A mobile screening programme for the cardiovascular and microvascular complications of Type 2 diabetes in primary care.

The Diabetes National Service framework (NSF), and the quality payments in the new contract for UK General Practitioners, promote regular screening for diabetes complications. The new contract also includes immediate incentives to meet screening and quality targets, but it will be difficult to meet these targets in primary care. We have developed a mobile 'annual review' programme for patients with Type 2 diabetes managed solely in primary care, that screens for cardiovascular disease, hypertension, retinopathy and neuropathy at the patient's general practice, and gives written foot care, dietary advice and level 1 smoking cessation advice to all patients.     

Magnitude of foot problems in diabetes in the developing world: a study of 1044 patients

Aim To gain insight into the prevalence of peripheral neuropathy, foot care practices, foot at risk and foot ulcers in patients with diabetes mellitus at a tertiary care centre. Methods A prospective case study involving 1044 patients with diabetes mellitus attending the diabetes clinic of a tertiary care centre in north India from January 2007 to May 2008. All subjects underwent a detailed clinical assessment including vibration perception threshold (VPT) and ankle brachial pressure index (ABI), along with metabolic parameters, and were categorized into ulcer, foot at risk and patients with no risk factors. Foot care practices were assessed with a questionnaire. Peripheral neuropathy was defined as VPT score ≥ 25 V. Peripheral vascular disease (PVD) was defined as ABI < 0.9. One hundred and forty‐nine patients with foot at risk were followed up for 9.0 ± 2.3 months (range 5–13 months). Results The prevalence of peripheral neuropathy was 34.9% and of PVD 12.6%. Two thirds of the patients were at risk for foot ulceration; 9% had an ulcer and 20.2% of them required amputation. Correct foot care practices were followed by 214 (20.5%) subjects of the whole study population and by only 135 (19.3%) of the patients with foot at risk. Improvement in glycaemic control in the patients on follow‐up was associated with improvement or stabilization of VPT score. Five (3.4%) patients developed new ulcers on follow‐up. Conclusion The high prevalence of neuropathy and PVD, coexisting with poor adherence to foot care practices predisposes to foot problems in people with diabetes in our study population.     

Peripheral Neuropathy as a Presenting Feature of Type 2 Diabetes: A Case-Controlled Study

The characteristics and outcome of 68 newly diagnosed Type 2 diabetic patients who presented with clinically evident peripheral neuropathy were compared with matched controls who had no neuropathy at diagnosis. All subjects (34 male) whose median age was 68 (range 47–89) yr were identified from a computerized diabetes register and presented in 1982–1990. The groups were compared at diagnosis for haemoglobin A₁, body mass index, blood pressure, smoking, and alcohol consumption, and for co-existent coronary and peripheral vascular disease. Mortality and morbidity were recorded to March 1991. Significantly more patients with neuropathy had co-existent peripheral vascular disease: 24(35%) compared to 6(9%) controls (p = 0.0021). Twenty (30%) of those with neuropathy and no controls had retinopathy at diagnosis, which was sight-threatening in 10. Seven (10%) with neuropathy but no controls presented with foot ulcers, one requiring limited amputation. Two more patients with neuropathy and one control subsequently developed foot ulcers resulting in one or more amputation in each group. Twenty-one (31%) of those with neuropathy and 14 (21%) controls died (p = 0.2109). In conclusion more diabetic patients with clinically evident peripheral neuropathy at diagnosis have peripheral vascular disease than matched patients without neuropathy. It is likely that macrovascular disease either exacerbates or causes the neuropathy in this group of patients. They are at high risk of developing foot ulceration and high priority should be given to foot care in planning their management.     

The Prevalence of Foot Ulceration and its Correlates in Type 2 Diabetic Patients: a Population-based Study

The prevalence of peripheral neuropathy, peripheral vascular disease, and foot ulceration in Type 2 diabetic patients in the community were determined in a community-based study. Eight hundred and eleven subjects (404 male, 407 female, mean age 65.4 (range 34–90) years, diabetes duration 7.4 (0–50) years) from 37 general practices in three UK cities were studied. Neuropathy was diagnosed clinically using modified neuropathy disability scores which were ascertained using structured interviews and clinical examinations by one observer in each city. Peripheral vascular disease was diagnosed if a history of revascularization was present or ≥ 2 foot pulses were absent. History of current or previous foot ulceration was recorded. The prevalence of neuropathy was 41.6% (95% confidence limits 38.3–44.9%) and the prevalence of PVD, 11% (9.1–13.7%). Forty-eight percent of neuropathic patients reported significant neuropathic symptoms. Forty-three patients (5.3% (3.8-6.8%)) had current or past foot ulcers; 20 of these were pure neuropathic ulcers, 13 neuroischaemic, 5 pure vascular, and 5 were unclassified. Multiple logistic regression showed history of amputation, neuropathy disability score, and peripheral vascular disease to be significantly associated with foot ulceration after adjusting for age and diabetes duration. A substantial proportion of Type 2 diabetic patients, often elderly patients who do not attend hospitals, suffered from peripheral neuropathy and peripheral vascular disease. These patients are at risk of foot ulceration and may benefit from preventive footcare.     

