Partnering With Your Patients With Diabetes
January 2020 Issue
Treating patients with diabetes has always been an uphill battle for most O&P practitioners, and an increasing diabetic population means the challenges will continue to grow, the experts say.
"The diabetic foot is one of the biggest challenges we face because of the many complications," says Dennis Janisse, CPed, consultant for Dr. Comfort, and assistant professor in the Department of Physical Medicine and Rehabilitation at the Medical College of Wisconsin, and CEO of National Pedorthic Services, headquartered in Brookfield, Wisconsin. "Diabetes isn't an easy disease. It's a tough disease for the patient, tough for the practitioner, and the numbers are just increasing."
Some of the issues that can pose challenges include:
- Health issues associated with diabetes that make it a difficult disease to treat
- Insurance coverage that limits the treatment options for diabetic patients
- Difficulty in motivating patients who may underestimate the complications
To help their patients, experts say that O&P practitioners need to be knowledgeable about the risks and work together with their patients to keep an eye out for potential complications.
"Whether it's orthotic or prosthetic involvement, if we can get these patients educated and get more eyes on them, we stand a better chance of discovering problems before they reach a critical stage," says Scott Cummings, PT, CPO, FAAOP, NextStep Bionics and Prosthetics, headquartered in Manchester, New Hampshire.
A Growing Problem
The population of people with diabetes has ballooned in recent years and is expected to increase even more in the coming years. According to the Centers for Disease Control and Prevention, more than 30 million people in the United States have diabetes. Also, more than 84 million adults—one in three—have prediabetes. By 2030, the Institute for Alternative Futures estimates that 54.9 million people will have diabetes, a 54 percent increase from 2015.
The rate of patients with complications tied to diabetes is also growing. According to the American Diabetes Association, about six in 100 U.S. patients have diabetic foot ulcers and about four in 1,000 will have a lower-limb amputation.
If a patient develops ulcers, that patient is much more likely to continue having complications. According to a 2017 study in the New England Journal of Medicine, patients with diabetic foot ulcers are 2.5 times more likely to die within five years. More than half of diabetic ulcers become infected and about 20 percent of infections will lead to some sort of amputation. Recurrence of ulcers is so prevalent that study authors recommend ulcers should be thought of as being in remission rather than healed. According to the results of the study, 40 percent of patients with a diabetic ulcer have a recurrence within one year after ulcer healing, almost 60 percent have a recurrence within three years, and 65 percent within five years.
With sobering statistics like these, the experts say that vigilance is key in the treatment of patients with diabetes. Especially with this disease, it's better to prevent problems, they say. Once the complications start, they can be difficult to control.
"It's almost a snowball effect if you don't have proper management," Janisse says.
Experts say that the challenge of treating patients with diabetes is that the disease itself makes it difficult for the patient to recognize potential complications in a timely manner. Some of these health complications include:
- Diabetic neuropathy, the loss of protective sensation, prevents the patient from feeling potential problems.
- Loss or deterioration of vision prevents the patient from being able to see potential problems.
- Obesity or loss of flexibility can make it difficult for patients to inspect their feet from all angles.
- A compromised immune system slows the healing process for the patients, and any wound that appears is more difficult to treat.
If a patient doesn't recognize the problem in time, his or her daily O&P intervention, such as using an orthosis or prosthesis, can make the situation even worse.
"They can't feel it, they can't see it, they end up with an open area that won't heal quickly and then we put it back into a dark, moist environment [of the socket]," says Cummings. "That's the perfect environment to cultivate a fungus or bacteria, and we're seeing the instances jump."
Of all of the contributing health issues, neuropathy is most likely to lead to complications, the experts say. Neuropathy is the common factor in almost 90 percent of foot ulcers, according to the journal Diabetes Therapy.
"That's why people get the ulcers," Janisse says. "They could have something in their shoe they don't know about or could be wearing a shoe that is way too small. If you had a stone in your shoe, you would stop and take it out. They don't feel it and could walk in the shoe all day long and by the end of the day, they'd have a hole in their foot. Then if they don't take care of it and it gets infected, it often leads to amputation."
Since patients often can't tell if they are losing sensation, O&P practitioners should always test for neuropathy instead of waiting for a patient to report it.
"If you ask if they have sensory loss, everyone will say no because they really have no idea; many times no one has addressed their sensation," Janisse says.
According to the International Diabetes Federation, testing for loss of sensation is the most important part of the foot exam. The federation recommends practitioners use a 5.07 monofilament, using 10 grams of pressure to assess the four main areas on the plantar surface. If the patient cannot feel even one of those areas, their risk category increases.
"You can have a totally normal foot, but if you can't feel the monofilament, it takes you from a zero to one risk category," Janisse says. "That means if there was a bulky seam in the shoe, there's a good chance the patient couldn't feel it." (See sidebar at right for more information about risk categorization.)
For patients who may have already had amputations, Cummings says that prosthetists should be extra careful in checking for skin health, both at their amputation site and on their sound side.
"We want to make sure there is no blistering and no areas of discharge," he says. "Patients put all sorts of lotions and creams on their residual limb and that's not always a good thing. But you do not want the skin to be overly dry."
He says he always explains to patients that the amputation did not eliminate their future risks. In fact, their sound side foot is now at more risk after the amputation, he says.
"They need to always be looking for warning signs," he says.
Even the most vigilant practitioner can't win the battle against diabetic complications if patients aren't on board, the experts say. Patients and practitioners need to be partners in the fight.
Unfortunately, that can be tough when so many patients underestimate their disease or aren't compliant with health recommendations, they experts say.
"Some folks with diabetes underestimate the warning signs and won't recognize the significance of them," Cummings says. "Having seen enough of these signs, I bring them to their attention and state how significant they can be."
