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4 Integrating Inpatient Care to Your Outpatient Wound Care Center: Key to Successful Patient…

patients reported that patients treated with NPWT) for closed incisions experienced nearly a 40% reduction in the risk of surgical site infections relative to those with standard dry sterile dressings. A statistically signicant reduction in wound dehiscence and seroma incidence was also reported [6]. MGUH’s limb surgeons began applying NPWT to closed incisions with the introduction of disposable short term use NPWT devices and were among the early identiers of the same benets described by Shiroky and colleagues. Now it is a frequent practice for our surgeons to place NPWT at the time they close an incision.

Once a patient is ready for discharge the surgeons will decide if NPWT should be continued. These patients are transitioned from the standard NPWT device that had been placed at the time of closure to a disposable seven or fourteen day unit. The patient will be instructed to leave the device on and operating until clinic follow-up. In cases where the device’s preprogrammed life will end before follow-up can be arranged, the patient will either be advised to disconnect the tubing, discard the device, and leave the dressing on and intact until follow-up or remove the NPWT dressing and place a dry dressing on the incision.

A One Page Snapshot ofEach Admission Provides anInvaluable Bridge

Once the myriad elements involved in discharging a limb patient come together and the patient is discharged, ensuring appropriate follow-up and capturing and communicating key elements of the admission are the next priority. Given the volume of patients discharged every day and the complicated nature of their care, an immediately available, easy-to-reference resource is necessary in order for the limb outpatient clinic staff to be able to eld the barrage of questions they receive. Literally within hours of discharge the clinic receives calls from patients, their families, home health nurses, and rehabilitation or skilled nursing facility staff. As the result of close interaction

with the clinic staff, the limb NP team developed a reference document called a discharge white sheet (Fig. 4.3) which they complete for every inpatient seen by the limb service. The document is available to all users of MGUH’s electronic medical record EMR (Cerner) and is found in Clinical Documents-Discharge Documents. Information contained in the one page document goes beyond that found in a traditional discharge summary and unlike a discharge summary which may not appear for weeks is available within 24h of a patient’s discharge.

Before the implementation of the white sheet, clinic staff spent a frustratingly long period of time trying to nd answers to commonly asked questions such as, “How often should my dressing be changed?” or “Can I bear weight on my incision?” Home health nurses and skilled nursing facilities also bombard the clinic with an assortment of questions. Using the white sheet, clinic staff can quickly answer just about any question regarding a recent admission.

Part of completing a white sheet involves conrming postoperative or follow-up appointments for discharged patients. Before the document was introduced the limb service invariably lost some patients to follow-up. This was most likely to happen with patients who the limb team saw as consults. By maintaining a patient list of all patients both primary and secondary and not removing patients from the list until a discharge white sheet is completed, limb NPs ensure appropriate follow-up is arranged for every patient seen by their team.

In addition to providing a snapshot of an admission, the white sheet can be used to manage post-discharge care. Some patients with less complicated, non-surgical wounds may not need to be seen in clinic immediately after discharge. Instead the NP team will forward the white sheet to the clinic RN pool requesting the patient be called within a certain period of time and asked about the status of his or her wound. Based on the patient’s response, the RN can then either advise the patient to continue monitoring their wound or arrange a clinic appointment for them.

White sheets are also forwarded to the outpatient clinic staff of other services such as the mus-

Discharge Date:

HPI and Procedures:65-year-old male with a PMH of DM TYPE2, HTN, CKD Stage 3, seen in clinic

since 1/2020 for chronic R heel ulcer. Presents with worsening drainage, odor and pain

Procedures:

2/1 Debridement R heel, instill VAC placemen 2/4 Debridement R heel, instill VAC placemen 2/9 Debridement and closure R heel

When to Return to Clinic

Discharged to: Home or Facility Name and Phone Number

Cliffwood Health and Rehab 301-

VNA Name and Phone Number:

Dressing Change Orders

R Heel: every 3 days Remove dressing, cleanse w/ normal saline, pat dr Apply non adherent over incision Cover with gauze and wrap with rolled cast padding Apply light ACE. Reapply shoe wear provided at discharg

Non-weight bearing R LE

Nascott / DM

[X] CAM Boot

Antibiotics

Prescriber, Medication, Dose, Duration:

Davis, Vancomycin 1.5gram IVPB q 12 hr thru 3/16/202

Labs Required: Include Frequency and Fax Number:

CBC, CMP, ESR and vancomycin trough weekly to 202 555 1234

Anticoagulation:

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N. R. Megas et al.

