A Health Care Provider’s Guide to Preventing Diabetes Foot Problems pptx

Partners who contributed to the development of this national effort include: American Association of Diabetes Educators American Diabetes Association American Orthopaedic Foot & Ankle So

F e e t C a n L a s t

a L i f e t i m e

A Health Care Provider’s Guide to Preventing Diabetes Foot Problems

“ eet Can Last A Lifetime” was produced by the National Diabetes Education Program (NDEP) The NDEP

is a partnership among the National Institutes of Health, the Centers for Disease Control and Prevention,and over 200organizations Partners who contributed to the development of this national effort include:

American Association of Diabetes Educators

American Diabetes Association

American Orthopaedic Foot & Ankle Society

American Podiatric Medical Association

Centers for Disease Control and Prevention

Health Care Financing Administration

Health Resources and Services Administration

Indian Health Service

Juvenile Diabetes Foundation International

New Mexico Medical Review Association

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health

Pedorthic Footwear Association

Veterans Health Administration

A joint program of the National Institutes of Health

F

F e e t C a n L a s t

a L i f e t i m e

A Health Care Provider’s Guide to Preventing Diabetes Foot Problems

A c k n o w l e d g m e n t s

Many people have contributed to the development of this kit Almost 20,000 copies of the kit have

been ordered since its first printing in 1998 Before reprinting this second edition, the original materials were reviewed, revised and updated Re p re s e n t a t i ves from the “Feet Can Last a Lifetime”

p a rtner organizations offered substantive comments on the content and presentation of the material for this second edition They are listed below

American Association of Diabetes Educators Council on Foot Care, American Diabetes Association Council on Foot Care, American Diabetes Association American Diabetes Association

Clinical Affairs, American Diabetes Association American Orthopaedic Foot & Ankle Society American Podiatric Medical Association Lower Extremity Amputation Prevention Program, Bureau of Primary Health Care, HRSA

Centers for Disease Control and Prevention, Division of Diabetes Translation

Centers for Disease Control and Prevention, Division of Diabetes Translation

Food and Drug Administration Health Care Financing Administration Health Care Financing Administration New Mexico Medical Review Association New Mexico Medical Review Association Bemidji Area Indian Health Service, PHS Indian Hospital, Cass Lake, Minnesota

Indian Health Service Diabetes Program Juvenile Diabetes Foundation International National Diabetes Education Program, NIDDK, National Institutes of Health

National Diabetes Education Program, NIDDK, National Institutes of Health

Pedorthic Footwear Association Veterans Health Administration, Louis Stokes Cleveland DVAMC National Diabetes Education Program, Contract Staff National Diabetes Education Program, Contract Staff

Christine Tobin, R.N., M.B.A., C.D.E.

Sharley Chen, Director

Melinda Salmon, Public Health Advisor

Dawn Satterfield, C.D.E.

Ann Corken, R.Ph, M.P.H.

Connie Forster Sharon Hippler Fred Pintz, M.D.

Leslie Shainline, R.N.C., M.S.

Stephen Rith-Najarian, M.D.

Lorraine Valdez, R.N., M.P.A., C.D.E.

Shira Kandel Joanne Gallivan, M.S., R.D.

Mimi Lising, M.P.H.

Nancy Hultquist Jeffrey Robbins, D.P.M.

Elizabeth Warren-Boulton, R.N., M.S.N., C.D.E.

Rachel Greenberg, M.A.

I n t ro d u c t i o n 2

T O O L S F O R D I A B E T E S F O O T E X A M S Tools for Diabetes Foot Exams 4

Flow Chart for Diabetes Foot Exams 5

Diabetes Foot Exam Pro c e d u re s 6

Quality of Care Measure s 7

Foot Exam Instru c t i o n s 8

Visual Foot Inspection 8

Annual Comprehensive Diabetes Foot Exam 9

Annual Comprehensive Diabetes Foot Exam Form 15

M E D I C A R E I N F O R M AT I O N M e d i c a re Coverage of Therapeutic Footwear for People with Diabetes 1 8 Statement of Certifying Physician for Therapeutic Footwear 1 9 P rescription Form for Therapeutic Footwear 1 9 R E F E R E N C E A N D R E S O U R C E M AT E R I A L S P revention and Early Intervention for Diabetes Foot Problems: A Research Review 2 2 R e s o u rce List 3 5 PAT I E N T E D U C AT I O N M AT E R I A L S " Take Care of Your Feet For A Lifetime"—Foot Care Ti p s for People with Diabetes 43

