Practitioners Talk About Challenges and Solutions to Improving Outcomes for Diabetes Patients

[caption id="attachment_249368" align="alignright" width="450"] peopleimages.com/stock.adobe.com[/caption] Orthotists and pedorthists know well the challenges their patients with diabetes face. Providing diabetic foot care for these patients can be challenging when complicated by factors including poor control of the underlying disease, diabetic skin issues that impact prosthesis fit and use, and side effects from medications. People with diabetes also face increased risks of nonhealing foot ulcers, amputation, and reamputation. In 2021, the National Institutes of Health identified amputation as an epidemic disproportionately impacting those with diabetes. Of the estimated 200,000 amputations that occur in the United States alone each year, approximately 130,000 of those are in people with diabetes. 1 One of the most common patient complications, diabetic foot ulcerations (DFUs), precedes 85 percent of diabetic amputations. 2 According to the International Diabetes Federation, the lifetime risk for foot ulcerations in people with diabetes is 15 to 25 percent. These statistics reinforce what O&P professionals are seeing in their own practices. As the diabetes epidemic grows, so does the need to improve patient outcomes. We asked O&P practitioners to share the issues they see impacting care, their strategies for managing these at-risk patients, and what they view as the best opportunities to improve patient outcomes. The clinicians we spoke with pointed to education, continuity of care from physician to practitioner, and access to the proper footwear as keys to improving the results patients get from their care. Practitioner and Patient Education When it comes to diabetes, the O&P specialist’s role extends beyond educating themselves to helping educate their patients as much as possible. And practitioners take their responsibility to help patients achieve the best possible outcomes seriously. Jon Jaskiewicz, CPO, Medical Center of Orthotics and Prosthetics, Maryland, worked with diabetes patients for much of his career. Although his practice has shifted, he recalls many of the challenges encountered in his time treating patients with diabetes. One of the most common, he says, was patient compliance with their care. “There generally wasn’t an unwillingness to be compliant, but more of an unawareness or passivity among patients,” he says. Continuity of Care Jaskiewicz says he saw patient compliance increase and better patient outcomes when there was continuity of care between the physician and the O&P practitioner. “When there isn’t good continuity of care, then you often get the worst-case scenarios,” he adds. He says that complications of the disease can impact the patient’s ability to comply with care instructions their doctors and practitioners provide, making continuity of care even more crucial. Better outcomes are also achieved in patients who have a good personal support system, he says. “Having someone at home that understands what’s going on and what to look out for has a major positive impact.” Insurance Coverage, Affordability [caption id="attachment_249366" align="alignleft" width="192"] Tada Images/stock.adobe.com[/caption] In addition to dealing with the complexities of the disease itself, O&P practitioners face the challenge of providing the best solutions for their patients with diabetes within the limitations of insurance coverage. This can be especially difficult when patients need highly customized footwear. In the US, the Medicare Therapeutic Shoe Bill often leaves patients with significant out-of-pocket costs if they hope to get the best possible footwear to address their needs. Dennis Janisse, CPed, president and CEO of National Pedorthic Service, Wisconsin, highlighted the negative impacts that lack of access to comprehensive insurance coverage can have in patient care. “Many patients can get by with what Medicare pays for shoes,” he says. “But when the problem gets more severe, where a more specialized orthotic is needed, that benefit is no longer adequate.” To stay within the scope of the shoe modifications covered by Medicare, patients are typically seen by a certified shoe fitter. As a result, Janisse says there are unintended consequences for those patients who need more advanced shoe modifications and would benefit significantly from seeing a certified pedorthist. “A certified shoe fitter’s education is often a single heat mold device and diabetic shoes,” he says. “And I see the results of it—it’s not their fault, but the solutions they can provide are limited as a result of a lack of Medicare coverage.” Medicare covers premade orthotics and custom-made inserts, including rocker/roller soles and sole flares. Rigid rocker soles are designed to offload plantar pressure in patients at risk of DFU and have been particularly effective when used in combination with custom