Understanding And Responding To The Challenges Of Diabetic Foot Care Through A Public Health Lens
Over the past year, physicians of all specialties gained a greater understanding and appreciation for public health and its strong influence over health-care delivery, outcomes and health equity. As we yearn to leave the pandemic in our rearview mirror, I hope the newfound appreciation of public health remains in the forefront.
Diabetes is a public health burden that can lead to devasting complications that decrease quality of life and independence for millions of Americans. Podiatrists play a critical role as advocates for public health with DPMs being essential providers serving the diabetic population. The prevention of adverse diabetic foot outcomes (e.g., ulceration, amputation, hospitalization) is public health in its purest form.
Public health differs from medical care. Public health aims to collectively avoid poor outcomes in the population whereas medical care aims to avoid poor outcomes in the individual patient directly in front of you. Improving a population’s health versus an individual person’s health requires one to recognize our health-care system’s limited resources and how best to distribute these limited resources for the highest gains for the most people. There are several steps podiatrists can take to ensure they provide the most effective and efficient care for their individual patients with diabetes while maximizing outcomes at the population level.
Emphasizing Risk Stratification And Efficient Resource Utilization
Primary prevention of complications (e.g. amputations) should ideally occur before peripheral neuropathy occurs. A program presented by the Health Resources and Services Administration, Lower Extremity Amputation Prevention (LEAP) simplifies key preventive steps and includes:
• an annual foot screening with peripheral arterial disease evaluation;
• patient education;
• daily self-inspection of one’s feet;
• footwear selection; and
• management of simple foot problems.1
Given that diabetic peripheral neuropathy (DPN) and peripheral arterial disease (PAD) are known precursors to ulceration, risk stratification is a key component to foot evaluations.2 Risk category 0 patients should receive screenings annually. These are patients with diabetes who have a normal exam and no evidence of DPN or PAD. Patients who exhibit loss of protective sensation (i.e., DPN) are considered to be in risk category 1 and should see their podiatrists every six months. Those with DPN, deformity and/or PAD are in risk category 2 and warrant at least quarterly visits. Lastly, anyone with a history of ulceration or amputation is considered high risk (category 3) and may need evaluation anywhere from monthly to quarterly.2
Adhering to these guidelines ensures effective use of our limited resources. Access to care from specialists can be a problem, especially in areas where there are few podiatrists available. Risk stratification allows physicians to identify and allocate care to those with the highest need. Clogging our schedules with risk category 0 patients for routine nail care several times per year reduces access for high-risk patients and can cause prolonged wait times to see a provider. In most areas, preventative foot care (i.e., nail debridement, callus debridement) may should may occur every two to four months for those who are in risk category 1 and above. In regions where wait times to see a provider are long, preventative care should be reserved for those in risk category 2 and above.
This not only ensures better access to providers but lessens unnecessary billing for procedures in a cohort of patients who are already at low risk for issues. Podiatrists are a valuable, limited resource. We must make decisions on how we will spend our time. Spending it with the highest-risk patients supports the ideal that we can prevent further complications from occurring. Seeing a low-risk patient less frequently does not mean that person is receiving suboptimal care or being ignored. Low risk patients do not require the frequency of visits of high-risk patients and seeing someone less frequently (i.e., once per year if risk category 0) will not increase his or her risk of poor outcomes.2
One should also avoid prioritizing resources such as therapeutic footwear for low-risk patients. Reiber and colleagues have demonstrated that footwear is most effective when one reserves it for those with DPN and/or foot deformities.3 Unfortunately, financial incentives do not always align with providers spending more time with high-risk patients. Health policy makers should focus on incentivizing providers who demonstrate efficient use of resources and not necessarily higher utilization of resources.
Recognizing The Impact Of Socioeconomic Factors On Health And Health-Care Outcomes
The term “working upstream” typically refers to social and economic efforts and/or policies that enable people to achieve better health. The privilege of influencing public policy at the highest level can subsequently provide downstream benefits. The epidemiology of diabetes demonstrates inequality in the incidence of disease and the rate of complications across race and socioeconomic status.4 We now realize that factors such as income, the neighborhood someone grew up in and race are all factors associated with whether someone is likely to have serious health issues in the future.