" To Do" List—for People with Diabetes 4 5

A D D I T I O N A L T O O L S

High Risk Feet Stickers for Medical Record

Flyers for Exam Room—in English and Spanish

Quick Reference Pocket Card with Disposable 5.07 (10gram) Monofilament Attached (See insert at page 15)

C o n t e n t s o f t h e K i t

National Hospital Discharge Survey Data indicate that 86,000people with diabetes in the United States

underwent one or more lower-extremity amputations in 1996 Diabetes is the leading cause of tion of the lower limbs Yet it is clear that as many as half of these amputations might be prevented through sim-ple but effective foot care practices The 1993landmark study, the Diabetes Control and Complications Trialfunded by the National Institute of Diabetes and Digestive and Kidney Diseases, conclusively showed that keep-ing blood glucose, as measured by hemoglobin A1c, as close to normal as possible significantly slows the onsetand progression of diabetic ner ve and vascular complications, which can lead to lower extremity amputations

amputa-I n t r o d u c t i o n

People who have diabetes are vulnerable to nerve

and vascular damage that can result in loss of

protec-tive sensation in the feet, poor circulation, and poor

healing of foot ulcers All of these conditions

con-tribute to the high amputation rate in people with

diabetes The absence of nerve and vascular

symp-toms, however, does not mean that a patient’s feet are

not at risk Risk of ulceration cannot be assessed

with-out careful examination of the patient’s bare feet

Early identification of foot problems and early

intervention to prevent problems from worsening can

avert many amputations Good foot care, therefore, is

an essential part of diabetes management – for

patients as well as for health care providers

This kit is designed for primary care and other

health care providers who counsel people with

dia-betes about preventive health care practices,

particu-larly foot care “Feet Can Last a Lifetime” is designed

to help you implement four basic steps for preventive

foot care in your practice:

Early identification of the high risk diabetic foot

Early diagnosisof foot problems

Early interventionto prevent further

deterioration that may lead to amputation

Patient educationfor proper care of the

feet and footwear

The kit includes all of the tools you need to identify and diagnose foot problems and to educate your patients:

• A quick-reference pocket card on preventing diabetes foot problems.

• A disposable monofilament for sensory testing (attached to pocket card).

• Instructions for a visual foot inspection.

• Instructions and a reproducible form for an annual comprehensive foot exam.

• Prescription forms to facilitate Medicare coverage of therapeutic footwear.

• Additional tools to facilitate visual and comprehensive foot exams.

• A review of current research.

• A list of additional resources.

• Patient education materials

All of the materials in the kit may be reproduced without permission and shared with colleagues and patients Feel free to duplicate the copier- ready masters for your practice To obtain additional copies of this kit, “Take Care of Your Feet for a Lifetime” companion booklets, and other diabetes information for your patients, call

1-800-438-5383 or visit the NDEP website at http://ndep.nih.gov on the Internet.

To o l s f o r

D i a b e t e s

F o o t E x a m s

To o l s f o r D i a b e t e s F o o t E x a m s

The following section provides tools to help you and your staff incorporate diabetes foot exams into clinical

practice and improve patient outcomes Research indicates that when tools like these are used by

providers, more examinations of lower extremities are performed, patients at risk for amputation are identified,and more patients are referred for podiatric care.1

Using these tools also will help providers meet the HealthyPeople 2010Diabetes Objectives that include increasing the proportion of persons with diabetes who have atleast an annual foot examination and reducing the frequency of foot ulcers and lower extremity amputations inpersons with diabetes

Current clinical recommendations call for a

com-prehensive foot examination at least once a year for all

people with diabetes to identify high risk foot

tions People with one or more high risk foot

condi-tions should be evaluated more frequently for the

development of additional risk factors People with

neuropathy should have a visual inspection of their

feet at every contact with a health care provider.2

In communities where the prevalence and

incidence of diabetes foot problems are high,

providers may determine that inspecting feet

at every visit – for both low and high risk

patients – is warranted

The following tools will help you incorporate

diabetes foot exams into your practice

Flow Chart for Diabetes Foot Exams – depicts the

desired sequence of exams for patients with low-risk

or high-risk feet

Diabetes Foot Exam Procedures – explains

the recommended procedures for conducting

compre-hensive foot examinations and visual inspections

Quality of Care Measures – specifies ways in whichdocumented foot care practices can be audited toindicate short, intermediate, and long-term outcomes.These outcomes can be used by providers to improvediabetes foot care performance

Foot Exam Instructions– provides step-by-stepinstructions for completing a visual inspection of thefeet and an annual comprehensive foot exam

