Prevalence and risk factors for diabetes-related foot complications in Translating Research Into Action for Diabetes (TRIAD)☆
Introduction
Diabetes can lead to a number of debilitating foot complications, including Charcot neuroosteoarthropathy, diabetic foot ulceration (DFU), and lower extremity amputation. Charcot neuroosteoarthropathy is a destructive joint disorder initiated by trauma to an insensate limb that leads to inflammation and collapse of the normal foot architecture (Frykberg & Belczyk, 2008). The prevalence of Charcot neuroosteoarthropathy among patients with diabetes has been reported to be between 0.1% and 0.9% (Fabrin et al., 2000, Lavery et al., 2003, Sinha et al., 1972). It has been estimated that 63% of patients with Charcot neuroosteoarthropathy will develop a foot ulcer (Sohn, Lee, Stuck, Frykberg, & Budiman-Mak, 2009), and the co-occurrence of Charcot and DFU confers a 12-fold higher risk of amputation (Sohn, Stuck, Pinzur, Lee, & Budiman-Mak, 2010). Peripheral polyneuropathy, foot deformities, and peripheral vascular disease contribute to DFU and amputation. It is estimated that people with diabetes have a 25% lifetime risk of developing a foot ulcer (Singh, Armstrong, & Lipsky, 2005), and 84% of lower extremity amputations have been attributed to non-healing DFUs (Pecoraro, Reiber, & Burgess, 1990).
In the United States, as many as 15% of people with diabetes will have lower extremity amputations during their lifetime (Deshpande, Harris-Hayes, & Schootman, 2008), and substantially higher rates are associated high-risk foot conditions like Charcot neuroosteoarthropathy and DFU (Helmer et al., 2011). While the causal pathways leading to Charcot and DFU, or eventually, lower-extremity amputation, may differ, they are all identified by comprehensive foot examination including inspection of the dermatologic and musculosketal systems, sensory examination, and pulse evaluation, and with appropriate treatment, often are preventable (Boulton et al., 2008). The American Diabetes Association (ADA) has concluded that preventive care teams, defined as multidisciplinary teams that utilize risk assessment tools, patient education, and therapeutic footwear, can decrease the risk of DFU and amputation by 50%–85% (Mayfield, Reiber, Sanders, Janisse, & Pogach, 1998). Managed care organizations, which provide access to care and prevention, should be well positioned to screen and prevent foot complications. Studies have not yet reported on the prevalence and risk factors of diabetic foot complications in managed care organizations other than in the VA (Helmer et al., 2011, Mayfield et al., 2004, Sohn, Budiman-Mak, Stuck, Siddiqui and Lee, 2010, Sohn, Stuck, Pinzur, Lee and Budiman-Mak, 2010, Stuck et al., 2008). Our objective was to describe the prevalence of diabetes-related foot complications in a managed care population and to identify the demographic and biological risk factors associated with each of the three major diabetes-related foot complications.
Section snippets
Study population
Translating Research Into Action for Diabetes has been described elsewhere (TRIAD Study Group, 2002). Briefly, TRIAD studied a random sample of adults with diabetes enrolled in 10 managed care health plans in eight states (California, Hawaii, Indiana, Michigan, New York, New Jersey, Pennsylvania, and Texas) that served ~ 180,000 patients with diabetes. Patients were eligible to participate if they were at least 18 years old, lived in the community, were not pregnant, had diabetes for at least 1
Results
At baseline, the average age of TRIAD participants was 61 (± 13) years and mean duration of diabetes was 12 (± 10) years. Between 1999 and 2003, 55 (0.8%) patients had a diagnosis of Charcot foot, 205 (2.9%) had a diagnosis of at least one DFU with incident debridement, and 101 (1.4%) had a lower extremity amputation procedure or a status code for a prevalent amputation. There were 6631 (94.8%) patients with no foot conditions.
In the bivariate models (Table 1), patients with Charcot foot were
Discussion
In our study of managed care patients, we found a relatively high prevalence of foot complications, particularly given uniform access to health care for all patients. Racial/ethnic minorities were less likely to have Charcot foot and DFU, and there were no racial/ethnic or income differences in the prevalence of lower-extremity amputation. Few studies have evaluated the racial/ethnic differences in the prevalence of Charcot foot (Frykberg & Belczyk, 2008). In one small study of foot pathology,
Acknowledgments
This study was jointly funded by Program Announcement 04005 from the Centers for Disease Control and Prevention (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases. Support was provided by the Biostatistics Core of the Michigan Diabetes Research and Training Center by Grant Number P60DK020572 and by the Methods and Measurement Core of the Michigan Center for Diabetes Translational Research by Grant Number P30DK09292601 from the National
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No potential conflicts of interest relevant to this article were reported.