orthoses. Flare modifications are added to the inside or outside of the sole of the shoe to provide additional support. Janisse says these modifications provide better outcomes when prescribed and fabricated by practitioners with a high level of expertise. “This is very important in reducing complications,” he says. “Poor shoe fittings are contributing to ulcerations and can lead to potential reamputation and other complications.” The issue is not as simple as pedorthists refusing to accept what Medicare is willing to pay to take on these more complex patient cases. Even when a practitioner is willing to work with Medicare, Janisse says, many of the necessary shoe modifications don’t fall under the description of rocker/roller or flare soles, and therefore don’t qualify for any coverage at all. “Rocker and roller soles are covered, but you have to understand what you want those soles to do,” he explains. “When you start modifying them, it gets tricky.” Still, Janisse says there are many in his profession, including him, who have worked with patients to significantly modify a Medicare-covered shoe to make it work better. “That is work that pedorthists do without getting paid—and you can only do so much of that and stay in business.” So, what’s the solution? For pedorthists, Janisse says it is about building a rapport with the patient’s physicians, as well as setting the stage with the patient as their trusted practitioner. “You have to use Medicare to the best of the patient’s advantage,” he says. “And then you have to explain to them that you’re going to give them the very best care—and that some of it will be covered, and some of it may not.” Even as an O&P practitioner, providing the best patient care extends beyond the footwear you’re providing. Like Jaskiewicz, Janisse emphasizes the importance of continuity of care. “We’re not doctors, but we need to reinforce the things their doctors are telling them,” he says. “We can talk to them about their blood sugar and activity levels and looking at their feet more regularly—because it really is to our advantage to get invested in how they’re caring for themselves to assure a better outcome of the footwear.” Janisse says practitioners can also reinforce patient compliance by helping them understand why they need to wear special shoes, even if they don’t want to. “I’ve been in this business a long time and it isn’t like it was back when I started—the shoes have come a long way.” Win-Win Opportunity for Patients and Practitioners Janisse, along with other O&P practitioners, played a major role in restoring an educational path to become a certified pedorthist last year. He hopes shoe fitters will capitalize on the opportunity to become certified, not only to grow their practices, but to also expand access to superior patient care. “I am a fan of the therapeutic shoe, but it’s not designed for the more complex issues,” he says. “More pedorthists will certainly help with access to proper care and better patient outcomes.” Marc Tessier, CPO, Nipissing Orthopaedic Lab, is based in North Bay, Ontario. He regularly travels further north along the Northeastern Ontario corridor to deliver services to Indigenous peoples, rural areas, and smaller communities—many of which are underserviced and have an aging population. “The hallmark is a lack of services to these small, rural areas,” he says. “Thirty percent don’t have doctors and are treated at emergency rooms and walk-in clinics.” “We see diabetic patients with a variety of risks—some are low risk and others come in that are at the immediate risk of amputation,” Tessier says. Loss of protective sensation (LOPS) due to diabetic neuropathy is a common issue. And because many patients aren’t seen regularly by a physician, they often come in very late when situations are urgent. Prevention Is Key [caption id="attachment_249365" align="alignright" width="405"] gal_03/stock.adobe.com[/caption] “A goal of better and earlier assessment and prevention of ulcers should be on everyone’s radars,” Tessier says. In his many years as a practitioner, he’s seen firsthand the difference prevention makes in patient outcomes. “We know that diabetic foot ulcers often lead to amputations,” he says. “And they happen for many reasons, primarily due to reduced joint flexibility, abnormal foot profiles, poor shoe fit, poor foot care practices, vascular issues associated with poor glycemic controls, peripheral artery disease, and especially LOPS.” There are two main objectives in treating DFUs. In the short term, wound closure is the goal, using offloading techniques to relieve pressure. In the longer term, the goal is to safely house the healed ulcer feet with proper footwear. “Once ulcer closure is achieved, you have to maintain that with diabetic-suitable footwear,” Tessier says. “Patients have to wear proper footwear for the rest of their lives—and they can live very normal lives.” Tessier reiterated the role prevention