Available online 12 November 2022

Abstract

Major non-traumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease (PAD). Incidence of major LEA consistently declined over the 1990s-2000s, but rates have plateaued or increased in many regions over the past decade. Marked racial, ethnic, socioeconomic, and geographic disparities in risk of LEA persist and are related to inequalities in access to care and differential rates of attempted limb preservation. Multidisciplinary diabetic foot and limb care (MDFC) is increasingly recognized as a necessary model for optimal management of persons with diabetic foot and vascular disease. This article reviews the role of MDFC in reducing major LEA and the specific ways in which MDFC can mitigate disparities in care delivery and limb preservation outcomes. Access to MDFC care among vulnerable populations remains a significant barrier to systematic reduction in major LEA.

Introduction

Non-traumatic lower extremity amputation (LEA) is a highly morbid late-stage complication of diabetes and peripheral artery disease (PAD), and marked racial and ethnic, socioeconomic, and geographic disparities in LEA exist. The majority of major LEA are avoidable with appropriate preventive care and management of incident diabetic foot ulcers (DFU). This review summarizes the epidemiology of DFU and PAD, recent trends in LEA incidence, and the role of multidisciplinary diabetic foot care in reducing major LEA, especially in populations that are disproportionately affected by LEA.

Section snippetsEpidemiology of diabetes, PAD, and diabetic foot disease

PAD and diabetes are the primary drivers of foot ulceration and LEA in the US, and together represent a major source of preventable morbidity, mortality, and healthcare utilization [1]. Diabetes affects more than 37 million US adults, and this number is rising rapidly, driven primarily by an increase in Type 2 diabetes [1]. The estimated US prevalence of PAD is 8 million to 12.5 million persons [2], though this likely underestimates the prevalence of asymptomatic disease. Diabetes is an

Differences and disparities in the risk of LEA

There are several well-defined clinical risk factors for DFU and diabetes-related LEA, most of which are related to longstanding disease and/or poor glycemic control. Racial and ethnic minority populations and persons with low socioeconomic status experience higher rates of diabetes and risk-associated comorbidities, including cardiovascular disease, PAD, neuropathy, and chronic kidney disease, compared to white persons and those with high income level [1,10,11]. Even after adjusting for

Components of multidisciplinary diabetic foot and limb care

Multiple society guidelines recommend management of DFU and PAD in a multidisciplinary care setting [3,17], though no clear data exist on the requisite components of an MDFC. Most described models include vascular surgery, podiatry, and a diabetologist at minimum (Table 1) [18]. The inclusion of podiatry, specifically, is shown to improve limb preservation rates [18]. MDFC should be capable of specialty wound care, but whether wound care is driven by surgeons or non-surgeon wound care

Multidisciplinary approach to treatment of diabetic foot ulcers

Complete wound healing as quickly as possible and achieving optimal functional status of the limb and patient are generally considered driving goals of DFU treatment. These are sometimes at odds (e.g., a trial of prolonged wound care for an ulcer with questionable healing potential to avoid a minor amputation that may not significantly affect functional status), in which cases shared decision making between patient and providers is essential. Treatment of DFU is founded upon several basic

MDFC and preserving the functional limb

Retrospective center-based cohort studies almost universally demonstrate improvement in both process measures and outcomes after the implementation of an MDFC model, and a recent systematic review by Musuuza and colleagues reported that 94% of included publications examining pre/post MDFC outcomes found a reduction in major LEA [19]. Centers in urban underserved areas have demonstrated excellent healing, limb preservation, and functional outcomes among populations with significant socioeconomic

Cost-effectiveness of MDFC

Diabetic foot complications result in annual excess healthcare expenditures of 50% to 200% above the baseline costs of diabetes-related care [44]. Direct treatment costs correlate with increasing WIfI stage, and WIfI stage 4 wounds are estimated to cost at least $50,546±$4887 from diagnosis to healing or LEA [42,47,48]. Pre-post historical analyses of MDFC have shown cost reductions of up to 20% per wound episode, primarily driven by fewer inpatient admissions; other studies have demonstrated

Barriers to MDFC access and implementation

MDFC are collaborative, often centralized care models in which referrals are inherently streamlined. Inability to access timely specialist care is a strong predictor of poor outcomes associated with non-white race/ethnicity and low income but can be mitigated by standardized referral pathways to and within MDFCs [14,20]. Large academic and/or tertiary MDFCs tend be in urban locations and are therefore well-positioned to serve minority and low-income urban communities where diabetes and

Conclusions

Diabetic lower extremity complications, including major LEA, are increasingly common, highly morbid, and largely preventable. Longstanding structural disparities in access to preventive and therapeutic care result in a disproportionately high burden of major LEA among racial and ethnic minorities and socioeconomically deprived populations, and meaningful reductions in major LEA cannot be achieved without addressing these inequities. Disparities in process and outcome measures of DFU care are

Acknowledgements

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of interests

Regarding manuscript submission entitled “Multidisciplinary approach to decreasing major amputation, improving outcomes, and mitigating disparities in diabetic foot and vascular disease”, authors Katherine M. McDermott, MD, Tara Srinivas, BS, MPhil, and Christopher J. Abularrage, MD.

References

[1] Centers for Disease Control and Prevention. National Diabetes Statistics Report. Atlanta, GA.: 2022.

[2] Barnes JA, Eid MA, Creager MA, Goodney PP. Epidemiology and Risk of Amputation in Patients With Diabetes Mellitus and Peripheral Artery Disease. ATVB 2020;40:1808–17. https://doi.org/10.1161/ATVBAHA.120.314595.

[3] Conte MS, Bradbury AW, Kolh P, White JV, Dick F, Fitridge R, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Journal of Vascular

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