Annual Comprehensive Diabetes Foot Exam Form– documents inspection of skin, hair, and nails,examination of musculoskeletal structures, pedal puls-

es, and protective sensation, assessment of risk for footproblems, assessment of footwear, and completing amanagement plan

See “Additional Tools” for these items:

High Risk Feet Stickers – designed for cre a t i n gbrightly colored “high risk” feet stickers on Ave rylabels to place on the medical re c o rd

E x a m i n a t i o nR o o mF l y e r s (English and Spanish)–encourage patients to re m ove shoes and socks in

p reparation for a foot exam

1 Litzelman DK, Slemenda CW, Langefeld, CD, et al Reduction of lower extremity clinical abnormalities in patients with insulin-dependent diabetes mellitus Annals of Internal Medicine 119(1):36-41, 1993.

non-2 American Diabetes Association: Clinical Practice Recommendations 2000 Diabetes Care 2000:23(Suppl.1);S55-56.

F l o w C h a r t f o r D i a b e t e s F o o t E x a m s *

*Adapted from Population-Based Guidelines for Diabetes Mellitus Health Promotion and Chronic Disease Prevention Program, Oregon Health Division and Oregon Department of Human Resources, 1997.

S t a r t

Type 1 and Type 2: when diagnosed

Annual Comprehensive Foot Exam and

Risk Categorization

Include education for self-care of feet and reassess metabolic control.

Low Risk Feet

Visually inspect feet as warranted

Visually inspect feet at every visit

Management plan to support self-care of the feet and identification of foot problems

Management plan to restore and/or maintain integrity of the feet

High Risk Feet

trained health care provider should:

• Assess skin, hair and nails, loskeletal stru c t u re, vascular status, and protective sensation.

muscu-• Inspect footwear for blood or other

d i s c h a rge, abnormal wear patterns,

f o reign objects, proper fit, appro p r ate material, and foot pro t e c t i o n

i-• Educate about self-care of the feet

• Educate about the importance of blood glucose monitoring including the use of the Hemoglobin A1c test

• Reassess metabolic contro l

Management plan

• The subsequent foot care ment plan depends on risk category, foot status, and metabolic control

manage-• High risk patients should be re f e rre d

to a health care provider with ing in foot care

train-Visual foot inspection to identify foot

p roblems A physician or other trained

s t a ff should perf o rm the foot inspection.

F re q u e n c y

Annually or when a new abnormality

is noted

At every visit

As warranted

Q u a l i t y o f C a r e M e a s u r e s

Clinical Documentation

The following should be

document-ed in the mdocument-edical record:

• Results of the annual comprehensive foot examination including risk assessment.

• Results of the visual foot inspection.

• Occurrence of patient education.

* This is the only action needed for providers to be in accord with the foot care component of a current set of national quality improvement measures The Diabetes Quality Improvement Project (DQIP) is a collaborative effort to improve diabetes care and the quality of life for people with diabetes DQIP uses a set of eight performance measures for diabetes, one of which specifies that “an annual foot exam for adults with diabetes”

be documented.

Numerous public agencies (the Department of Defense, the Health Care Financing Administration, the Indian Health Service, and the Veterans Health Administration) and private groups (the American Diabetes Association Provider Recognition Program and the National Committee for Quality Assurance) are using some or all

of the DQIP measures

M e a s u re s

Short-term Impact: A successful program will show an

increase in the percentage of the population with diabetes for whom the following is documented:

• A comprehensive foot exam and risk assessment

in the past year.*

• A visual foot inspection at each routine visit in the past year.

• Foot care education in the past year.

A survey could be conducted to ask patients to report when they last had a sensory test, foot inspection, and self-care education in the past year.

Intermediate-term Impact: A successful program will show a

decrease in the incidence of hospital admissions or gency room visits for lower extremity infections,

emer-osteomyelitis, and ulcerations.

Long-term Outcomes: A successful program will show a

decrease in the incidence of distal and proximal lower extremity amputations.

