Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting.
BACKGROUND
While lower-extremity amputation (LEA) is a frequent complication of diabetes, effective strategies for the prevention of LEA in primary care settings have not been extensively studied.


METHODS
This prospective study of American Indians with diabetes in a rural primary care clinic was divided into three periods: the standard care period (1986 to 1989), during which patients received foot care at the discretion of the primary care provider; the public health period (1990 to 1993), during which patients were screened for foot problems and high-risk individuals received foot care education and protective footwear; and the Staged Diabetes Management (SDM) period (1994 to 1996), during which comprehensive guidelines for diabetic foot management were adapted by the primary care clinicians to their practices and were systematically implemented.


RESULTS
A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation. Patient sex distribution, mean age, and mean duration of diabetes were similar i the three periods. The average annual LEA incidence was 29/1000 diabetic person-years for the standard care period (n = 42), 21/1000 for the public health period (n = 33), and 15/1000 for the SDM period (n = 20), an overall 48% reduction (P = .016). Overall, the incidence of a first amputation declined from 21/1000 to 6/1000 (P < .0001).


CONCLUSIONS
The customization and systematic implementation of practice guidelines by local primary care providers was associated with improved diabetic foot care outcomes. SDM has relevance to primary care organizations seeking to improve outcomes for patients with diabetes.
Rith-Najarian
S
S
Bemidji Area Indian Health Service Diabetes Program, Minnesota 56601, USA. srithnajarian@nchs.com
Branchaud
C
C
Beaulieu
O
O
Gohdes
D
D
Simonson
G
G
Mazze
R
R
D000328:Adult; D000368:Aged; D000671:Amputation, Surgical / Q000706:statistics & numerical data*; D017719:Diabetic Foot / Q000145:classification / Q000175:diagnosis / Q000517:prevention & control / Q000628:therapy*; D005260:Female; D006801:Humans; D007198:Indians, North American; D008297:Male; D008875:Middle Aged; D008910:Minnesota; D010353:Patient Education as Topic; D010817:Physician-Patient Relations; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000458:organization & administration; D011446:Prospective Studies; D012307:Risk Factors