SLR - July 2022 - Jordan Finck, DPM
Reference: Lo ZJ, Chandrasekar S, Yong E, Hong Q, Zhang L, Chong LRC, Tan G, Chan YM, Koo HY, Chew T, Sani NF, Cheong KY, Cheng LRQ, Tan AHM, Muthuveerappa S, Lai TP, Goh CC, Ang GY, Zhu Z, Hoi WH, Lin JHX, Chew DEK, Lim B, Yeo PS, Liew H. Clinical and economic outcomes of a multidisciplinary team approach in a lower extremity amputation prevention programme for diabetic foot ulcer care in an Asian population: A case-control study. Int Wound J. 2022 May;19(4):765-773. doi: 10.1111/iwj.13672.Scientific Literature Review
Reviewed By: Jordan Finck, DPM
Residency Program: University Hospital – Newark, NJ
Podiatric Relevance:
As Podiatrists, we know that the average diabetic patient has anywhere from a 15-20 percent lifetime risk of developing a foot ulcer. Furthermore, a large percentage of these patients will go on to have a lower extremity amputation. Concomitantly, we as practitioners play a significant role in managing these diabetic foot ulcers and have the available knowledge to successfully heal a large percentage of such ulcers with appropriate care and intervention. However, an improved and expedited outcome can be obtained by utilizing a multidisciplinary team of health professionals. This approach can help lead to the best outcomes in terms of limb preservation, which ultimately translates to long term cost benefits for the health industry and improved quality of life for the patient.
Methods:
A case-control (prospective cohort comparison against a retrospective cohort) study was performed at a university tertiary hospital in Singapore. The study included all patients above the age of 21 years, with pre-existing DM and referred for foot ulcers (distal to malleolus). Patients with venous ulcers or ulcers of mixed arteriovenous etiology were excluded from the study. Retrospective analysis was performed for patients referred to the conventional vascular surgery specialist outpatient clinic, while prospective analysis was performed for patients referred to the multidisciplinary lower extremity amputation prevention program (LEAPP) clinic. Patients had completed a one-year follow-up at the time of analysis. Health economic analysis was performed by the evaluation of cost avoidance for both cohorts. Major lower extremity amputation (LEA) rate was calculated and adjusted appropriately. Covariates were considered in risk adjustment and simulation of cost avoidance was performed based on the risk-adjusted major LEA rates between the two groups.
Results:
When comparing between the retrospective cohort and the LEAPP cohort, there was a significant decrease in mean time from referral to index clinic visit (38.6 versus 9.5 days, P < .001), increase in outpatient podiatry follow-up (33 percent versus 76 percent, P < .001), decrease in one-year minor amputation rate (14 percent versus 3 percent, P = .007), and decrease in one-year major amputation rate (9 percent versus 13 percent, P = .05).
Conclusions:
Utilizing a multidisciplinary approach demonstrated a significant reduction in minor and major amputation rates and improved annualized cost avoidance. This, in turn, is associated with decreased waiting time for referral to specialists, vascular workup, vascular interventions, and improved podiatry and medical care. This becomes very critical for improving overall patient outcomes and preventing the downward spiral of negative events including infection, hospitalization, and eventual surgical intervention to include the worst-case scenario of lower extremity amputation. Employing these principles can improve healthcare cost burden, and most importantly, improve quality of life for our patients.