higher in the second year.

"Costs for treating the highest-grade ulcers are eight times higher than are those for treating low-grade ulcers."

The study also noted that physicians are not reimbursed for aggressive efforts to prevent foot problems.

"As is typical with American medicine, you wait till it happens before you treat it," Dr. Gibbons said. "With everything we do, we don't do enough about prevention and preventative care."

The cost of diabetes care is climbing exponentially with the incidence of diabetes rising by 1 percent per year, he said, noting that the American Diabetes Association now says 24 million Americans have type 1 or type 2 diabetes. Nearly 80 million others have prediabetes, which involves elevated blood-sugar levels and other indicators leading to diabetes.

If the trend continues, Dr. Joseph said, one-third of all Americans could have diabetes within two decades.

Besides the physical limitations of diabetes foot problems, the emotional costs are equally severe.

"The emotional costs to the patient include time lost from work, effects on self-esteem and there's a tremendous cost from absenteeism," Dr. Gibbons said. "The emotional consequences are tremendous."

Information about Dr. Joseph's Self-Management System for the Diabetic Foot, is available at 724-378-0881.

David Templeton: dtempleton@post-gazette.com or 412-263-1578.

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(c)2013 the Pittsburgh Post-Gazette

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Copyright Pittsburgh Post-Gazette (PA) 2013

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