"Educating patients, that is really important," Cummings says. "Some patients get it and some patients don't."
He always asks his patients about their sound side foot, but has learned through the years to not always accept the answer he gets.
"The first answer they give is almost always ‘fine,'" he says. "In my experience, that's not always true."
He often asks additional questions that might get more information or even asks them to show how they inspect their feet so he can make sure they are doing it properly.
"I drill down a little deeper and don't take their initial answers," he says. "I tend to follow up more aggressively."
Many times, Janisse says, patients aren't to blame if they aren't taking care of their foot as well as they should.
"It's hard to take care of your foot if you can't feel it," he says. "They need to be educated about what to look for so they can take responsibility for themselves."
Janisse says to help patients fully participate in their care, he is honest with them about what they could face and also about what he has seen in his career.
"I don't believe in scare tactics; I don't go there," he says. "But I will talk about personal experiences and what I have seen. It makes it more real if you can talk about a real person."
He says he also keeps brochures on hand that he can give his patients so they have reference material they can keep at home.
Convincing patients to wear the best footwear can also be difficult, the experts say. Many times patients won't wear the shoe that is best for their foot health because they don't like the look of it.
"I don't think diabetic patients understand the critical importance of their footwear because they don't feel the difference," says Robert Schwartz, CPed, president and CEO of Eneslow Pedorthic Enterprises, headquartered in New York. "Even though many have the shoes they are supposed to wear in their closet, there's evidence they aren't wearing them or are only wearing them occasionally."
Education about why they need to wear their specialized shoes is important, Schwartz says. Some companies have worked to make a better-looking shoe for patients with diabetes, but reimbursement levels are so low that O&P practitioners don't have a lot of options for what they can offer.
Limitations of Treatment
In 1998, the U.S. Congress passed the Diabetic Therapeutic Shoe Bill, which made it possible for Medicare patients with diabetes to receive a new pair of therapeutic shoes and three sets of inserts per year.
Patients without money who needed these shoes suddenly had access to them. Janisse was one of the consultants for the bill and says that even though it gave more patients access, often it's still not enough. Not only that, but some patients may now have worse shoes than they would have had before the bill, he says.
"What Medicare pays for isn't the ultimate solution," he says. "It's definitely appropriate for people at the lower end of the risk scale and the allowance for the shoes is adequate. Where we run into a problem is the most important part of the prescription is the part that goes next to the foot."
He says the allowance for most inserts is about $90.
"For most practitioners, a good foot orthotic is $300 to $600," he says.
"There are guidelines to a certain degree about what it's supposed to be made out of and as a result, the people with serious complications don't necessarily get the best solutions unless they are willing to pay for it out of pocket."
Before the Therapeutic Shoe Bill, pedorthists had more options when it came to treating their patients with diabetes, Janisse adds.
"From a footwear standpoint, we actually did a better job before Medicare started paying for the shoes," he says. "We had more of a selection of shapes of shoes, but when Medicare started paying, all of a sudden everyone had to have shoes that fell within the reimbursement range, and the manufacturing went overseas, and we lost the variety of shapes and sizes."
That standardization in manufacturing means that many patients aren't getting the best shoe for their unique foot, Schwartz says.
"The Therapeutic Shoe Bill made the delivery system more routine than a diabetic shoe really should be," he says. "It tends to offer ready-made components dispensed by people who don't have the skills to modify and customize for best results. It narrowed the profile of care to things that were less expensive rather than things that were best."
Before the bill, it was easier to give patients what they needed, he says.
"Once it starts to have a fixed retail price, you have to have a lower fixed cost," Schwartz says. "In the old days before the bill, you just did the right thing and some things were more expensive and some things were less expensive."
Schwartz disliked the system so much that he is no longer a Medicare provider. Now he only takes patients who pay out of pocket and want quality, customized shoes.
"We were not willing to sell cheaper shoes in order to fit the financial formula," he says. "We were not willing to do the cheaper inserts. We wanted to give the best products for each person's needs, and we were inhibited from doing that."
The decision cost him $500,000 in revenue, but he says it was the right choice for his business.
"The only diabetic patients we still have are the hard-core cases where we try to save peoples' feet," he says. "Only patients who want the very best care and are willing to pay for it. That's a narrow population."
With solutions sometimes limited, that makes it even more important for O&P practitioners to be vigilant about the care of their patient with diabetes, the experts say.
After spending much of their careers treating patients, the experts say they have learned one main lesson: Don't underestimate diabetes.
Cummings says that he now spends much more time educating his patients with diabetes about possible complications than he spent at the beginning of his career.
"I tend to follow up more aggressively…. I also tend to spend more time reviewing the information multiple times. Every visit I give them another dose of instructions and what to watch out for."
If he sees something potentially concerning, he's more likely to suggest a patient make an appointment to see a physician, instead of waiting for the next scheduled checkup.
"I'm more likely to say, ‘I'm not crazy about the look of this, can you give your doctor a call?'" he says. "Sometimes it's ok, but there have been some instances when a doctor will tell me that we caught it just in time."
Janisse says he is more likely to take more documentation on his cases than when he started. He will take pictures of ulcers so he can track their progress and to protect himself if patients have concerns with their care. He's also much more likely to ask for more frequent follow-up appointments than he might for his other patients.
"Some of my patients with more serious complications, I see every two weeks," he says. "With this disease, we need to take a little more responsibility and management." When Janisse saw his first patient with diabetes, he didn't have firsthand knowledge of the effects of the disease. Now, with years of experience and seeing the many different turns his patients have taken, he takes diabetes very seriously.
"When you get into the nitty gritty, when you see the ulcers and deformities and how it effects peoples' lives, it really hits home."
Maria St. Louis-Sanchez can be contacted at firstname.lastname@example.org.