Six Strategies to Help Reduce Diabetes-Related Lower Extremity Amputations Among Minority Populations

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Lower extremity amputation rates related to diabetes have been gradually increasing each year since 2009, says a new report from the Centers for Medicare & Medicaid Services’ (CMS) Quality Innovation Network National Coordinating Center (QIN NCC). The data, gathered from Medicare fee-for-service beneficiaries between July 1, 2015 and June 30, 2016, found that of the nearly 38 million beneficiaries’ inpatient claims data examined in 50 states and three territories, almost 32,000 people with diabetes had a documented non-traumatic lower extremity amputation of a partial to whole foot or leg. (Toe amputation alone was not included.)

Further, the data show that, like diabetes, lower extremity amputations continue to impact racial and ethnic minority beneficiaries at disproportionate rates. Nationally, Hispanics had an amputation rate two-and-a-half times greater than whites; blacks had a rate three-and-a-half times greater than whites; and Native Americans had a rate four-and-a-half times greater than whites.

"Further, the data show that, like diabetes, lower extremity amputations continue to impact racial and ethnic minority beneficiaries at disproportionate rates."

These amputations carry a significant financial burden. In 2012, it was estimated that Medicare beneficiaries with diabetes and lower extremity wounds accounted for $41 billion in costs, which is about 1.6 percent of all Medicare health care spending.

Foot care is important for everyone. But uncontrolled diabetes—and other related factors—increase the risk of ulcers and is the single greatest cause of preventable foot amputations. Here are six tips—three for providers and three for beneficiaries—from the QIN NCC on how to promote healthier feet and reduce amputations, especially among those populations most at risk.

What Can Providers Do?

1. Get Up-to-Date Records: Obtain patients’ prior history of ulceration, amputation, Charcot foot, angioplasty or vascular surgery, cigarette smoking, retinopathy and renal disease, and assess current symptoms of neuropathy (pain, burning, numbness) and vascular disease (fatigue, claudication).

2. Perform Regular Exams: Perform a comprehensive foot examination at an initial visit and on at least an annual basis, to identify risk factors for ulcers and amputation, such as skin and foot deformities; pulses in the legs and feet; or the absence of patellar and Achilles reflexes. See the Centers for Disease Control and Prevention’s Provider Toolkit, Working Together to Manage Diabetes: A Toolkit for Pharmacy, Podiatry, Optometry and Dentistry, for more information.

3. Teach Best Practices: Provide recommendations for daily foot care, including how to properly examine feet and toes, as well as guidance about the risks of walking barefoot and avoiding shoes that are too small. The Quality Improvement Organization (QIO) Program’s Provider 3-Minute Foot Exam is a helpful resource. 

What Can Beneficiaries Do?

1. LOOK: Look at your feet every day for cuts, blisters, red spots, ingrown toenails and swelling. If you can’t look at your feet, use a mirror or ask someone to help you look. Make this a habit after your morning shower or at night before bed, after you have removed shoes and socks.

2. LOVE: Regularly follow these foot care and general health practices.

  • Try to achieve or maintain good blood sugar control. This can help prevent or at least slow down nerve damage progression.
  • Wash feet in warm soapy water and thoroughly dry them, paying special attention to between your toes. After drying, moisturize tops and bottoms of feet daily after cleaning (do not put lotion between toes).
  • Trim toenails regularly. If you cannot see, feel or reach your feet, or if your toenails are thick or yellow, or if they curve and grow into your skin, have a doctor trim your toenails. Medicare covers regular visits to a podiatrist that include toenail trimmings.
  • Wear shoes and socks, or shoes and nylons. Wear socks without seams, and socks that are not too tight. Check inside your shoes before putting them on.
  • Protect feet from hot and cold.
  • When seated, keep the blood flowing in your legs by not crossing your legs.
  • Do not smoke. Be active or gradually increase activity by walking, swimming or dancing.

3. SHOW: Take your shoes and socks off every time you go to the doctor. You should have a full foot exam at least once a year by your doctor, and the American Diabetes Association standards of care recommend a foot check at every visit. Ask if you need special shoes to protect your feet; your doctor or foot doctor should guide you on this. Call your doctor right away if you find a cut, sore, blister or bruise on your foot that does not heal after a few days.

Click here to learn more about CMS' Everyone with Diabetes Counts' Foot Care Campaign.

Snapshots of Success:

CMS’ Everyone with Diabetes Counts (EDC) program is working to combat diabetes and lower extremity amputations. EDC’s diabetes self-management education (DSME) classes include training in self-foot care and teach people when to contact their doctor if there is a potential problem. Here are two snapshots of success from Quality Innovation Network-Quality Improvement Organizations (QIN-QIOs) where small changes made a big impact:

Alliant Quality QIN-QIO, the QIN-QIO serving Georgia and North Carolina:

One of our EDC DSME class participants almost always wore flip flops, and when we talked about foot care, she said she wore them because shoes were uncomfortable. We reviewed with her foot care best practices and safety, and she was given ideas to help with transitioning to socks and shoes comfortably. She said she would try. The next week, she came to our class after having recently visited the Emergency Department for an injury resulting from the continued use of flip flops. With the education and encouragement provided by the EDC DSME classes, she finally made the change and now wears socks and shoes out of the house at all times, which is critical for preventing injuries for diabetes patients.” – Jeana Partington, Alliant Quality Task Manager for Diabetes Care in North Carolina

HealthInsight QIN-QIO, the QIN-QIO serving Nevada, New Mexico, Oregon and Utah:

We recently hosted an EDC DSME class to provide new beneficiaries with an overview about the importance of foot care for people with diabetes. After the training, one of the participants went home and checked her shoes and her feet, as instructed. To her surprise, she found a small pebble lodged inside of her shoe that she did not know was there because she did not feel it. She then checked her feet where she found a small area of indentation and a skin irritation where the pebble had been rubbing against her foot. But, again, she hadn’t felt it. If left unchecked, this irritation could have had serious implications for the patient’s health down the line. Fortunately, because of the knowledge gained in the DSME class, she knew to check her shoe, remove the pebble, and follow up with her physician.” – Janet Tennison, HealthInsight Diabetes Lead in Utah