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Am Fam Physician. 1999;59(2):447-450

Despite evidence that foot care can prevent amputations, this continues to be a commonly neglected aspect of management in patients with diabetes. Rith-Najarian and colleagues conducted a prospective study to evaluate the impact of foot care guidelines for patients with diabetes at an American Indian health service clinic.

The study, which began in 1986 and continued through 1996, was divided into three phases. The first phase, from 1986 to 1989, was an observation period to determine the types of foot care provided to patients with diabetes. This was followed by the second phase (1990 to 1993), during which patients were screened for foot problems, and high-risk patients received foot-care education and protective footwear. High-risk patients were considered those who demonstrated insensitivity to a 10-g monofilament examination, had a foot deformity or had a history of foot ulcers or prior amputation.

The final phase of the study, conducted from 1994 to 1996, included the implementation of systematic screening, diagnostic and treatment guidelines for diabetic foot management. These guidelines contained specific algorithms for foot care, treatment options and schedules for follow-up (see the accompanying figure). The practice guidelines are available at the Journal of Family Practice Web site (; click on “supplemental material”).

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The first phase of the study revealed no systematic method of diabetic foot management. Similarly, in the second phase, there was no consistent approach to foot care or ulcer assessment. After the staged diabetes management guidelines were developed, changes were implemented at the Indian health service clinic. A foot care team was organized, flow sheets based on the guidelines were developed, and standardized management strategies were executed.

A total of 639 patients were included in the study. Patients did not significantly differ in age, sex or duration of diabetes. The average annual incidence of amputation during the standard care phase (phase one) was 29 per 1,000 patient-years. In the second phase, the average annual incidence was 21 per 1,000. The average annual incidence of amputations dropped to 15 per 1,000 in the final phase of the study. Among patients with intact limbs, the rate of first amputation was reduced by 71 percent between the first and third phases.

The authors conclude that screening, along with some basic interventions such as patient education and protective footwear, reduced lower extremity amputation rates by 28 percent compared with the rate during standard care. After the staged diabetes management system was implemented, a 48 percent reduction in lower extremity amputations was achieved. The authors recommend the staged diabetes management system for reducing the rate of amputation in patients with diabetes. Similar methods may also be useful for reducing other complications and improving outcomes in patients with diabetes.

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Copyright © 1999 by the American Academy of Family Physicians.

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