DISCHARGE WHITE SHEET

02/11/2021

t t

: 2/21 @ 9:00 with CEA

555- 1239

Weight bearing status of operative extremity:W

none

Pain Medication, dosage and quantity prescribed:

Oxycodone 5 mg ,1-2 tabs q 4 prn, qty: 20 tabs

Fig. 4.3 Discharge white sheet

4 Integrating Inpatient Care to Your Outpatient Wound Care Center: Key to Successful Patient…

culoskeletal/soft tissue infectious disease. This keeps the service updated regarding patients who were discharged on IV antibiotics and may need follow-up with an ID attending. It also provides the necessary information needed to contact a patient’s infusion company should dosing levels or duration of therapy require adjustment.

Skillful Outpatient Clinic Care Furthers theProgress Made During anInpatient Stay

MGUH’s Center for Wound Healing sees over 300 patients a week; there are often ten exam rooms in use at a time. As the limb team’s volumes grew to this level, clinic staff learned to maximize efciency in order to see such a large number of new, follow-up, and postoperative patients. Patients are rst taken to an exam room by a medical assistant who obtains vital signs, removes any dressing, and starts the visit entry in the electronic medical record. An RN then sees the patient, documenting HPI and wound dimensions, updating medications, and further updating the visit note. Next the attending sees the patient. At this stage procedures such as debridements or biopsies may be performed and imaging may be obtained. Once the attending has nished with the patient, the RN nalizes the visit, reviews instructions, conrms follow-up plans, and initiates visiting nurse orders or starts surgery coordination packets if necessary. If orthotic or prosthetic needs exist, a specialist is available to be called into the exam room.

In addition to the limb team’s attendings, two outpatient NPs see patients in the outpatient clinic. These NPs have their own designated independent clinic days and see a variety of patient types of particular benet, they often see postoperative appointment patients and patients with chronic wounds such as venous stasis ulcers that do not require surgical intervention. By managing these patients, the NPs free up time for the team’s surgeons to spend with more complex and new patients. When not running their own clinics the NPs work alongside the surgeons during patient visits and contribute their clinical exper-

tise to the triaging of patient inquiries. In the District of Columbia NPs have full independent prescriptive privileges which allow clinic staff to turn to them to handle patient medication requests, once again, freeing up the surgeons.

Communication Between theNP Team andtheOutpatient Clinic Sta Is Critical

Recognizing their shared responsibility for a limb patient’s outcome, the inpatient NPs and outpatient nursing staff regularly communicate with one another. In addition to the exchange of information through discharge white sheets, an inpatient NP will often reach out to the clinic nursing staff with information about a patient’s admission or to discuss possible clinic follow-up options. Conversely the clinic nursing staff regularly reaches out to the inpatient NPs to alert them to details regarding a complicated admission such as a patient with poor venous access who will require a central line. In some cases where very close monitoring is warranted, arrangements are made for a patient to have RN appointments in addition to their regular provider appointments.

Day-After-Discharge Calls Flag Problems

The Joint Commission recommends hospitals develop a process that provides for timely postdischarge follow-up with patients. Ideally telephone or in-person follow-up should take place within 24–48h after discharge [7]. At MGUH, a case management staff member makes this phone call. During the call, patients are asked about their understanding of their medications, home care, and planned follow-up. Regularly information gleaned from these calls is forwarded to the inpatient NPs who then reconnect with patients to clear up any post-discharge confusion. A frequent issue encountered is the failure of home nursing services to see patients as ordered. Prior to this program’s implementation, it was not until

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N. R. Megas et al.

the rst post-op visit that the limb team became aware of the fact a patient was not receiving wound care that had been ordered. These calls also identify problems regarding the medications prescribed at discharge. Because medication errors are behind many of the adverse events patients experience following hospital discharge [8], these calls are particularly important. In some cases patients are found to be unaware of new medications prescribed for them or to not have received scripts for new medications.