F o o t E x a m I n s t r u c t i o n s

Visual Foot Inspection

Objectives

• Quickly identify an obvious foot problem

• Document foot inspection findings

• Determine the need for a comprehensive foot exam

• Schedule follow-up care and referrals

Instructions

A physician, nurse, or other trained staff may complete this inspection

1 Inspect the foot between the toes and from toe to heel Examine the skin for injury, calluses, blisters,fissure, ulcers, or any unusual condition

2 Look for thin, fragile, shiny, and hairless skin—all signs of decreased vascular supply

3 Feel the feet for excessive warmth and dryness

4 Remove any nail polish Inspect nails for thickening, ingrown corners, length, and

fungal infection

5 Inspect socks or hose for blood or other discharge

6 Examine footwear for torn linings, foreign objects, breathable materials, abnormal wear

patterns, and proper fit

7 If any new foot abnormality is found, the patient should be scheduled immediately

for a comprehensive foot examination

8 Document findings in the medical record

Frequency of Inspection

Current clinical recommendations1call for visual inspection of the feet:

• At every visit for people who have neuropathy

• At least twice a year for people with one or more high risk* foot conditions to screen for the opment of additional risk factors

devel-• At least annually, or more often if warranted, for low risk feet.*

In populations where the prevalence and incidence of diabetes foot problems are high, providersmay determine that inspection of the feet at every visit — for both low and high risk patients — iswarranted To facilitate foot inspection and examination, consider adopting a policy such as “For all patients with diabetes, remove shoes and socks in preparation for examination.”

*Refer to chart on page 13 for definitions of risk.

1 American Diabetes Association: Clinical Practice Recommendations 2000 Diabetes Care 2000:23(Suppl.1); S55-56.

Annual Comprehensive Diabetes Foot Exam

by removing shoes and socks/hose

I Presence of Diabetes ComplicationsComplete the questions as directed.

Question 1 : Does the patient have any history of the macro- and micro-vascular complications of betes or a previous amputation?

dia-Patients who have been diagnosed with peripheral neuro p a t h y, nephro p a t h y, re t i n o p a t h y, peripheralvascular disease or cardiovascular disease are likely to have had diabetes for several years and to be atrisk for diabetes foot problems A positive history of a previous amputation places the patient perm a-nently in the high risk category Specify the type and date of amputation(s)

Question 2 : Does the patient have a foot ulcer now or a history of foot ulcer?

A positive history of a foot ulcer places the patient permanently in the high risk category This son always has an increased risk for developing another foot ulcer, progressive deformity of thefoot, and ultimately, lower limb amputation

per-II Current HistoryComplete the questions as directed.

Question 1 : Is there pain in the calf muscles when walking—i.e., pain occurring in the calf or thigh when walking less than one block that is relieved by rest?

This question is to determine whether the patient experiences intermittent claudication when ing This pain is an indication of peripheral vascular disease or impaired circulation

walk-Question 2 : Has the patient noticed any changes in the feet since the last foot exam?

Patients may notice changes in skin and nail condition or sensory perception if they areperforming self-tests with a monofilament

• Collect the necessary data to assess feet for risk

of complications

• D e t e rmine the patient’s risk status

• Document foot exam findings

• D e t e rmine the need for therapeutic foot wear

• D e t e rmine the need for re f e rral to foot care

s p e c i a l i s t s

• Schedule self-management education

• Develop an appropriate management plan

• Schedule follow-up care and re f e rr a l s

Questions 3 and 4 : Has the patient experienced any shoe problems? Has the patient noticed any blood or other discharge in socks or hose?

New shoes can cause unexpected pressure and irritate underlying skin Blood or other

discharge from a foot wound can be the first indication of a severe foot problem

Question 5 : What is the patient's smoking history?

Cigarette smoking is a major risk factor for microvascular and macrovascular disease and is

likely to contribute to diabetes foot disease

Question 6 : What is the patient’s most recent hemoglobin A1c test result?

Elevated hemoglobin A1c values are independently associated with a twofold risk

of amputation

III Foot ExamComplete the questions or fill in the items as directed.

Item 1 Condition of the skin, hair and toenails

Questions: Is the skin thin, fragile, shiny and hairless? Are the nails thick, too long, ingrown, or infected with fungal disease?

• Examine each foot between the toes and from toe to heel Record any problems by drawing orlabeling the condition on the foot diagram Skin that is thin, fragile, shiny, and hairless is an indica-tion of decreased vascular supply Loss of sweating function may cause cracking of the skin and fis-

s u res that can become infected

• Remove any nail polish Check toenails to see if they are ingrown, deformed, or fungal Thick nails may indicate vascular or fungal disease If severe nail or dry skin problems are present, refer the patient to a podiatrist or a nurse foot care specialist

Measure, draw in, and label the patient’s skin condition.

