CDC: Rate Of New Diagnosed Diabetes Cases Is Slowing

Fewer people are being diagnosed with diabetes from year to year, according to a recent report by the Centers for Disease Control and Prevention (CDC). The CDC notes that new diabetes cases totaled 1.7 million in 2009 but that number dropped to 1.4 million in 2014.

“Our findings suggest that after decades of continued growth in the prevalence and incidence of diagnosed diabetes, the diabetes epidemic may be beginning to slow for the first time,” notes the CDC report.

While Gerit Mulder, DPM, does not believe the number of patients with diabetes is decreasing, he says as the population stabilizes and does not continue to increase, there would be a concomitant decrease in new cases reported.

“I believe in the next ten years, the total number of diabetics will continue to increase,” says Dr. Mulder, a Professor of Surgery and Orthopedics at the Wound Treatment and Research Center at the University of California, San Diego.

Gary Rothenberg, DPM, says the CDC’s data goes against some of the predictions and projections that the International Diabetes Foundation has about the growth of diabetes over the next few decades. While the CDC focuses on diagnosed cases of diabetes, he notes that the burden of diabetes now and into the future is among the undiagnosed.  

Barry Rosenblum, DPM, says the drop in new cases could possibly be due to a reduction in obesity and a focus on healthier practices. He and Dr. Mulder say changes in the diet of the younger population would be effective in lowering diabetes diagnosis in younger patients.

“To impact diabetes rates, the problem of obesity needs to be addressed,” agrees Dr. Rothenberg, a Clinical Assistant Professor in the Department of Metabolism, Endocrine and Diabetes at the University of Michigan School of Medicine. “This is particularly important among children.”

The CDC emphasizes that diabetes is still an “urgent public health epidemic” that affects over 29 million Americans. It also notes that the rate of new diagnoses of diabetes is increasing in some groups of patients, including African-Americans, Latinos and those with less than a high school education.

Dr. Rosenblum, an Assistant Clinical Professor of Surgery at Harvard Medical School and the Associate Chief of the Division of Podiatric Surgery at Beth Israel Deaconess Medical Center in Boston, notes the aforementioned subset of patients “may not necessarily have access to medical care as readily (as other populations).”

Dr. Mulder adds that diet and lifestyles tend to be less healthy in those socioeconomic groups, a point echoed by research from Arizona State University. In addition, Dr. Rothenberg cites a genetic link with diabetes in African- and Latin-Americans.

The CDC notes that its data “suggest a change in momentum, a turning of the tides,” but Drs. Rosenblum, Mulder and Rothenberg are not so sure. Dr. Rosenblum says the change would need to be apparent over a longer period of time to represent a turning tide of diabetes diagnosis.

“I am not confident that the tides are turning,” says Dr. Rothenberg. “There is still a lot of work to be done. I am still treating too many wounds and doing too many toe amputations.”

Can A Chopart Amputation Help Avert Major Amputation?

By Brian McCurdy, Managing Editor

Chopart amputation is “the last chance to avoid major amputation” for patients with diabetes who have serious foot complications, according to a recent study in the Journal of Foot and Ankle Surgery.

The study focused on 83 patients who had Chopart amputations between 2009 and 2011 with a mean follow-up of 2.8 years. Thirty-eight of 83 patients had gangrene, 31 had abscesses and 14 had osteomyelitis. The study authors note that of 83 patients, 47 healed at a mean period of 164.7 days. In addition, there was ulcer recurrence in 15 patients and 23 patients required a major amputation. The study authors suggested that surgeons consider the Chopart amputation as a viable option for limb salvage in the study’s high-risk population.

Thomas Roukis, DPM, PhD, cites “extremely favorable” experiences with Chopart amputations for neuropathic Charcot midfoot deformity salvage and trauma, but not for those with ischemia and tissue loss. With the Chopart procedure, he says surgeons can attain the best outcomes when performing tendon balancing to limit equinus and varus contracture of the calcaneus from occurring.

Dr. Roukis notes long-term maintenance of functional use of the limb is mutifactorial but the use of protective bracing is important following a Chopart amputation since surgeons remove the forefoot/midfoot and the use of traditional shoe gear and in-shoe orthoses is not possible. He and his colleagues published a review in Foot & Ankle Specialist confirming that patients who have the Chopart procedure can maintain a residual functional limb for more than 12 months with the use of a properly fitting high-profile prosthetic device for lifelong ambulation.

The quality of life for patients following a Chopart amputation is generally good as they maintain the length of the leg and in an emergency could ambulate on the limb without the brace, notes Dr. Roukis, a Fellow and the Immediate Past President of the American College of Foot and Ankle Surgeons. He says most patients prefer their native limb and a brace over a prosthesis for a below-knee amputation.

CMS Reverses Decision On Limiting Prosthetic Coverage

By Brian McCurdy, Managing Editor

The Centers for Medicare and Medicaid Services (CMS) has reversed a decision that would have curtailed patient access to prosthetic lower limbs.

Last summer, CMS had released identical local coverage decisions that could have affected reimbursement for prosthetics, according to Modern Healthcare, which notes that CMS will now work with a group of clinicians and patient advocates to devise a revised policy. Although CMS noted its original decision was not intended to restrict access to medically necessary prostheses, the agency originally suggested that amputees who use a cane or crutches at any point instead of donning their prosthetic limbs had prostheses that were not medically necessary.

The language in the proposed CMS changes was “extremely troubling and would ultimately reduce the potential for amputees to access their community, work, play, and pursue leisure activities. Consequently, their health would decline and their utilization of the healthcare system would unnecessarily increase,” says Ryan Fitzgerald, DPM, FACFAS, who is affiliated with the Greenville Health System Center for Amputation Prevention in Greenville, S.C.  

Dr. Fitzgerald quotes the Amputee Coalition of America, which criticized the fact that under the scrapped decision, Medicare would have no longer considered patients’ potential functional abilities with an appropriate device when determining prosthetic needs. Furthermore, he notes that patients would have received a less functional prosthesis or be denied a device just because they may not have been able to attain the “appearance of a natural gait.”

Medicare currently provides prosthetic coverage based on a patient’s “K level,” which is sometimes ambiguous and determined by a combination of potential and realized skills, needs and abilities of the amputee, according to Todd O’Hare, CPO, PT, one of the managing prosthetists at the Greenville Health System Center for Amputation Prevention. He notes that evidence-based objective measures can correlate with an amputee’s ability and skills.  

“We as prosthetists can perform these evaluation tools but unfortunately CMS does not recognize our documentation to be supportive of determining a patient’s K level,” says Mr. O’Hare.