Frequency of risk factors for foot ulceration in individuals with chronic kidney disease

Background: Although chronic kidney disease (CKD) has been associated with foot ulceration, the pathological pathway involved remains unclear. This pilot study was designed to investigate the risk factors for foot ulceration in individuals with CKD who do not have diabetes. The aims of this study were to establish the risk status for foot ulceration in individuals with CKD and to identify the particular foot ulcer risk factors most prevalent in this group. Methods: One hundred outpatients were recruited from a metropolitan hospital and allocated into one of four groups: (i) control: neither diabetes nor CKD, (ii) diabetes alone, (iii) coexisting CKD and diabetes and (iv) CKD alone. All participants were assessed for past/current foot ulcers, peripheral neuropathy, vascular insufficiency, structural deformity and skin pathology. Comparisons were made between the groups regarding the prevalence of these factors. Results: Participants with CKD who did not have diabetes displayed no significant differences in risk factor presentation from those with diabetes alone. Of the participants with CKD and no diabetes, 36% had peripheral neuropathy, 20% had vascular insufficiency and 24% had the copresentation of peripheral neuropathy and structural deformity. Overall, participants with both CKD and diabetes had the highest presentation of past/current foot ulcers, peripheral neuropathy and vascular insufficiency, all significantly more frequent in this group than in controls (P < 0.05). Eight of the total 10 participants found to have a past/current foot ulcer were in end‐stage kidney failure. Conclusion: Individuals with CKD frequently display risk factors for foot ulceration. Risk factors are more prevalent in individuals who also have diabetes and foot ulcers become more frequent with progression to end‐stage kidney failure. Risk assessment and patient awareness strategies should therefore be extended to include all patients with CKD so as to reduce future foot ulcer development.     

A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population

Summary A cross-sectional multicentre study of randomly selected diabetic patients was performed using a standardised questionnaire and examination, to establish the prevalence of peripheral neuropathy in patients attending 118 hospital diabetes clinics in the UK. Vibration perception threshold was performed in two centres to compare with the clinical scoring systems. A total of 6487 diabetic patients were studied, 53.9% male, median age 59 years (range 18– 90 years), 37.4% Type 1 (insulin-dependent) diabetes mellitus, with a median duration of diabetes 8 years (0–62 years). The overall prevalence of neuropathy was 28.5% (27.4– 29.6 %) (95 % confidence interval) in this population. The prevalence in Type 1 diabetic patients was 22.7% (21.0– 24.4 %) and in Type 2 (non-insulin-dependent) diabetic patients it was 32.1 % (30.6–33.6 %). The prevalence of diabetic peripheral neuropathy increased with age, from 5% (3.1– 6.9 %) in the 20–29 year age group to 44.2 % (41.1–47.3 %) in the 70–79 year age group. Neuropathy was associated with duration of diabetes, and was present in 20.8 % (19.1–22.5 %) of patients with diabetes duration less than 5 years and in 36.8 % (34.9–38.7 %) of those with diabetes duration greater than 10 years. Mean vibration perception threshold measured at the great toe was 21.1±13.5 SD volts and correlated with the neuropathy disability score, r=0.8 p<0.001. In conclusion, diabetic peripheral neuropathy is a common complication associated with diabetes. It increases with both age and duration of diabetes, until it is present in more than 50% of Type 2 diabetic patients aged over 60 years. An increased awareness of the high prevalence of peripheral neuropathy, especially in older patients, should result in improved screening programmes in order to reduce the high incidence of neuropathic diabetic foot ulceration.     

Regional differences in risk factors and clinical presentation of diabetic foot lesions.