• Measure and draw on the form any corns, calluses, pre-ulcerative lesions (a closed lesion,

such as a blister or hematoma), or open ulcers

• Use the appropriate symbol to indicate what type of lesion is present—i.e., callus, ulcer,

redness, warmth, maceration, pre-ulcerative lesion, fissure, swelling or dryness Maceration

is present if the tissue is friable, moist, and soft

• Label areas that are significantly dry, red, or warm (warmer than other parts of the foot

or the opposite foot)

Item 2 : Musculoskeletal Deformities

• Foot deformities may be the result of diabetic motor neuropathy The function of intrinsic muscles is lost, causing the toe digits to buckle as other muscles become imbalanced Muscle wasting occurs The plantar fat pad becomes displaced and the metatarsal heads become more prominent Limited joint mobility occurs and contributes to the potential for toe and foot injury If Charcot foot is present, there are severe bone and joint changes and the foot

is swollen and warm to the touch

• Indicate any of the foot deformities listed—i.e., toe deformities, bunions, foot drop, prominentmetatarsal heads, or Charcot foot The more serious deformities are illustrated above Prominentmetatarsal heads are evidence of major deformity such as midfoot collapse

Item 3 : Pedal Pulses

Check the pedal pulses (posterior tibial and dorsalis pedis) in both feet and note whether pulses arepresent or absent

Bunions (Hallux Valgus)

Plantar View of Charcot Joint

Item 4 : Sensory Exam

The sensory testing device supplied in this kit is a 5.07 (10-gram) Semmes-Weinstein nylon

monofila-ment mounted on a holder that has been standardized to deliver a 10-gram force when properly

applied Research has shown that a person who can feel the 10-gram filament in the selected sites is

at reduced risk for developing ulcers Because sensory deficits appear first in the most distal portions

of the foot and progress proximally in a “stocking” distribution, the toes are the first areas to lose

protective sensation

• The sensory exam should be done in a quiet and relaxed setting The patient must not watch

while the examiner applies the filament

• Test the monofilament on the patient’s hand so he/she knows what to anticipate

• The five sites to be tested are indicated on the examination form

• Apply the monofilament perpendicular to the skin’s surface (see diagram A below)

• Apply sufficient force to cause the filament to bend or buckle, using a smooth, not a jabbing

motion (see diagram B below)

• The total duration of the approach, skin contact, and departure of the filament at each site

should be approximately 1to 2seconds

• Apply the filament along the perimeter and NOT ON an ulcer site, callus, scar or necrotic tissue

Do not allow the filament to slide across the skin or make repetitive contact at the test site

• Press the filament to the skin such that it buckles at one of two times as you say “time one” or

“time two.” Have patients identify at which time they were touched Randomize the sequence of

applying the filament throughout the examination

• To order additional disposable or reusable monofilaments, see the Resource List on page 35

IV Risk Categorization

Based on the foot exam, determine the patient’s risk category A definition of “low risk” or “high risk”

for recurrent ulceration and ultimately, amputation, is provided in the following chart, along with

minimum suggested management guidelines Individuals who are identified as high risk may require a

more comprehensive evaluation

See the Resource List for obtaining information about other foot exam forms and risk categorization

schemes developed by the Bureau of Primary Health Care’s Lower Extremity Amputation Prevention

Apply the monofilament perpendicular

to the skin’s surface.

Apply sufficient force to cause the filament to bend or buckle

Risk Category

D e f i n e d

Low Risk Patients

None of the five high risk characteristics below

High Risk Patients

One or more of the following:

Loss of protective sensation Absent pedal pulses

Foot deformity History of foot ulcer Prior amputation

Management Guidelines

• Perform an annual comprehensive foot exam

• Assess/recommend appropriate footwear

• Provide patient education for preventive self-care

• Perform visual foot inspection at provider’s discretion

• Perform an annual comprehensive foot exam

• Perform visual foot inspection at every visit

• Demonstrate preventive self-care of the feet

• Refer to specialists and an educator as indicated

(Always refer to a specialist if Charcot foot is suspected.)

• Assess/prescribe appropriate footwear

• Certify Medicare patients for therapeutic shoe benefits

• Place a “High Risk Feet” sticker on the medical record

Management Guidelines for Active Ulcer or Foot Infection

• Never let patients with an open plantar ulcer walk out in their own shoes

Weight relief must be provided

• Assess/prescribe therapeutic footwear to help modify weight bearing and protect the feet

• Conduct frequent wound assessment and provide care as indicated

• Demonstrate preventive self-care of the feet

• Provide patient education on wound care

• Refer to specialists and a diabetes educator as indicated

• Certify Medicare patients for therapeutic footwear benefits

• Place a “High Risk Feet” sticker on the medical record

Once feet are categorized as high risk, it is unlikely that risk status will change unless vascular gery is performed At subsequent visits the provider should assess for the development of additionalrisk factors and focus on maintaining the integrity of the feet and on metabolic control Patientsshould be educated about avoidance of injury, use of therapeutic footwear, and preventive self-care

sur-V Footwear Assessment

Question 1 Does the patient wear appropriate shoes?