Well Managed Transitions Impact aHospital’s Bottom Line

Beginning in October of 2012 the Patient Protection and Affordable Care Act instituted the Hospital Readmission Reduction Program. As part of the program hospitals were nancially penalized if they had excess readmissions among patients with select conditions. The initial round of penalties was for readmissions after admission for heart attack, congestive heart failure, or lung infection [9]. Recently knee arthroplasty was added to the program. It is reasonable to expect that over time, pressure on readmissions will be exerted on most admissions. In this environment, an effective discharge process becomes critical for a hospital’s nancial health.

Readmissions are not the only discharge related events that can negatively impact a hospital’s bottom line. 2013 Care Transition Measures were added to the Hospital Consumer Assessment of Healthcare Providers and

Systems (HCAHPS). HCAHPS is the survey tool used by the Centers for Medicare and Medicaid to determine if a facility can collect 100% of its Medicare reimbursements or is docked up to 2% in the event of poor ratings on the survey. The three questions that comprise the Care Transition Measures were:

• Question 1:“The hospital staff took my preferences and those of my family or caregivers into account in deciding what my health care needs would be when I left the hospital” (focus on when the patient was in the hospital).

• Question 2: “When I left the hospital, I had a good understanding of the things I was responsible for in managing my health” (focus on discharge preparedness).

• Question 3: “When I left the hospital, I clearly understood the purpose for taking each of my medications” (focus on medication understanding at time of hospital discharge).

With the addition of these measures, well

managed transitions are important not only for patients’ health and safety, but also for a hospital’s bottom line.

MGUH’s limb salvage patients consistently

rate their discharge experience very highly as shown in Fig.4.4 benchmarking the limb salvage team’s 2020 performance on the three care transition questions against all hospitals and against academic hospitals. The work that the limb NPs do to manage every patient’s discharge is felt to be a signicant driver for these results.

Percentile When Benchmarked Against all Hospitals

Question 1 94th96th

Question 2 98th99th

Question 3 91st90th

Fig. 4.4 MGUH limb service performance on HCAHPS care transition measures

Percentile When Benchmarked Against Academic Hospitals

4 Integrating Inpatient Care to Your Outpatient Wound Care Center: Key to Successful Patient…

Conclusion

Effectively bridging inpatient admission and outpatient care is a key element behind MGUH’s successful limb salvage program. The process, spearheaded by a team of nurse practitioners includes the fundamental elements for effective care transitions put forth by The Joint Commission in 2014: interdisciplinary coordination and collaboration of patient care in care transitions, shared accountability by all clinicians involved in care transitions, and provision of appropriate support and follow-up after discharge [10]. The process enjoys unilateral support from the team’s surgeons and residents and from the outpatient clinic staff. In addition patients and their families often communicate to the providers and staff that they appreciate the continuity of care provided by the inpatient nurse practitioners. The process’s linchpins, timely, effective communication, and attention to detail ensure smooth transitions and allow the team to maximize its rate of limb salvage successes.

References

1. Kleinpell RM, Grabenkort WR, Kapu AN, Constantine R, Sicoutris C. Nurse practitioners and physician assistants in acute and critical care: a concise review of the literature and data 2008–2018. Crit Care Med. 2019;47(10):1442–9. https://doi.

org/10.1097/CCM.0000000000003925.

2. Kripalani S, Jackson AT, Schnipper JL, Coleman EA.Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2:314–23. https://doi.org/10.1002/

jhm.228.

3. Patel H, Yirdaw E, Yu A, Slater L, Perica K, Pierce RG, Amaro C, Jones CD.Improving early discharge using a team-based structure for discharge multidisci-

plinary rounds. Prof Case Manag. 2019;24(2):83–9.

https://doi.org/10.1097/NCM.0000000000000318.

PMID: 30688821

4. The Joint Commission. Hot topics in health care, issue #2. Transitions of care: The need for collaboration across entire care continuum. 2013. http://www.

jointcommission.org/assets/1/6/TOC_Hot_Topics. pdf. Accessed 12 Jan 2021.

