We Are Failing Our Patients With Diabetes

My career in medicine has spanned approximately 26 years. Nineteen-ninety-six was my first year of residency training as well as my first real exposure to the emerging specialty of wound care.   

To put things into perspective, during my first year of training, there were approximately 300–500 wound care products on the market. That may seem like a lot, especially considering there are now thousands of products that wound providers and others may choose from. Consider, however, that when I began clinical practice, the resources available were considerably different when compared to what is available today.

In 1996, hydrogels and alginates were cutting edge. Additionally, there were:

•    No negative pressure wound therapy systems
•    No cellular- and tissue-based products
•    No engineered topical growth factors
•    No endovascular revascularization
•    No simple total contact casting systems
•    No collagen dressings
•    No silver-impregnated dressings
•    No honey, fish, bovine, ovine, or porcine wound products
•    Managed wound care was limited and in the form of the company known as Curative Technologies. Curative’s proprietary technology was Procuren, which was a platelet derived growth factor solution derived from the blood of the afflicted patient.
•    Hyperbaric oxygen therapy was not a significant modality or used to the extent it is today
•    Magnetic resonance imaging (MRI) was very limited versus the use of bone scans, computed tomography (CT) and plain film to assess for osteomyelitis, let alone to detect the presence of a deep abscess
•    Algorithms for managing diabetic foot ulcers (DFU) and venous leg ulcers (VLU) were not readily available or accessible

Additionally, there was:

•    No methicillin-resistant Staphylococcus aureus (MRSA)
•    No internet
•    No smart phones with digital photography
•    No electronic medical records (EMRs)
•    Limited information and research
•    The team approach, Toe and Flow, was not part of the vernacular
•    Wet to dry was still the most used dressing

I can only imagine how the lives of many of my patients, let alone my own life, would have been positively impacted if, when I was beginning my career, I had access to any number of the items on this list.  

I have seen the wound care community grow in so many ways, and as our specialty emerges, it attracts more outstanding, dedicated professionals. We have also seen recognition by related specialties, such as infectious disease, interventionists (cardiology, radiology, and vascular surgery), endocrinology, nephrology, hospitalists, and others, who recognize the importance of the service that wound care professionals provide.

Why Have Things Gotten Worse?

At times it seems like the experiences of 1996 happened a few days ago, and other times, they feel like another lifetime. One would like to think that with all the technological advancements in wound healing and limb preservation over the past 20 plus years, that things would be improving accordingly. They have not.

At least where the management of DFUs and non-traumatic amputation are concerned, things have gotten progressively worse since 2009.¹

For a while, lower extremity amputation rates seemed to be declining, for reasons that could be partially attributed to some of the technologies mentioned, as well as the embracing of the team approach to wound healing.  

Why are we experiencing not only an increase in minor amputation, but in amputation at every level from toe to above the knee? Between 2010 and 2015, amputation rates rose to 4.6 per 1,000 patients, exceeding their previous high in 2000. There has been a steady increase in amputation rates since 2012 and 2015, the analysis first presented in January 2019 in Diabetes Care by Geiss, Yanfeng, et al.¹

Based on personal observation and informal polling of my colleagues, an additional disturbing trend has also been occurring. The acuity levels of wounds encountered and underlying comorbidities in younger patients have become increasingly apparent, as well as validated by Geiss and Yanfeng.¹The increases in rates of total, major, and minor amputations were most pronounced in young (age 18–44 years) and middle-aged (age 45–64 years) adults and more pronounced in men than women.¹

The key question, then, is why are we failing?   

For starters, in 1996, we had approximately 16 million people in the US living with diabetes. As of 2021, we now have approximately 34.2 million diabetics in an ever-increasing general population of 331 million, that also includes an estimated 88 million pre-diabetics, according to Centers for Disease Control annual statistics.²

Diabetes certainly has played a prominent role in these sobering statistics, but diabetes alone is not the only variable that must be considered.  

Access to care may be a factor, which Tan and colleagues explored in “The Affordable Care Act Medicaid Expansion Correlated with Reduction in Lower Extremity Amputation among Minorities with DFU” in Diabetes in June 2020.³ A comparison was performed that compared states’ early adoption of expanded Medicaid services via the Affordable Care Act versus states that were not early adopters. Among noteworthy findings, odds of major lower extremity amputation among non-white Medicaid patients decreased by 17.3% in early adopter states, while major lower extremity amputation rates increased by 1% in non-adopter states.³

Working Toward Solutions

Finding a cause is certainly imperative when attempting to solve any problem. The more pressing question as it pertains to wound healing and amputations may be how do we arrive at solutions, especially when the availability of resources to heal wounds is greater than at any other time?

Are the solutions to be found with future breakthroughs in pharma, medical devices, findings from research in wound healing, or some other area? Possibly.

The one area of focus that will determine success or not, will be the role of the patients, and their collective engagement. Ultimately, we know it is better to prevent than it is to treat. Educating patients with ways to become more proactive when managing their diabetes is certainly challenging, especially once they have reached the stage where foot wounds become a reality. Do patients really understand what is at stake, not only once diagnosed with diabetes, but at the onset of their first wound?  

To appreciate the impact that education of patients and their support systems, as well as how self-assessment and early recognition can play a vital role in better outcomes, one only need to look at breast cancer and how self-examination and buddy checks have positively impacted the lives of those (and their loved ones) with that disease.

We are failing, and it is imperative that we address what has become an overwhelming stress on everyone from patients, providers, and the healthcare system. Despite the advances in wound care technologies, perhaps the most impactful solutions will result from being proactive versus reactive.

Dr. Desmond Bell is the Founder and President of “The Save A Leg, Save A Life” Foundation, a multidisciplinary non-profit organization dedicated to the reduction in lower extremity amputations and improving wound healing outcomes through education, evidence-based methodology and community outreach. He also serves as Chief Medical Officer of Omeza, an evidence-based medical technology company and consumer healthcare products company initially focused on healing chronic wounds and preventing their recurrence. In 2020, he joined MD Coaches as an Executive Physician Coach, serving as a peer to peer mentor.

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References
1.    Geiss LS, Yanfeng L, et al. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2019 Jan; 42(1):50–54
2.    CDC. National Diabetes/basics. Feb. 2021.   
3.    Tan T, Calhoun E, Knapp S, Marrero D, Wei Z, Armstrong D. The Affordable Care Act Medicaid expansion correlated with reduction in lower extremity amputation among minorities with DFU. Diabetes. 2020 Jun; 69(Supplement 1).