Question 2 Does the patient need inserts?

Question 3 Should corrective footwear be prescribed?

Check inside shoes for foreign objects, torn lining, and proper cushioning Improper or poorly fittingshoes are major contributors to diabetes foot ulcerations Counsel patients about appropriate

footwear All patients with diabetes need to pay special attention to the fit and style of their shoesand should avoid pointed-toe and open-toe shoes, high heels, thongs and sandals Assess the materialand construction of footwear Unbreathable and inelastic materials such as plastic should be avoided.Recommend use of materials such as canvas, leather, suede, and other materials that are breathableand/or elastic Footwear should be adjustable with laces, Velcro, or buckles Record the results of yourfootwear assessment

Properly fitted athletic or walking shoes are recommended for daily wear If off-the-shelf shoes areused, make sure that there is room to accommodate any deformities High risk patients may requiredepth-inlay shoes or custom-molded inserts (orthoses), depending on the degree of foot deformityand history of ulceration (See Medicare Coverage of Therapeutic Footwear on page 18.)

VI Education

Question 1 : Has the patient had prior foot care and other relevant diabetes education?

Question 2 : Can the patient demonstrate appropriate foot care?

Indicate whether the patient has received prior education by checking yes or no in the blank

Patient education about foot care and other aspects of self-care is an essential component of

preventive diabetes care Observe whether the patient can demonstrate appropriate self-care

of the feet Refer for smoking cessation counseling if necessary Determine whether the patient understands the need for, and results of, hemoglobin A1c tests

VII Management Plan

Complete the management plan, indicating actions for patient education, any diagnostic tests

including hemoglobin A1c, footwear recommendations, referrals, and follow-up care

Note:The management of foot problems may be the responsibility of different health care providers.For example, in some communities, certified nurses provide home health services or practice in primarycare or foot care clinics to provide specialized diabetes foot care

Shoes must protect and support the feet Shoes must accommodate

foot deformities. Shoe shape must match foot shape.

IV Risk Categorization Check appropriate box.

V Footwear Assessment Indicate yes or no.

1 Does the patient wear appropriate shoes? Y _ N _

2 Does the patient need inserts? Y _ N _

3 Should corrective footwear be prescribed? Y _ N _

VI Education Indicate yes or no.

1 Has the patient had prior foot care education? Y N

2 Can the patient demonstrate appropriate foot care? Y N

3 Does the patient need smoking cessation counseling?

Provide patient education for preventive foot care Date:

Provide or refer for smoking cessation counseling Date:

Provide patient education about HbA1c or other aspect

Name: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Date: _ ID#: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

I Presence of Diabetes Complications

1 Check all that apply.

II Current History

1 Is there pain in the calf muscles when walking that is relieved by rest?

Y N

2 Any change in the foot since the last evaluation? Y N

3 Any shoe problems? Y _ N

4 Any blood or discharge on socks or hose? Y N

5 Smoking history? Y _N _

6 Most recent hemoglobin A1c result

% date

III Foot Exam

1 Skin, Hair, and Nail Condition

Is the skin thin, fragile, shiny and hairless? Y _ N _

Are the nails thick, too long, ingrown, or infected with fungal disease? Y _ N _

Measure, draw in, and label the patient’s skin condition, using the key and the foot diagram below.

C=Callus U=Ulcer PU=Pre-Ulcer F=Fissure M=Maceration R=Redness S=Swelling W=Warmth D=Dryness

2 Note Musculoskeletal Deformities

❏ Toe deformities

❏ Bunions (Hallus Valgus)

❏ Charcot foot

❏ Foot drop

❏ Prominent Metatarsal Heads

3 Pedal Pulses Fill in the blanks with a

“ P ” or an “ A ” to indicate present or absent

Posterior tibial Left _ Right _

Dorsalis pedis Left _ Right _

❏ Low Risk Patient

All of the following:

❏ Intact protective sensation

❏ Pedal pulses present

❏ No deformity

❏ No prior foot ulcer

❏ No amputation

❏ High Risk Patient

One or more of the following:

❏ Loss of protective sensation

❏ Absent pedal pulses

M e d i c a r e

I n f o r m a t i o n

M e d i c a r e C o v e r a g e o f T h e r a p e u t i c

F o o t w e a r f o r P e o p l e W i t h D i a b e t e s

Me d i c a re provides coverage for depth-inlay shoes, custom-molded shoes, and shoe inserts for people with

diabetes who qualify under Me d i c a re Pa rt B Designed to pre vent lower-limb ulcers and amputations inpeople who have diabetes, this Me d i c a re benefit can pre vent suffering and save money