5. Hyldig N, Birke-Sorensen H, Kruse M, Vinter C, Joergensen JS, Sorensen JA, Mogensen O, Lamont RF, Bille C. Meta-analysis of negative-pressure wound therapy for closed surgical incisions. Br J Surg. 2016;103(5):477–86. https://doi.org/10.1002/

bjs.10084. PMID: 26994715; PMCID: PMC5069647.

6. Shiroky J, Lillie E, Muaddi H, Sevigny M, Choi WJ, Karanicolas PJ. The impact of negative pressure wound therapy for closed surgical incisions on surgical site infection: a systematic review and metaanalysis. Surgery. 2020;167(6):1001–9. https://doi.

org/10.1016/j.surg.2020.01.018. Epub 2020 Mar 3.

PMID: 32143842.

7. The Joint Comission. Hot topics in health care: transitions of care: the need for a more effective approach to continuing patient care. 2012. https://www.jointcom-

mission.org/assets/1/18/Hot_Topics_Transitions_of_ Care.pdf. Accessed 26 Dec 2020.

8. Moore C, Wisnivesky J, Williams S, McaGinn T.Medical errors related to discontinuity of care from an inpatient to and outpatient sett. J Gen Intern Med. 2003;18:646–51.

9. McIlvennan CK, Eapen ZJ, Allen LA. Hospital readmissions reduction program. Circulation. 2015;131(20):1796–803. https://doi.org/10.1161/

CIRCULATIONAHA.114.010270. PMID: 25986448;

PMCID: PMC443993.

10. Sheikh F, Garhecha E, Bellantonni M, Christmas C, Lafrenierre J, Arbaje A. A call to bridge across silos during care transitions. Jt Comm J Qual Patient Saf. 2018;44(5):270. https://doi.org/10.1016/j.

jcjq.2017.10.006.

11. Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG, Hellman R, Kim PJ, Lipsky BA, Pile JC, Pinzur MS, Siminerio L.Inpatient management of diabetic foot disorders: a clinical guide. Diabetes Care. 2013 Sep;36(9):2862–71. https://doi.

org/10.2337/dc12- 2712. PMID: 23970716; PMCID:

PMC3747877.

Diabetic Foot Ulcers

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bytheNumbers: Epidemiology ofLimb Salvage

RominaDeldar, AdaahA.Sayyed, ZoeK.Haner, andJohnS.Steinberg

Introduction

According to the International Working Group on the Diabetic Foot (IWGDF), a diabetic foot is an infection, ulceration, or destruction of the foot associated with neuropathy and/or peripheral arterial disease (PAD) in people with diabetes mellitus [1]. Diabetic foot ulcers (DFUs) are a preventable complication of diabetes that can lead to increased disability if left untreated, lower extremity (LE) amputation. DFUs have profound implications for the individual, community, and health system at large. It is estimated that 4.8 million people (7% of the population) in the UK,

30.3 million (9.4%) in the USA, and 366 million (7%) of the world’s population carry a diagnosis of diabetes [2, 3]. In 2019, the International Diabetes Federation (IDF) estimated that 463 million people globally live with diabetes and predicted that by 2045, more than 700 million people will be living with the disease [4].

R. Deldar (*) · A. A. Sayyed · Z. K. Haffner Department of Plastic and Reconstructive Surgery, MedStar, Georgetown University Hospital, Washington, DC, USA e-mail: romina.deldar@medstar.net;

zkh@georgetown.edu

J. S. Steinberg Department of Plastic Surgery, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA e-mail: John.Steinberg@medstar.net

DFUs serve as a major source of global morbidity and mortality due to repeated hospital admissions and increased risk of amputations, which may incur substantial healthcare costs [2,

4]. Approximately 50% of DFUs will become

infected, and about 20% will require LE amputation [5]. In fact, diabetic foot wounds are the most common cause of non-traumatic LE amputations worldwide and are responsible for an estimated 67% of LE amputations in the USA [6–8]. Furthermore, patients with diabetic foot complications have a high rate of recurrent foot ulcers [9] and worse survival than that of many common cancers [10]. Recent advances in management have focused on limb salvage modalities and multidisciplinary team collaboration to prevent DFUs and avoid amputations. This chapter provides an overview of the epidemiology of diabetic foot wounds, including the associated healthcare costs and implications associated with major amputations versus limb salvage efforts.