BACKGROUND: Problems associated with the diabetic foot are worldwide. However, there may be regional variation among risk factors and clinical presentation. Prospective comparative data concerning this topic are rare. AIM: To determine differences in underlying risk factors and clinical presentation of foot problems among people with diabetes in different regions. PATIENTS AND METHODS: Six hundred and thirteen consecutive patients with diabetic foot lesions from three centres [Soest-Germany (GER), Dar-es-Salaam, Tanzania (TAN) and Chennai, India (IND)] were included during the period June 1998 through December 1999. Diabetes-related data, risk-factor profiles, and lesion-related data were collected for each patient. Due to varying proportions of recurrent lesions among the centres, only data from patients with newly presenting diabetic foot lesion were analysed. RESULTS: Of the 613 patients sampled, 368 (60%) were treated for newly presenting diabetic foot lesion. In all three centres, patients were predominately male and had Type 2 diabetes. The average diabetes duration until the onset of the initial foot lesion was 14 years in GER and 12 years in IND, but only 5 years in TAN. The corresponding patient ages were 71, 56 and 51 years. Neuropathy was common to patients in all three centres. Peripheral vascular disease (PVD) was a frequent risk factor in GER (48%). In TAN and IND it was far less common (12 and 13%), probably due to younger patient populations, shorter diabetes duration and lower proportions of smokers. Inadequate footwear was the most common cause of foot lesions in GER (19%), while lack of footwear, irregular foot care and burns were the primary precipitating factors among patients in TAN and IND. CONCLUSION: Similarities in different regions of the world among people with diabetes suffering newly presenting foot lesions include a predominance of males and patients with Type 2 diabetes, as well as a high frequency of diabetic neuropathy. However, differences concerning age, diabetes duration, peripheral vascular disease, and precipitating factors contributing to injury are also observed.     

Are Type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics

In the context of a nationwide outcomes research program on Type 2 diabetes, we investigated physician and patient practices related to foot care. Patients filled in a questionnaire investigating whether they had received information about foot care, how often they had had their feet examined in the last year, and how often they usually checked their feet. Analyses were adjusted for patient case-mix and physician-level clustering. Overall, 3564 patients were recruited by 125 diabetes outpatient clinics (DOCs) and 103 general practitioners (GPs), of whom 6.8% suffered form lower limb complications. The presence of foot complications was correlated with insulin treatment, cigarette smoking, low levels of school education, and the presence of other diabetic complications. More than 50% of the patients reported that they had not had their feet examined by their physician and 28% referred that they had not received foot education. Patients with lower levels of school education and income, as well as overweight individuals, were less likely to receive foot education. Physicians tended to perform foot examination more often in males, low-income patients, those with foot complications, and those treated with insulin, but not in patients with the highest risk of foot complications, that is, those with diabetic neuropathy or peripheral vascular disease (PVD). GPs tended to perform foot examination less frequently than diabetologists do. Foot self-examination was not performed by 33% of the patients. Those individuals who had received foot education or had had their feet examined were more likely to check their feet regularly. A substantial proportion of Type 2 diabetic patients is not offered adequate foot care, even in the presence of major risk factors for lower limb complications. Patient knowledge and practices are strongly related to physicians' attitudes.     

Prevalence of the diabetic foot syndrome at the primary care level in Germany: a cross-sectional study

Aims The diabetic foot syndrome (DFS) is an important complication of diabetes mellitus resulting in amputations, disability and reduced quality of life. DFS is preventable. The aim was to investigate the prevalence of the DFS at the primary care level in Germany. Methods This was a cross-sectional study of the prevalence of DFS, associated factors and glycaemic control at the primary care level in Germany. We examined an unselected sample of participants with known diabetes who were insured by Deutsche BKK, a large healthcare insurer. Results Three hundred and forty-one general practitioners examined 4778 participants with diabetes mellitus: 366 (7.7%) participants (mean age 49 ± 16 years) had Type 1 and 4412 participants (mean age 66 ± 10 years) had Type 2 diabetes. DFS was diagnosed in 138 patients, resulting in a prevalence of 3.6%[95% confidence interval (CI) 1.9, 6.0] in Type 1 and 2.8% (95% CI 2.3, 3.4) in Type 2 diabetes. DFS was independently associated with age, duration of diabetes, height, current smoking and insulin therapy. There was no significant effect of glycaemic control on the risk of DFS. The prevalence of other abnormal foot findings was: peripheral neuropathy 9.7%, peripheral arterial disease 14.8% (absent dorsalis pedis), 12.4% (absent tibialis posterior), acute diabetic foot ulcer 0.8%, amputations of lower extremities 1.5%, and amputations limited to toes 0.5%. Conclusions The prevalence of the DFS at the primary care level in Germany is 2.9%. Almost 50% of patients with DFS had major or minor amputations. Common risk factors such as hyperkeratosis and poor glycaemic control can be modified. Effective therapeutic approaches in addition to methods for primary and secondary prevention of DFS should be used more widely.     