How Individuals Qualify

The M.D or D.O treating the patient for diabetes

must certify that the individual:

1 Has diabetes

2 Has one or more of the following conditions in one

or both feet:

• history of partial or complete foot amputation

• history of previous foot ulceration

• history of pre-ulcerative callus

• peripheral neuropathy with evidence of callus

f o r m a t i o n

• poor circulation

• foot deformity

3 Is being treated under a comprehensive diabetes

care plan and needs therapeutic shoes and/or

inserts because of diabetes

Type of Footwear Covered

If an individual qualifies, he/she is limited to one

of the following footwear categories within each

calendar year:

1.One pair of depth shoes and three pairs of inserts

2 One pair of custom-molded shoes (including

inserts) and two additional pairs of inserts

Separate inserts may be covered under certain criteria

Shoe modification is covered as a substitute for an

insert, and a custom-molded shoe is covered when the

individual has a foot deformity that cannot be

accom-modated by a depth shoe

What the Physician Needs to Do

1 The certifying physician (the M.D or D.O.)

over-seeing the diabetes treatment must review and sign a

“Statement of Certifying Physician for Therapeutic

Shoes” (see form on page 19)

2 The prescribing physician (the D.P.M., D.O.,

or M.D.) must complete a footwear prescription(see form on page 19) Once the patient has thesigned statement and the prescription, he/she cansee a podiatrist, orthotist, prosthetist or pedorthist

to have the prescription filled The supplier willthen submit the Medicare claim form (Form HCFA1500) to the appropriate Durable MedicalEquipment Regional Carrier (DMERC), keepingcopies of the claim form and the original statementand prescription

Note that in most cases, the certifying physician and the prescribing physician will be two different individuals.

Patient Responsibility for Payment

Medicare will pay for 80%of the payment amountallowed The patient is responsible for a minimum

of 20%of the total payment amount and possiblymore if the dispenser does not accept Medicareassignment and the dispenser’s usual fee is higher than the payment amount The maximum paymentamounts per pair as of2000are:

Patient Name: HIC # :Address:

I certify that all of the following statements are true:

1 This patient has diabetes mellitus —ICD-9Code:

(ICD-9diagnosis codes250.00-250.93)

2 This patient has one or more of the following conditions (check all that apply):

3 I am treating this patient under a comprehensive plan of care for his/her diabetes

4 This patient needs special shoes (depth or custom-molded shoes) and/or inserts because of his/her diabetes

Certifying Physician Information

P r e s c r i p t i o n F o r m f o r T h e r a p e u t i c F o o t w e a r

(Prescribing physician may be different from certifying physician.)

Address:

Diagnosis:

Change to be effected:

Additional relevant information, such as systemic conditions or allergies to specific materials:

Prescribing Physician Information

R e f e r e n c e a n d

R e s o u r c e M a t e r i a l s

The Scope of the Problem

National Goals for Diabetes Foot Care

During their lifetime, 1 5p e rcent of people

with diabetes will experience a foot ulcer and betwe e n

1 4and 2 4p e rcent of those with a foot ulcer will re q u i re

amputation (1) National Hospital Discharge Su rve y

data for 1 9 9 6indicate that 8 6 , 0 0 0people with diabetes

u n d e rwent one or more lowe r - e x t remity amputations

(2) Diabetes is the leading cause of amputation of the

l ower limbs Yet it is clear that at least half of these

amputations might be pre vented through simple but

e f f e c t i ve foot care practices

Healthy People 2010, the U.S Department of

Health and Human Services’ report (3) that specifies

health objectives for the nation, calls for:

a) An increase in the proportion of people with

dia-betes aged 18years and older who have at least an

annual foot examination (baseline 55 percent,

target 75percent)

b) A d e c rease in foot ulcers due to diabetes (baseline

and target figures are “d e ve l o p m e n t a l” )

c) A decrease in lower extremity amputations

due to diabetes (baseline 11per 1,000, target

5per 1,000per year) This objective is based on the

estimate that at least 50percent of the amputations

that occur each year in people with diabetes can be

prevented through screening for high risk patients

and the provision of proper foot care

Ethnic Groups At Higher Risk for Amputation

Analysis of a statewide California hospital discharge database indicated that in 1991, the age-adjusted incidence of diabetes-related lower extremityamputations per 10,000 people with diabetes was 95.3

in African Americans, 56.0in non-Hispanic whites,and 44.4in Hispanics Amputations were1.72and