plays. Wearing diabetic- suitable footwear with the insoles that come with them, or sometimes with custom-made orthotics, will lower the chance of foot injuries and reduce the likelihood of foot wounds developing in the first place. Daily foot examination and care are also important, he says. If vision is affected by diabetes, for example, having a second set of eyes to look for things that patient may miss makes a big difference. Wound maintenance includes wearing proper shoes indoors. Tessier says the discipline—and additional expense—of wearing diabetic suitable footwear indoors is often where things break down. “Patients need one pair of footwear worn indoors for all ambulatory and standing activities, and they need a second pair when outdoors,” he says. “Sometimes they will need offloading insoles or custom-made foot orthotics, which are also expensive.” Affordability of care is certainly a factor. Much like Medicare in the US, restrictions in coverage of diabetic footwear are a reality of Canada’s tax-funded healthcare. Another aspect of living with long-standing diabetes is the development of Charcot foot, which affects 8-10 percent of people living with the disease. This devastating complication is a leading cause of amputations. Early diagnosis and immobilization are imperative, Tessier says. Diagnostic imaging and limiting weight bearing on the foot while it stabilizes is also crucial. Wearing a removable cast walker, or custom-made Charcot restraint orthotic walker (CROW) is indicated for these patients. In the harsh northern Ontario climate, however, maintaining the life of a custom-made CROW, removable cast walker, or other specialized footwear is tough. As a result, patient compliance is often low since wearing removable cast walkers in winter exposes the foot, making it harder to keep it warm and dry. Tessier believes better products that can be worn over these boots would make a difference. “A company called New England Overshoe (NEOS) makes wonderful boot and shoe covers—I’d like to see a NEOS-style cover made for removable cast walkers,” he adds. “That would improve outcomes tremendously.” Educated Care It’s imperative, Tessier says, for physicians and practitioners to do all they can to educate these patients about proper foot care. “When you’re diagnosed with diabetes, it’s upsetting, and there is a lot to learn about how to control it and how to properly care for the feet,” he says. “Retaining new information when there is cognitive impairment is a challenge, so it’s important for doctors and O&P practitioners to provide resources and literature patients can refer back to regularly.” When it comes to O&P education, Tessier said there are thorough prevention-focused practitioner resources available. The International Working Group on the Diabetic Foot (IWGDF) Guidelines on the Prevention and Management of Diabetes-Related Foot Disease is one of the most important resources practitioners should be using, he says. 3 The document offers practical guidance on patient assessment, DFU prevention, and diagnosing and managing other diabetic foot complications. Best Practice Recommendations for the Prevention and Management of Diabetic Foot Ulcers, published by Wounds Canada, is another resource that’s been foundational in Tessier’s approach to patient care. “I refer back to these often when I am educating patients.” Ultimately, diabetic control continues to be a complex challenge, but Tessier remains optimistic about practitioners’ ability to make a difference. “Many people get frustrated with all of the things they need to do to manage it, and a lot of people can’t make the necessary changes long term,” he says. “But a lot of people do change their lives for the better once diagnosed.” While a cure for diabetes would be life changing for millions, he says, patients and care providers must focus on the things they can do now that will lead to the best possible outcomes. “It’s very multifaceted, and it’s an expensive cycle,” he says. “Ulcer management is expensive, and amputation is traumatic and expensive—so meaningful change really depends on greater awareness and prevention.” Tara McMeekin is a writer and editor based in Colorado. References National Institutes of Diabetes and Digestive and Kidney Diseases. 2021. Reducing Disparities in Diabetic Amputations. https://www.niddk.nih.gov/health-information/professionals/diabetes-discoveries-practice/reducing-disparities-in-diabetic-amputations#:~:text=A%3A%20There’s%20an%20epidemic%20of,of%20those%20people%20have%20diabetes. Ratliff, H., N. Shibuya, and D. C. Jupiter. 2021. Minor vs. major leg amputation in adults with diabetes: Six-month readmissions, reamputations, and complications. Journal of Diabetes and Its Complications 35(5):107886. International Working Group on the Diabetic Foot. 2023. https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-Guidelines-2023.pdf

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