title: Implementation of routine foot check in patients with diabetes on hemodialysis: associations with outcomes.
abstract: OBJECTIVE
  Patients with diabetes are at increased risk of foot ulcers, which may result in limb amputations. While regular foot care prevents ulcerations and amputation in those patients with diabetes not on dialysis, evidence is limited in diabetic hemodialysis patients. We investigated the association between the implementation of a routine foot check program in diabetic incident hemodialysis patients, and major lower limb amputations.
  
  
  METHODS
  In 1/2008, monthly intradialytic foot checks were implemented as part of standard clinic care in all Fresenius Medical Care North America hemodialysis facilities. Patients with diabetes who initiated hemodialysis between 1/2004 and 12/2007 constituted the preimplementation cohort, and patients starting hemodialysis between 1/2008 and 12/2011 comprised the postimplementation cohort. In addition, we conducted a sensitivity analysis where we excluded patients from the clinics with <10 patients in the postimplementation period and where percent difference in patient with diabetes number between postimplementation and preimplementation period was <20%. We compared lower limb amputation rates employing Poisson regression models with offset of exposure time in these two cohorts.
  
  
  RESULTS
  We studied 35 513 patients in the preimplementation and 25 779 patients in the postimplementation cohort. In the postimplementation cohort, amputation rate decreased by 17% (p=0.0034). The major lower limb amputation rate was 1.30 per 100 patient years in preimplementation and 1.07 in postimplementation cohort. These beneficial results were corroborated in the multivariate analysis (p=0.0175) and were even more pronounced in the sensitivity analysis (p=0.0083).
  
  
  CONCLUSIONS
  Monthly foot checks are associated with reduction of major lower limb amputations in diabetic incident hemodialysis patients.
authors.affiliation: University Medical Center Ljubljana, Ljubljana, Slovenia; Renal Research Institute, New York, New York, USA.
authors.forename: Andreja
authors.initials: A
authors.lastname: Marn Pernat
authors.affiliation: University Medical Center Ljubljana, Ljubljana, Slovenia; Renal Research Institute, New York, New York, USA.
authors.forename: Vanja
authors.initials: V
authors.lastname: Peršič
authors.affiliation: Renal Research Institute, New York, New York, USA; Fresenius Medical Care North America, Waltham, Massachusetts, USA.
authors.forename: Len
authors.initials: L
authors.lastname: Usvyat
authors.affiliation: Renal Research Institute , New York, New York , USA.
authors.forename: Lynn
authors.initials: L
authors.lastname: Saunders
authors.affiliation: Fresenius Medical Care North America , Waltham, Massachusetts , USA.
authors.forename: John
authors.initials: J
authors.lastname: Rogus
authors.affiliation: Fresenius Medical Care North America , Waltham, Massachusetts , USA.
authors.forename: Franklin W
authors.initials: FW
authors.lastname: Maddux
authors.affiliation: Tufts University School of Medicine , Boston, Massachusetts , USA.
authors.forename: Eduardo
authors.initials: E
authors.lastname: Lacson
authors.affiliation: Renal Research Institute, New York, New York, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA.
authors.forename: Peter
authors.initials: P
authors.lastname: Kotanko
keywords: End Stage Renal Failure; Foot Care; Lower Extremity Complications