An assessment of the coverage of a district-wide diabetic retinopathy screening service.

AIMS: To assess the coverage of the diabetes retinopathy screening service (DRSS) in North Staffordshire, to identify patient characteristies associated with non-attendance and to assess the proportion of patients with diabetic retinopathy who achieved glycaemic and blood pressure (BP) control targets. METHODS: Data for all patients who underwent annual retinal screening between 1 May 2000 and 30 April 2001 were obtained from the North Staffordshire Diabetes Register. Age, gender, ethnicity, socio-economic status, type and duration of diabetes were compared between patients who underwent eye screening and those who did not. Frequencies of patients who achieved glycaemic and BP targets in these groups of patients were compared to the remaining patients. RESULTS: 5646 of the 11682 (48%) patients on the diabetes register underwent retinal screening during the year. Patients with Type 2 diabetes, older patients, patients belonging to ethnic minorities and those wholly managed in primary care were less likely to attend for eye screening (P < 0.05 for all groups) with ethnic minority or primary care management demonstrating independent influence (P < 0.001). The percentage of patients with retinopathy achieving HbA1c and systolic BP targets was significantly lower than in their unaffected counterparts (chi2 = 63, P < 0.001 and chi2 = 71, P < 0.001 respectively). CONCLUSIONS: The efficacy of the DRSS in North Staffordshire is low and might be improved by targeting specific patient groups. Glycaemic control and systolic BP control needs to be improved in patients with diabetic retinopathy.     

Predictors of attendance at diabetic retinopathy screening among people with type 2 diabetes: Secondary analysis of data from primary care

AimsTo estimate the uptake of diabetic retinopathy screening among adults with type 2 diabetes and to identify and compare factors associated with attendance at the national diabetic retinal screening programme, and other screening services provided by ophthalmic surgeons, community ophthalmologists and optometrists.MethodsAn observational retrospective cohort study was carried out using data from the 2016 audit of care delivered by general practices (n = 30) enrolled in a structured diabetes care initiative.Attendance at any screening in the previous 12 months, and attendance across different types of service (national programme and other screening services) was calculated. Logistic regression was performed to examine predictors associated with (1) attendance at any screening and (2) attendance at the national programme (RetinaScreen). Sociodemographic, clinical, and lifestyle factors were examined as predictors.ResultsData were available for 1106 people with type 2 diabetes aged ≥18 years.Overall, 863 (78%) of patients had a record of screening attendance in the previous 12 months. Of those screened, 494 (57.2%) attended RetinaScreen only, 258 (28.7%) attended other screening services only, and 111 (12.9%) attended both services.Statistically significant predictors of attendance at any screening were tablet/injectable controlled diabetes, attendance at a diabetes nurse specialist (DNS) in the past 12 months and a blood glucose level which was not on target (HbA1c >7.0% or >53 mmol/mol). In addition to these factors, when examining predictors of attendance at the national screening programme specifically, females were less likely to attend.ConclusionsMost patients managed in a structured diabetes care programme in primary care attended screening. Those with on target blood glucose control, those who were on oral or injectable medication or had been seen by a DNS were more likely to attend for annual screening. Of those who attended screening, almost one-third attended other screening services and so were not availing of the national programme, which is free, quality assured and has an integrated treatment arm.     

Sudomotor dysfunction is associated with foot ulceration in diabetes

Aim To examine the relationship between sudomotor dysfunction and foot ulceration (FU) in patients with diabetes. Methods Ninety patients with either Type 1 or Type 2 diabetes [30 without peripheral sensorimotor neuropathy (PN), 30 with PN but without FU and 30 with FU] were recruited in this cross‐sectional study. Assessment of PN was based on neuropathy symptom score (NSS), neuropathy disability score (NDS) and vibration perception threshold (VPT). Sudomotor dysfunction was assessed using the sympathetic skin response (SSR). Cardiac autonomic nervous system activity was assessed by the battery of the classical autonomic function tests. Results Patients with foot ulcers had longer duration of diabetes, higher values of VPT and NDS and lower values of the autonomic functions tests in comparison with the other study groups. Sudomotor dysfunction and cardiac autonomic neuropathy were significantly more common in the FU group. Multivariate logistic regression analysis after adjustment for gender, body mass index, duration of diabetes and glycated haemoglobin (HbA_1c) demonstrated that the odds ratio (95% confidence intervals) of FU increased with measures of neuropathy such as NDS ≥ 6 (10.2, 6.2–17.3) and VPT ≥ 25 volts (19.8, 9.9–47.5), but was also significantly increased with absent SSR (15.3, 5.3–38.4). Conclusions Sudomotor dysfunction is associated with increased risk of FU and should be included in the screening tests for identification of diabetic patients at risk of ulceration.     