Understanding these social determinants of health enables providers to be more empathetic to the patient and provides insight into why a person may be dealing with the condition in the first place. For example, poor diet is a known precursor to diabetes. People who come from a poor socioeconomic status or live in a region where food deserts/food swamps are common, are more likely to lack access to healthy foods or have financial restraints that do not allow them to purchase high-quality food.5,6 Many of us can recall what it was like to be a poor college student when the cheapest foods were also the least healthy. For many, this financial struggle continues into adulthood, leading to a higher risk of obesity-related diagnoses like diabetes. Upstream policies that enable better access to healthy food choices will likely contribute to a decrease in diagnoses that correlate with obesity.
However, diet is not the only struggle. Many children and adults live in neighborhoods that are unsafe for walking and playing. These neighborhoods often have limited “green space” with minimal or unsafe outlets for people to enjoy recreation in parks and playgrounds.
Additionally, race inequality continues to be a problem in health care. African-Americans are about twice as likely to have a lower extremity amputation in comparison to Caucasians (5.0 to 6.5 per 10,000 versus 1.2 to 2.5 per 10,000).7 This statistic does not appear to be explained by comorbidities or overall health status. Goldberg and colleagues demonstrated that African-Americans were more likely to have an amputation even if they were considered low-risk for the complication (5.1 per 1,000) in comparison to Caucasians who were also in the low-risk category (2.6 per 1,000).8 There is considerable work to be done regarding current socioeconomic barriers but from the physicians’ standpoint, the first step is empathy and the second step is advocacy.
Opportunity is not equally distributed among us and some people have additional barriers to overcome before they can achieve optimal health. One can suppress preconceived, often unconscious, biases or judgements via knowledge and understanding of these barriers.
Joshua Freeman, MD, the author of Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System, wrote that, “The important point is that health care providers, including physicians, should not be casting blame on the victims of ill health but can and should be involved in advocating for the societal changes that will enhance people’s health and increase their capability.”9 Although these social issues fall outside of traditional medicine, physicians are known leaders in the community and have the power and platform for change.
Final Thoughts: Making A Difference
Podiatrists currently play a vital role daily in public health. We may be able to achieve higher gains in terms of prevention and improved treatment outcomes if we shift our gaze toward improving the population’s health versus focusing solely on the individual patient. This requires an understanding of the socioeconomic barriers that exist and employing evidence-based guidelines to minimize inefficiencies in health-care delivery.
Dr. Albright is a member of the Board of Directors of the Connecticut Podiatric Medical Association and is in practice in Darien, Conn. She also completed a Fellowship Masters in Public Health from Dartmouth College as part of with the American Podiatric Medical Association’s publich health fellowship.
1. Human Resources and Services Administration. Lower Extremity Amputation Prevention (LEAP). Available at: https://www.hrsa.gov/hansens-disease/leap . Published 2019. Accessed February 1, 2021.
2. Schaper NC, van Netten JJ, Apelqvist J, Bus SA, Hinchliffe RJ, Lipsky BA. Practical guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diab Metabol Res Rev. 2020;36(Suppl 1):e3266.
3. Reiber GE, Smith DG, Wallace C, et al. Effect of therapeutic footwear on foot reulceration in patients with diabetes: a randomized controlled trial. JAMA. 2002;287(19):2552-2558.
4. Spanakis EK, Golden SH. Race/ethnic difference in diabetes and diabetic complications. Curr Diab Rep. 2013;13(6):814-823.
5. Wang DD, Leung CW, Li Y, et al. Trends in dietary quality among adults in the United States, 1999 through 2010. JAMA Int Med. 2014;174(10):1587-1595.
6. Chen D, Jaenicke EC, Volpe RJ. Food environments and obesity: household diet expenditure versus food deserts. Am J Pub Health. 2016;106(5):881-888.
7. Lefebvre KM, Lavery LA. Disparities in amputations in minorities. Clin Orthop Relat Res. 2011;469(7):1941-1950.
8. Goldberg JB, Goodney PP, Cronenwett JL, Baker F. The effect of risk and race on lower extremity amputations among Medicare diabetic patients. J Vasc Surg. 2012;56(6):1663-1668.
9. Freeman JM. Health, Medicine and Justice: Designing a Fair and Equitable Healthcare System. Friday Harbor, Wash.: Copernicus Healthcare; 2015.
