Preventative Screening Measures
and Risk Stratification
There have been numerous attempts to provide population-based screening and disease management algorithms for patients with diabetes that can be easily determined and applied universally from the largest metropolitan center to the smallest rural community. These screening measures attempt to provide risk classification and stratification among those patients with diabetes. Risk stratification involves the determination of those factors that may lead to negative outcomes in patients with diabetes, such as neuropathy or musculoskeletal deformity. Such stratification based upon risk assessment allows the clinician to triage those patients who present at high risk for appropriate, timely intervention as well as providing treatment and follow-up algorithms, which can be utilized, to provide continued surveillance for those patients who, while being diabetic, do demonstrate reduced overall risk. It is vital, then, that clinicians be able to appropriately determine risk, and there have been numerous studies that have elucidated the major risk factors for the development of lower extremity ulceration, which include vasculopathy, loss of protective sensation (LOPS), musculoskeletal deformity, history of a previous amputation, and hyperglycemia. One algorithm which can be utilized by clinicians to appropriately stratify this patient population is the Foot Risk Classification system proposed by Armstrong and Lavery, which categorizes patients into four different risk groups and provides suggested treatment and follow-up algorithms.

The US Department of Health and Human Services has created a five-step lower extremity amputation prevention (LEAP) program that clinicians can utilize in the evaluation of the diabetic patient. Developed at the HRSA National Hansen's Disease Program in 1992, the LEAP program is focused toward identifying those patients who have LOPS and includes annual patient screening, patient education, daily self-inspection, appropriate footwear selection, and early management of simple foot problems to reduce risk.

Community Action: Amputation Prevention Support
Considering the staggering evidence in support of screening measures and risk stratification of patients with diabetes, the question remains how best to implement these screening programs where they are most needed to effectively reduce the development of lower extremity ulceration and subsequent non-traumatic amputations. To be effective, these screening measures and intervention algorithms must be accessible to the patient populations, and it therefore stands to reason that community-based programs will demonstrate superiority. Indeed, a study in New Jersey demonstrated that following the institutionalization of an HHS LEAP program in a local hospital system; there was a trend toward an overall reduction in the number of lower extremity amputations at participating institutions.

A recent study from Brazil in the Journal of Diabetology & Metabolic Syndrome demonstrated significant improved compliance and an overall reduction in the development of lower extremity ulcerations following the establishment of a community program which included risk stratification and preventative care education. To be effective, community programs must partner health care providers –such as internists, endocrinologists, and podiatric surgeons—and their respective patients, where the patient assumes personal responsibility for their care and becomes a full partner with the health care team in preventing foot problems, thus promoting patient compliance and accountability through self-management and unity of action. Patient self-management includes appropriate glycemic control, daily lower extremity self examination to all for early detection of pre-ulcerative lesions, blisters, erythema, and swelling as well as callus development and other potential problem areas.

Conclusion
Considering the significant risk associated with the development of DFU’s and subsequent progression toward lower extremity amputation, i t is incumbent upon those clinicians involved in the care of patients with diabetes to implement screening processes that can help to prevent lower extremity ulcerations before they occur.  Community based programs which partner the patient and health care provider and empower the patient to take a more active role in the management of their disease process have demonstrated their efficacy and such programs can provide clinicians an opportunity to perform preemptory screening and risk stratification among these high risk patient and triage these patients toward appropriate, timely intervention, thus limiting the comorbidity and mortality associated with the lower extremity manifestations of diabetes.    As health care providers involved in the management of patients with diabetes, there is evidence to support the establishment of community-based programs, and it is important that we seek out and develop these opportunities in our communities and our residency programs.  The literature clearly demonstrates that these paradigms can truly make a difference in our patient’s lives.

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