Reducing Amputation Rates in Patients With Diabetes at a Military Medical Center: The Limb Preservation Service Model

Driver VR, Madisen J, Goodman RA. Diabetes Care. 2005;28:248-253.

Diabetes is the leading cause of nontraumatic amputations in the United States. A majority of lower extremity amputations (LEAs; approximately 85%) are preceded by foot ulcers. The goal of this study was to describe and evaluate the Limb Preservation Service (LPS), the Madagan Army Medical Center’s (MAMC) multidisciplinary diabetic foot care program. The LPS model and treatment paradigm are described. The program was evaluated by assessing the incidence and distribution of diabetes-related LEAs that were documented between 1999 and 2003.

A total of 4940 patients with diabetes were treated at MAMC in 2003, a figure that represented a 48% increase from 1999. The LPS was created in 1995, due to concerns regarding the increased incidence of LEAs. Services provided by the LPS include prevention and education, wound care, infection management, surgical and hospital management, research, community outreach, and footwear assessment, and the creation of orthotics, prosthetics, and shoes. The LPS treats approximately 400 patients per month.

The LPS foot examination involves 7 parts, including:

• General clinical history, diabetes-specific history, and diabetes knowledge assessment
• Current history, including A1C and any current illnesses
• Foot exam, including assessment of the following:
  • Skin, hair, and nails
  • Musculoskeletal defects
  • Sensory and motor function
  • Gait
  • Vascular function
  • Presence of ulcers
• Risk categorization (eg, low, moderate, or high)
• Footwear assessment
• Foot care education
• Foot care management plan

In terms of program evaluation, incidence and type of LEAs between 1999 and 2003 were the outcomes of interest. Data from the LPS were compared with national averages from the Centers for Disease Control’s Diabetes Surveillence Statistics. The results demonstrated that although diagnosed diabetes increased by 48% during the 4-year evaluation period, the number of LEAs decreased from 33 in 1999 to 9 in 2003 (incidence rates of 9.9/1000 and 1.8/1000, respectively). In addition to the decreased rate of LEAs, the study also demonstrated a positive finding with regard to LEA type. Patients of the LPS had an increased number of toe and foot amputations compared with the national average, potentially due to the LPSs philosophy of reacting quickly to amputation indications so that as much of the limb can be salvaged as possible.

Overall, the results of this study demonstrate the effectiveness of a multidisciplinary, state-of-the-art foot care clinic for patients with diabetes. The success of this project suggests that integrated care for diabetic neuropathy can reduce the incidence of diabetic amputations and have beneficial effects on both patient quality of life and financial resources.