Clinical profile of diabetic foot infections in south India--a retrospective study.

AIMS: The aim of the study was to determine the profile of diabetes foot infections in south Indian diabetic subjects. The causative factors for delayed wound healing and the recurrence of infection were also studied. METHODS: During a period of 6 months, 374 patients who had undergone some surgical procedure for foot infection were available for follow-up (M:F 227:147, mean age 54.9 +/- 9.4 years, diabetes duration 10.9 +/- 7.7 years). All of them had records of clinical and treatment details, laboratory data including biothesiometry, Doppler tests and electrocardiogram (ECG) records. Foot ulcers were classified according to Wagner's classification. RESULTS: Majority of the patients had grade II and III ulcers (50% and 26.5%, respectively), grade IV was seen in another 21.9%. The median healing time was 44 days. Recurrence of infection which occurred in 53% was more common in patients with neuropathy and peripheral vascular disease (PVD). CONCLUSIONS: Recurrence of foot infection was common among south Indian Type 2 diabetic subjects and was related to the presence of PVD and neuropathy. There is also a need for improvement in footwear and foot care education.     

The association between baseline characteristics and the outcome of foot lesions in a UK population with diabetes.

AIMS: To explore the relationships between time to healing of diabetic foot ulcers and baseline characteristics of both patients and their ulcers. METHODS: All patients were included who were referred to a specialist clinic over a 4-year period. Age, gender, type and duration of diabetes, ulcer site, ulcer duration and baseline characteristics were recorded. Postcode was used to derive an index of social deprivation. Patients were followed up to 1 year. The primary outcome measure was time to healing. Those who died or had an ulcer-related amputation were censored at the time of death or amputation and classified as unhealed. RESULTS: Mean age of 449 participants (63.7% male) was 66.7 years; 42.7% had evidence of peripheral arterial disease, and 80% had peripheral neuropathy. Median ulcer duration at presentation was 29 days; 60.5% ulcers had an area of < 1 cm(2) and 68.3% of all ulcers healed without amputation during the follow-up period. Univariate analysis revealed dose-response relationships between time to healing and increasing duration of diabetes, increasing ulcer area, ulcer site and peripheral arterial disease. No associations were found with age, gender, diabetes type, deprivation index, peripheral neuropathy or infection. The relationship between healing time and ulcer area, peripheral arterial disease and diabetes duration remained significant on multivariate analysis. CONCLUSIONS: The dominant factors influencing healing are cross-sectional area at presentation and the degree of peripheral arterial disease. Further work is needed to define how those at greatest risk may be identified and best managed.     

Factors associated with diabetic patients at high risk for foot ulceration

In order to define risk factors for foot ulcers, associated with the major contributing factors (peripheral sensorimotor neuropathy, peripheral vascular disease, altered foot biomechanics and history of foot ulceration or lower limb amputation), a multivariate analysis was performed in 446 patients free from foot ulceration. Four significant risk factors for foot ulcers have been identified: retinopathy, poor psychosocial status, hyperkeratosis, and diabetes duration. A relation was present between the probability of belonging to the high-risk groups and the number of associated factors. This study points out to the importance of screening especially in case of diabetes of long duration, with microvascular complications, and in socially-deprived people.     

