Podiatric care for diabetic patients is associated with reduced risk of major amputation and death

1. For diabetic patients undergoing hemodialysis, receiving foot and ankle care from a podiatrist within 3 months of a new diabetic foot ulcer diagnosis was associated with a reduced risk of major amputation and death.

Evidence Rating Level: 2 (Good)

Study Rundown: Diabetic foot ulcers (DFUs) are a significant complication of diabetes, contributing to 80% of lower extremity amputations, as well as diminished quality of life and greater mortality risk. About 10-32% of patients undergoing hemodialysis also suffer from active DFUs. Previous studies suggest that the onset of hemodialysis increases the risk of developing DFUs among those with diabetes. In this retrospective cohort study, researchers aimed to determine whether receiving foot and ankle care from a podiatrist has an impact on the risk of major amputation or death for those who develop a diabetic foot ulcer while undergoing hemodialysis. In this retrospective cohort study of 14,935 participants with both diabetes and renal failure, 18.4% received podiatry care within 3 months of a new DFU diagnosis. Those who were followed by a podiatrist had a reduced risk of major amputation or death, compared to those who did not receive podiatry care. Overall, this study suggests that patients with renal failure who are at risk for DFUs may benefit from podiatry care to reduce the risk of diabetes-related amputations and mortality. 

Click to read the full study in JAMA Network Open

In-Depth [retrospective cohort study]: 14,935 adult patients with diabetes and renal failure undergoing hemodialysis were included in this retrospective cohort study, using data from the United States Renal Data System. All participants were Medicare beneficiaries. The index date was 2017, which was the time of the first DFU diagnosis. Participants were excluded from this study if they had a prior DFU in 2016, a history of major amputation, or a prior renal transplant. The remaining participants, mean (SD) age, 59.3 (12.7) years, were 55.4% male, 2.7% Asian, 35.0% Black/ African American, 17.7% Hispanic, and 58.5% White. Overall morbidity and mortality were high for this population, with 28.3% of participants undergoing a major amputation and a mortality rate of 44.6%. 

The main exposure of this study was foot and ankle care by a podiatrist, provided during the 3 months leading up to diagnosis of a DFU. 2736 of the participants received podiatry care, while 12,199 did not. Those receiving care from a podiatrist were more likely to be male, older, and have a greater burden of comorbidities  74% of those without podiatry care experienced major amputation and/or death, while these outcomes occurred for 70% of those with podiatry care. Podiatry care was associated with an 11% reduced risk of death or amputation (hazard ratio [HR], 0.89 95% CI, 0.84-0.93) compared to those without this care, determined via multivariate regression analysis. Overall, this study demonstrates that patients receiving dialysis who are receiving foot and ankle care from a podiatrist have a reduced risk of lower limb amputations and death. A limitation of this study is that the frequency of podiatry care was unknown, and it was also unknown whether participants were receiving foot and ankle care from other sources, such as their primary care providers. As well, the follow-up period of this study was relatively short, which limits the ability to draw more long-term conclusions. Overall, this study demonstrates that among diabetic patients undergoing hemodialysis, receiving foot and ankle care from a podiatrist within 3 months of a new DFU diagnosis is associated with a reduced risk of major amputation and death. 

Image: PD

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