Prevalence andScope oftheProblem

The incidence of DFUs has risen secondary to the increasing worldwide prevalence of diabetes and the prolonged life expectancy of diabetic patients [11]. Among those living with diabetes, the lifetime risk of developing a DFU is approximately 25%, with up to 40% of diabetics having a risk of

https://doi.org/10.1007/978-3-031-27725-2_5

R. Deldar et al.

undergoing LE amputation [2, 4, 12, 13]. By 2050, the number of people in the USA with diabetes is expected to exceed 48.3 million, which will consequently increase the DFU burden [14,

15]. The prevalence of DFUs is estimated to be

19–34%, whereas the recurrence rate of DFUs is estimated to be 40% within 1 year and 65% within 3 years [1]. Approximately 50% of patients with DFUs will experience infectious complications that necessitate hospitalization [16, 17]. Patients with infected DFUs have a 55.7 times greater risk of hospitalization and a 154 times higher risk of amputation compared to patients with non-infected DFUs [16]. In 2006, it was reported that 1.6 million people underwent amputation in the USA; this number is expected to rise to 3.6 million in 2050 [18].

The annual prevalence of DFUs among Medicare beneciaries with diabetes is approximately 8% [19]. It has been reported that during foot ulcer episodes-of-care, all-cause inpatient admissions were 2.8 times more likely, and death was 1.5 times more likely compared to periods following healing within the same beneciaries [20]. Several possible physiological mechanisms for the independent association between foot ulceration and all-cause mortality have been hypothesized, including acute consequences of DFUs, such as severe sepsis and its sequelae (e.g., multiorgan failure), and long-term consequences such as chronic inammation of the cardiovascular and renal systems associated with DFUs [21].

The provision of comprehensive preventive care to arrest the development of DFUs in highrisk populations may improve healthcare outcomes beyond those associated traditionally with diabetic foot syndrome. Evidence-based preventive care includes routine foot exams by specialist providers, structured education regarding patient self-care, daily self-exams, use of appropriate therapeutic footwear worn by the patient at all times, once-daily foot temperature monitoring to identify inammation that could precede DFUs, and aggressive and prompt treatment of any pre-ulcerative lesions (e.g., callus or blister) [22]. A study by Isaac etal. [23] incorporated these recommended practices and found signi-

cant reductions in all-cause inpatient admissions (RRR=52%). Another study found that patients receiving preventive foot exams over 1 year had lower odds of hospitalization for any cause within that year (OR=0.67) [24].

Healthcare Costs oftheDiabeticFoot

DFUs place a signicant burden on healthcare budgets worldwide due to the complex and lengthy course of treatment from prevention of foot disease to LE amputation. Direct costs include admissions, wound dressings, antibiotics, and surgery, while indirect costs result from the social and psychological impacts of diabetic foot disease [25]. Although the largest direct expenditures are related to hospital admissions, the loss of productivity and decreased quality of life further contribute to additional expenses [25]. Compared to colorectal cancer, the costs derived from diabetic foot care contribute to three-fold higher expenses [26]. Although many studies over the past 20 years have published economic analyses of DFUs, the exact costs related to this complication are difcult to ascertain due to the complexity of the condition and variations in healthcare systems, reimbursement methods, access to care, and research methodologies.

From the time a patient is diagnosed with a DFU, the patient and hospital systems experience exponential increases in expenses; a ve-fold increase in costs occurs within the rst year following development of the ulcer, with costs rising as the severity of ulcers increases [27]. This necessitates team-based interventions and aggressive treatment strategies at earlier disease stages to try and prevent amputations. Other major sources of expenditure in patients with DFUs are the use of emergency room services and repeated hospitalizations [27]. Compared to diabetic patients without foot ulcers, DFU-related costs are estimated to add approximately 9–13 billion USD to the costs already associated with diabetes [28]. From 2006 to 2010, DFUs further contributed 1.9 billion USD to the US Emergency Department and 8.78 billion USD to inpatient

5 Diabetic Foot Ulcers bytheNumbers: Epidemiology ofLimb Salvage

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departments per year [14]. An estimated 10.5% of DFU cases underwent LE amputations, resulting in 115,957 USD cost per major amputation [14].