2.17times more likely in African Americans comparedwith non-Hispanic whites and Hispanics, respectively.Hispanics had a higher proportion of amputations(82.7percent) associated with diabetes as opposed toother causes of amputation, than did AfricanAmericans (61.6percent) or non-Hispanic whites (56.8

percent) (4)

Age-adjusted amputation rates in south Texas in

1993were60.68per 10,000for non-Hispanic whites,

94.08for Mexican Americans, and 146.59for AfricanAmericans (5) The incidence of amputations for PimaIndians in Arizona was 24.1per 1,000 person-yearscompared to 6.5per 1,000person-years for the overallU.S population with diabetes (6) Increased awarenessand identification of diabetes-related foot disease isespecially important in these high-risk ethnic groups.The President’s Initiative to Eliminate Racial andEthnic Disparities in Health is focused on eliminatingserious disparities in health access and outcomes expe-rienced by racial and ethnic minority populations insix areas of health Diabetes is one of the targetedareas A near term goal for this initiative is to reducelower extremity amputation rates among AfricanAmericans with diabetes by40percent (7)

P r e v e n t i o n a n d E a r l y I n t e r v e n t i o n f o r

D i a b e t e s F o o t P r o b l e m s : A R e s e a r c h R e v i e w

Research articles, most published since 1990, were identified and retrieved through computerized searches of

the National Library of Medicine database (MEDLINE) This review is not meant to summarize the entireliterature on the subject, but rather to present a condensation and consolidation of the major findings concernedwith prevention of and early intervention for diabetes foot disease

Frequency of Foot Examinations

Foot examinations, both by people with diabetesand their health care providers, are critical preventiveactions In the 1989National Health Interview Survey(NHIS), 52percent of all people with diabetes statedthat they checked their feet at least daily, but 22per-cent stated that they never checked their feet Moreself-exams were reported by insulin-treated individualsthan those who did not use insulin (8)

Estimates of the frequency of provider-performedannual foot examinations vary Data from the Centersfor Disease Control’s Behavioral Risk Factor

Surveillance System (BRFSS) indicate that 55percent

of adults with diabetes ages 18years and older reportedhaving at least an annual foot examination by a healthcare provider in 1998(mean value from 39states) (9)

BRFSS data from 1995to 1998indicate that 86.3

percent of people with diabetes had seen a physician

or other health care provider for diabetes care in theprevious 12months; 67.7percent of adults with dia-betes reported having had their feet examined in theprevious 12months (10) In an earlier nationwide survey, primary care physicians reported performingsemi-annual foot examinations for 66percent ofpatients with type 1diabetes and for 52percent ofpatients with type 2diabetes (11)

Personal and Financial Costs

Diabetes foot disease is a major burden for both theindividual and the health care system and may increase

as the population ages The total annual cost for themore than 86,000amputations is over $1.1billion dol-lars This cost does not include surgeons’ fees, rehabil-itation costs, prostheses, time lost from work, and dis-ability payments (12) Regarding quality of life, a study

of patients with diabetes showed that those with foot ulcers scored significantly lower than those without foot ulcers in all eight areas of a measure

of physical and social function (13)

Foot disease is the most common complication ofdiabetes leading to hospitalization In1995, foot dis-ease accounted for 6percent of hospital discharges listing diabetes and lower extremity ulcers, and in

1995the average hospital stay was 13.7days The average hospital reimbursement from Medicare for

a lower-extremity amputation in 1992was $10,969,and from private insurers it was $26,940 At the same time, rehabilitation was reimbursed at a rate

of $7,000to $21,000(14)

Prevalence estimates for ulcers in diabetes patientpopulations vary Fifteen percent of all patients withdiabetes in a population-based study in southernWisconsin experienced ulcers or sores on the foot orankle The prevalence increased with age, especially

in patients who were aged 30or under at diagnosis

of diabetes (15) In a large staff-model health nance organization, the incidence, outcomes and costs

mainte-of treatment for foot ulcers were studied over two years

in a group of patients with diabetes In this tion, the incidence was nearly 2percent per year andthe direct medical care cost for a 40- to 65-year-oldmale with a new foot ulcer was $27,987over the twoyears after diagnosis (16)

popula-After an amputation, the chance of another tation of the same extremity or of the opposite extrem-ity within 5years is as high as 50percent The 5-yearmortality rate after lower extremity amputation rangesfrom 39to 68percent (8)