Issue: Volume 65 - Issue 8 - August 2019 ISSN 2640-5245
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From a wound care clinician’s perspective, the results of a recent study that show an increase in the rate of nontraumatic lower extremity amputations in young and middle-aged1 persons with diabetes mellitus are almost counterintuitive. After decreasing 43% between 2000 and 2009, the amputation rate among adults with diabetes mellitus increased 50% between 2009 and 2015 to a point that is just slightly lower (4.62 per 1000 persons) than the rate in 2000 (5.38 per 1000). The increase was statistically significant among young (18–44 years) and middle-aged (45–64 years) adults.
Ironically, during that same time, we saw a substantial increase in knowledge about diabetes, diabetes management, and risk factors for lower leg foot wounds and amputations; plus, clinicians had ready access to a plethora of guidelines to help them manage diabetes mellitus and prevent foot ulcers and amputations.2-5 In addition, if a wound does develop, we know what is needed to help it heal and to prevent complications such as amputations; we know offloading devices and techniques must be used and how to use them.5,6 Although evidence to substantiate the efficacy of one “modern” dressing type versus another or one type of growth factor versus another has not been clearly established,7,8 the basics of topical care — that is, keep the wound free of pressure, free of necrotic tissue, and moist — are well known.2-4,6
So what is the problem? Why did this knowledge not translate into further reductions in lower extremity amputations, especially when we consider these data do not include outpatient procedures such as minor amputations, where the largest increase (62%) was observed. This could suggest a change in clinical decision making (eg, earlier intervention to reduce the risk of major complications), but the rate of major amputations also increased. Although examining reasons for this change in trend was not the purpose of the study by Geiss et al,1 the authors speculated that the characteristics of the population had changed, in part because of the great recession. In other words, these adults may not have had access to the care available. Most likely and not coincidentally, after years of declining, the rate of emergency room admissions due to other complications of diabetes such as hyperglycemic crises, stroke, and acute myocardial infarctions also has been increasing in persons <65 years of age since 2009.9 By contrast, rates among persons >65 years of age (covered by Medicare) continue to slowly decline.
The number of uninsured and underinsured adults increased by tens of millions when the recession started in 200710 while (for example) the cost of insulin almost tripled between 2009 and 2015.11 At the same time, almost 50% of adults who currently have insurance have plans with high deductibles that, especially among lower income adults, increases the risk of delays in seeking care and affects their ability to optimally manage glucose levels.10,12
When all is said and done, the recent increase in diabetes complication rates in young and middle-age adults does not appear to be related to what clinicians do or do not know nor about what they are or are not doing. Rather, it appears to be another example of the potential effects of social determinants of health, aggravated perhaps by recent losses of health insurance coverage and health insurance changes. According to predictions rendered 43 years ago (!), the “poor and sick” would experience increased long-term mortality under high-level cost sharing plans.13 The questions before us now are: 1) How can we help the patients who need us the most? 2) How can we maximize their potential for self-management? 3) What are we going to do to address the deleterious effects of ongoing health insurance changes and increases in costs of care on the health of millions of Americans, all while continuing to provide the best care we know how?
The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP. This article was not subject to the Wound Management & Prevention peer-review process.