Few studies address the economic benets of interventions for prevention and treatment of diabetic foot disease. The most common predictive model used is the Markov model for costeffectiveness, a mathematical tool utilized to obtain projections of costs and effects for interventions [27]. Use of preventive strategies has led to reduc- tions in 5-year costs related to DFUs, with the Markov model predicting cost-savings of greater than 90% if low-cost preventive measures are implemented to reduce the incidence of DFUs and resultant amputations [26]. Educational interventions, therapeutic footwear coverage, and multidisciplinary team approaches can avoid up to 72%, 53%, and 47% of amputations, respectively. These cost reductions translate into $1,100,000, $850,000, and $750,000in potential savings within 1 year of use of each intervention, highlighting the signicant cost-saving benets of preventive measures [29].

Guideline-based management of DFUs has been shown to improve survival, reduce diabetic foot complications, and decrease cost when compared to usual care. Clinical and economic outcomes illustrate reduced amputation rates, costs, and length of stay. Emphasis on early recognition and prevention of DFUs alongside early consultation of limb preservation services is of immense importance in order to prevent signicant pathologic abnormality and increased risk of amputation.

Amputation Versus Limb Salvage

The incidence of non-traumatic LE amputations is at least 15 times greater in patients with diabetes than with any other concomitant medical illness [12]. Over 85% of major LE amputations in diabetics are preceded by foot ulcers [30, 31]. Previous studies have reported that apart from severity of ulcer, age [32], low socioeconomic status, smoking [33, 34], male sex [35], renal impairment [36], diabetic neuropathy [37], glucose levels [38], and PAD [39] are factors associ-

ated with risk of amputation [30]. Among diabetics, approximately 55% of all amputations occur in people over the age of 65 [2].

While our data shows that a well performed LE amputation in a multidisciplinary setting can greatly improve outcomes, the general literature tells us that only two-thirds of diabetic patients who undergo major LE amputation will ambulate with a prosthesis [40]. This likely contributes to why major LE amputees are three times more likely to die within 1 year of surgery compared to patients who have not undergone major LE amputation [40]. A retrospective review by Ducic and Attinger found that by preserving the limb in diabetic patients using advanced soft-tissue reconstructive techniques, the survival at 8 years was 59% [41]. Oh etal. evaluated 121 cases of reconstructed diabetic foot and reported a limb salvage rate of 84.9% and 5-year survival of 86.8% [42]. Aggressive limb salvage attempts are justied in diabetic patients with foot wounds, whenever possible...and especially when the patient has poor prosthetic rehabilitation potential.

Globally, the rate of major LE amputations is decreasing. This is likely secondary to several factors, including improved management of diabetes and its complications, advanced wound healing modalities, and increased pursuit of diabetic limb salvage. Limb salvage is dened as preservation of the ankle joint and avoidance of a major amputation [43]. Partial foot (or minor) amputations up to the level of the transverse tarsal joint (Chopart’s joint) and calcanectomies are considered to be successful limb salvage procedures. These surgeries are performed once the diabetic foot wound has been adequately debrided to healthy tissue. It has been shown that wounds heal 30% faster when debrided weekly [44]. Evans etal. [45] reported a 2-year survival rate of 80% (70 of 88 patients) following proximal forefoot and midfoot amputations, compared to 48% (12 of 25) in patients who underwent BKA. A 2014 study of 154 diabetic patients who underwent toe amputations or transmetatarsal amputation (TMA) for forefoot gangrene reported the 5-year survival of the limb salvage group was

81.6% and 36.4% for the failed limb salvage group [46]. A recent study evaluated diabetic

R. Deldar et al.

patients with ulcers of the heel, the second most common location of DFUs [47], who underwent a vertical contour calcanectomy [48] and found that nearly one-third of patients had no ulcer recurrence, amputation, or mortality 1 year after the procedure. Limb salvage efforts in diabetic patients should be considered before major LE amputations due to increased morbidity and mortality.