A preventative foot care programme for people with diabetes with different stages of neuropathy

The aim of this study was to assess the efficacy of a preventative foot care programme, applied in a normal outpatient setting to decrease the incidence of foot ulcers in people with diabetes diagnosed as having neuropathy by neuropathy disability score (NDS), in relation to the severity of neuropathy based on the vibration perception threshold (VPT). A structured continuous preventative foot care programme was designed to ensure proper footwear, walking foot hygiene, callus care, nailcutting, water temperature checks, use of warming devices, bathroom surgery, foot care products and self-inspection. Continual foot-care education and treatment, including podiatry, were available. Evaluation was at least every 6 months. Diabetic patients (n=308) with neuropathy (NDS > or =6), 72.3+/-10.7 years old, 45% men, 10.9+/-8.8 years duration of diabetes, and HbA(1c) 6.5+/-1.3%, without a history of foot lesions were recruited over 3 years and followed-up for 4.6 (3-6) years. A low risk group (n=124) had a VPT<25 V while 184 had a VPT > or =25 V (high risk). In all 220 patients (71%) complied with the programme, compliance being 76 and 68% in low and high risk groups. The low risk group developed nine ulcers in nine patients, and the high risk group 24 ulcers in 19 patients. Of these eight and 19 ulcers, respectively, were in the non-compliant patient group, giving relative risk of 22 and eight compared with people attending the programme. Thus compliance with a preventative foot programme reduces the incidence of foot ulceration in people with diabetes with neuropathy. This decrease is relatively greater in patients with less severity of neuropathy. The simple design should be widely generalisable.     

Systematic screening for diabetic retinopathy with a digital fundus camera following pupillary dilatation in a university diabetes department.

AIMS: Screening for diabetic retinopathy (DR) is highly inadequate in France because of insufficient infrastructure and increasing disease prevalence. We describe the results of the first systematic DR screening programme established in a university diabetes department. METHODS: In this cross-sectional study conducted over 1 year, consecutive adult patients underwent three-field retinal photography with the Topcon TRC NW6S digital fundus camera following pupillary dilatation with Tropicamide 1%. A questionnaire provided information on patients' systemic and ocular history. Glycated haemoglobin (HbA1c) was measured at the screening visit.Two ophthalmologists graded the retinal photographs in a masked fashion. RESULTS: Of 1157 patients attending the diabetes department, 1153 (99.7%)underwent photographic screening. Images were gradable in 96% patients.Diabetic retinopathy was detected in 522 (45%) patients and sight-threatening DR in 167 (14%). Of 704 (61%) patients previously believed to have no DR,254 (34%) screened positive. The presence of DR was associated with age,insulin use and non-Caucasian ethnicity in Type 2 patients, and with duration of diabetes and HbA1c in Type 1 and Type 2 patients. Associated ocular pathologies were diagnosed in 612 (53%) patients. CONCLUSIONS: Our photographic screening programme using pharmacological mydriasis provided a high screening coverage feasible in a hospital setting. We obtained information regarding prevalence and associated risk factors of DR inpatients attending a tertiary care centre. Screening was well accepted by patients and met with no protest from city ophthalmologists. It generated considerable interest among endocrinologists and feedback of results is expected to improve optimization of glycaemic control.     

Hidden dangers revealed by misdiagnosed diabetic neuropathy: A comparison of simple clinical tests for the screening of vibration perception threshold at primary care level

Aim

Diabetic peripheral neuropathy is an important complication and contributes to the morbidity of diabetes mellitus. Evidence indicates early detection of diabetic peripheral neuropathy results in fewer foot ulcers and amputations. The aim of this study was to compare different screening modalities in the detection of diabetic peripheral neuropathy in a primary care setting.

Disease management for the diabetic foot: effectiveness of a diabetic foot prevention program to reduce amputations and hospitalizations

OBJECTIVE: To demonstrate the effectiveness of a diabetic foot disease management program in a managed care organization. METHODS: We implemented a lower extremity disease management program consisting of screening and treatment protocols for diabetic members in a managed care organization. Screening consisted of evaluation of neuropathy, peripheral vascular disease, deformities, foot pressures, and history of lower extremity pathology. We stratified patients into low and high-risk groups, and implemented preventive or acute care protocols. Utilization was tracked for 28 months and compared to 12 months of historic data prior to implementation of the disease management program. RESULTS: After we implemented the disease management program, the incidence of amputations decreased 47.4% from 12.89 per 1000 diabetics per year to 6.18 (p<0.05). The number of foot-related hospital admissions decreased 37.8% from 22.86 per 1000 members per year to 14.23 (37.8%). The average inpatient length-of-stay (LOS) was reduced 21.7% from 4.75 to 3.72 days (p<0.05). In addition, there was a 69.8% reduction in the number of skilled nursing facility (SNF) admissions per 1000 members per year (Table 1) and a 38.2% reduction in the average SNF LOS from 8.72 to 6.52 days (p<0.05). CONCLUSION: A population-based screening and treatment program for the diabetic foot can dramatically reduce hospitalizations and clinical outcomes.