Wound Care for Patients With Diabetes: Why Have Outcomes Not Matched Innovations?

My career in medicine has spanned approximately 26 years. My first year of residency training was 1996. This year also marked my first real exposure to the then emerging specialty of wound care. To put things into perspective, during that first year of training, I recall noting approximately 300 to 500 wound care products on the market. That may seem like a lot, especially considering there are now thousands of products that wound providers and others may choose from. Consider, however, that when I began clinical practice, the resources available were considerably different when compared to what is available today.

In 1996, hydrogels and alginates were cutting edge. Additionally, there were:

·      no negative pressure wound therapy systems;

·      no cellular- and tissue-based products;

·      no engineered topical growth factors;

·      no endovascular revascularization options;

·      no simple total contact casting systems;

·      no collagen dressings;

·      no silver-impregnated dressings;

·      no honey, fish, bovine, ovine, or porcine wound products.

In my observation and experience, there were other differences in the wound care space, as well. Managed wound care was limited. Hyperbaric oxygen therapy was not a significant modality, nor used to the extent it is today. Clinicians did not use magnetic resonance imaging (MRI) with significant frequency versus bone scans, computed tomography (CT) and plain film radiographs to assess for osteomyelitis, let alone to detect the presence of a deep abscess. Algorithms for managing diabetic foot ulcers (DFUs) and venous leg ulcers (VLUs) were not readily available or accessible.

Additionally, I remember there were other things that did not exist as they do today:

·      methicillin-resistant Staphylococcus aureus (MRSA);

·      the internet;

·      smart phones with digital photography;

·      electronic medical records (EMRs);

·      overall information and research;

·      the team approach of Toe and Flow¹; and

·      liberal use of any dressing other than wet-to-dry.

I can only imagine how the lives of many of my patients, let alone my own life, would have been positively impacted if, when I was beginning my career, I had access to any number of the items on these lists. I have seen the wound care community grow in so many ways, and as our specialty emerges, it attracts more outstanding, dedicated professionals. I’ve also seen recognition arise from related specialties, such as infectious disease, interventionists (cardiology, radiology, and vascular surgery), endocrinology, nephrology, hospitalists, and others, who recognize the importance of the service that wound care professionals and podiatrists provide.

Where is the Disconnect?

At times it seems like the experiences of 1996 happened a few days ago, and other times, they feel like another lifetime. One would like to think that with all the technological advancements in wound healing and limb preservation over the past 25-plus years, that things would improve accordingly. Unfortunately, they have not. At least where the management of DFUs and non-traumatic amputation are concerned, things have gotten progressively worse since 2009.² For a while, lower extremity amputation rates seemed to decline, for reasons partially attributable to some of the technologies mentioned above, as well as embracing a team approach to wound healing. 

Why do some studies show not only an increase in minor amputation, but in amputation at every level from toe to above the knee? Between 2010 and 2015, amputation rates rose to 4.6 per 1,000 patients, exceeding their previous high in 2000. There has been a steady increase in amputation rates since 2012 and 2015, as presented in January 2019 in Diabetes Care by Geiss, Yanfeng, and colleagues.²

Based on personal observation and informal polling of my colleagues, an additional disturbing trend has also exists. Growing acuity of wounds and underlying comorbidities in younger patients are increasingly more apparent, as well as validated by Geiss and Yanfeng.² The increases in rates of total, major, and minor amputations were most pronounced in young (age 18 to 44 years) and middle-aged (age 45 to 64 years) adults and more pronounced in males than females.²

We must ask ourselves and reflect upon why this is the case. For starters, in 1996, we had approximately 16 million people in the US living with diabetes. As of 2021, there are approximately 34.2 million in an ever-increasing general population of 331 million, that also includes an estimated 88 million with prediabetes, according to Centers for Disease Control annual statistics.³

Diabetes certainly plays a prominent role in these sobering statistics, but diabetes alone is not the only variable to consider. Access to care may be a factor, which Tan and colleagues explored in “The Affordable Care Act Medicaid Expansion Correlated with Reduction in Lower Extremity Amputation among Minorities with DFU” in Diabetes in June 2020.⁴ They performed a comparison of states’ early adoption of expanded Medicaid services via the Affordable Care Act versus states that were not early adopters. Among noteworthy findings, odds of major lower extremity amputation among non-white Medicaid patients decreased by 17.3 percent in early adopter states, while major lower extremity amputation rates increased by 1 percent in non-adopter states.⁴

Working Toward Solutions

Finding a cause is certainly imperative when attempting to solve any problem. The more pressing question as it pertains to wound healing and amputations may be, how do we arrive at solutions, especially when the availability of resources to heal wounds is greater than ever? Might we find these solutions with future breakthroughs in pharma, medical devices, findings from research in wound healing, or some other area? Possibly.

I believe that the one area of focus that will determine success or not, will be the role of the patients, and their collective engagement. Ultimately, we know it is better to prevent than it is to treat. Educating patients with ways to become more proactive when managing their diabetes is certainly challenging, especially once they reach the stage where foot wounds become a reality. Do patients really understand what is at stake, not only once diagnosed with diabetes, but at the onset of their first wound? 

To appreciate the impact that education of patients and their support systems, as well as how self-assessment and early recognition can play a vital role in better outcomes, one only need to look at breast cancer and how self-examination and buddy checks positively impact the lives of those (and their loved ones) with that disease.

It is imperative that we address what has become an overwhelming stress on everyone from patients, providers, and the health care system. Despite the advances in wound care technologies, perhaps the most impactful solutions will result from being proactive versus reactive.

Dr. Desmond Bell is the Founder and President of the Save A Leg, Save A Life Foundation, a multidisciplinary non-profit organization dedicated to the reduction in lower extremity amputations and improving wound healing outcomes through education, evidence-based methodology and community outreach. He also serves as Chief Medical Officer of Omeza, an evidence-based medical technology company and consumer healthcare products company initially focused on healing chronic wounds and preventing their recurrence. In 2020, he joined MD Coaches as an Executive Physician Coach, serving as a peer-to-peer mentor.

This article originally appeared in Today’s Wound Clinic. It is adapted with permission. The original article can be found here.

1.   Rogers LC, Andros G, Caporusso J, Harkless LB, Mills Sr JL, Armstrong DG. Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg. 2010;52(3 Suppl):23S-27S.

2.   Geiss LS, Yanfeng L, Hora I, Albright A, Rolka D, Gregg EW. Resurgence of diabetes-related nontraumatic lower-extremity amputation in the young and middle-aged adult U.S. population. Diabetes Care. 2019;42(1):50–54

3.   Centers for Disease Control and Prevention. Diabetes Basics. Available at: https:www.cdc.govdiabetesbasicsindex.html . Revised December 21, 2021. Accessed March 29, 2022.

4.   Tan T, Calhoun E, Knapp S, Marrero D, Wei Z, Armstrong D. The Affordable Care Act Medicaid expansion correlated with reduction in lower extremity amputation among minorities with DFU. Diabetes. 2020;69(Supplement 1):217-OR.