Socioeconomic andEthnic Disparities inDiabetic Foot Management

Research has shown a correlation between level of education and diabetes prevalence, with an estimated 12.6% of adults with less than a highschool level education having diabetes compared to 7.2% of adults with an education level greater than high school [3]. Furthermore, socioeconomic status and insurance coverage may inuence which diabetic patients will have an opportunity for limb salvage. Multiple studies have found that nonwhite, low-income, Medicare, and Medicaid patients were more likely to undergo amputation for leg ischemia and to have less access to limb salvage procedures compared with higher-income patients who had private insurance [49, 50]. A possible explanation for this observed disparity is that economically disadvantaged individuals often present with more advanced ischemia probably due to a lack of access to preventative care.

Amputation rates vary within ethnic populations across the world. Reports have shown a higher incidence of major LE amputation in African-Americans compared to Caucasian people with diabetes [51]. A Kaiser health study found that from 2011 to 2017, doctors in California performed more than 82,000 diabetic amputations; African American and Latino patients were more than twice as likely as Caucasians to undergo amputations secondary to diabetes [52]. Risk factors, such as smoking, low socioeconomic status, and poor access to healthcare, may contribute to these ethnic disparities [53, 54]. Asian diabetic patients have a

much lower incidence of LE amputation than Caucasian patients [55]. The lower prevalence of PAD and neuropathy among Asians may serve as protective factors against LE amputation [56, 57].

Mortality andOutcomes

In the USA, diabetes-related mortality has surpassed the number of deaths due to acquired immunodeciency syndrome (AIDS) and breast cancer combined [2, 3, 58]. In 2016, diabetes was the direct cause of 1.6 million deaths [59]. There is a signicant mortality risk associated with development of DFUs. A 2015 study from the UK demonstrated the 5-year mortality risk for patients with DFUs is 2.5 times higher than diabetic patient without a foot ulcer [60]. A similar study in Norway showed the 10-year mortality risk was twice as high for patients with history of DFU compared to diabetic patients without history of foot ulceration when adjusted for age, sex, and various comorbidities [61]. The 1-year mortality rate for DFU patients alone is estimated to be 5% [62]. This mortality rate increases up to 25% if the DFU becomes infected [63]. The mortality rate dramatically increases up to 68% at 5 years, a rate comparable to several types of cancer and congestive heart failure [58, 63, 64]. Furthermore, DFU patients typically present with metabolic syndrome, the constellation of insulin resistance, central obesity, dyslipidemia, and hypertension, placing them at increased risk of cardiovascular events [64].

Even with aggressive management, many DFUs will eventually require LE amputation, often within just 4 years of diagnosis. The risk of amputation in diabetics is 30–40 times higher than non-diabetics [64]. Following major LE amputations, 30-day mortality rates of 5.7% for below-knee amputations and 16.5% for aboveknee amputations have been reported [65]. A recent systematic review found that following major LE amputation, mortality is estimated at over 33%, 53%, 64%, and 80% at 1, 3, 5, and 10 years, respectively [66]. A New Zealand study evaluating 300,000 patients who underwent

5 Diabetic Foot Ulcers bytheNumbers: Epidemiology ofLimb Salvage

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major LE amputation observed an overall 30-day mortality rate of 11% and 90-day mortality rate of 18% [67]. Infected DFUs that require emergent amputation carry a mortality risk of up to 50% due to severe sepsis and the effects of tissue necrosis [68]. In general, more proximal LE amputations in diabetic patients are associated with higher in-hospital and 30-day mortality [69].

Mortality risk following with LE amputation increases with concurrent PAD and renal disease [70, 71]. One-year survival rate after LE amputation in patients with end-stage renal disease (ESRD) on hemodialysis is estimated to approach 50% [72], which is notably lower than those of patients who are hospitalized for heart failure or myocardial infarction. In comparison, diabetic limb salvage procedures, such as minor LE amputations, portend signicantly lower mortality rates compared to major amputations. A metaanalysis found the mortality rates after minor amputation in diabetic patients to be 3.5% at 1 month, 20% at 1 year, 28% at 3 years, 44.1% at 5 years [59]. Therefore, whenever possible, limb salvage should be attempted in diabetic patients who present with foot ulcers to minimize morbidity and mortality.

Financial Disclosure Statement The authors have no nancial disclosures, commercial associations, or any other conditions posing a conict of interest to report.

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