Gary Rothenberg is a Clinical Assistant Professor in the Department of Internal Medicine at the University of Michigan School of Medicine in Ann Arbor. He previously served as the Attending Podiatrist and Residency Director at the Miami VA Medical Center in Florida. Jeffrey Page is a Professor at the School of Podiatric Medicine at Midwestern University in Glendale, Arizona. At the time the article was written he was the Interim Chief and Residency Director of the Phoenix VA Medical Center. Rodney Stuck is Professor of Orthopaedic Surgery and Rehabilitation at Loyola University Medical Center and Hines VA Medical Center in Illinois. Charles Spencer is a Rehabilitation/Wound Care Physical Therapist at the Salt Lake City VA Medical Center in Utah. Lonnie Kaplan is a Staff Podiatrist at the Coatesville VA Medical Center in Pennsylvania. Ian Gordon is a Vascular Surgeon at the Long Beach VA Medical Center in California. Correspondence: Gary Rothenberg (gmrdpm@gmail.com)
Author disclosures Gary Rothenberg serves as a Consultant Medical Director for Podimetrics. All other authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Introduction: Diabetic foot ulcers (DFUs) are devastating, common, and costly. The mortality of veterans following a DFU is sobering with ulceration recognized as a significant marker of disease severity. Given the dramatic impact of diabetic foot complications to the veteran and the US health care system, the US Department of Veterans Affairs (VA) has long recognized the importance of preventive care for those at risk. Telemedicine has been suggested as a modality to reach veterans at high risk of chronic wound formation.
Observations: The purpose of this review is to: (1) present the evidence supporting once-daily remote temperature monitoring (RTM), a telemedicine approach critical to improving both veteran access to care and diabetic foot outcomes; (2) summarize a 2017 study published by VA providers who have advanced clinical understanding of RTM; (3) present previously unpublished data from this study comparing high-risk VA and non-VA cohorts, highlighting the opportunity for additional focus on DFU prevention within the VA; and (4) report on recent VA use of a RTM technology based on this research, emphasizing lessons learned and best practices.
Conclusions: There is a significant opportunity to shift diabetic foot care from treatment to prevention, improving veteran outcomes and reducing resource utilization. RTM is an evidence-based, recommended, but underused telemedicine solution that can catalyze this needed paradigm shift.
Diabetic foot ulcers (DFUs) are devastating, common, and costly. This burden is borne disproportionately by veterans who have high prevalence of type 2 diabetes mellitus (T2DM) and other precipitating risk factors.1 The mortality of veterans following a DFU is sobering, and ulceration is recognized as a significant marker of disease severity.
A 2017 study by Brennan and colleagues reported a 19% mortality rate within 1 year, and only 29% survive past 5 years.2 DFUs are often complicated by peripheral arterial disease (PAD) and diabetic immune dysfunction, contributing to chronic wounds and infection.3,4 About 60% of all foot ulcers become infected, and > 20% of patients with a diabetic foot infection require amputation.5,6
A 2010 retrospective study reports that > 3,400 veterans have a diabetes-related lower extremity amputation annually, vastly surpassing the rate of amputation secondary to trauma in the Veterans Health Administration (VHA).7,8 The inpatient costs for each amputation exceeded $60,000 in fiscal year 2010, and these amputation-related costs represent only 1 component of the total expense to the VHA attributable to diabetic foot complications.7 A recent systematic review by Chan and colleagues estimated mean annual costs in the year following a foot ulcer to be $44,200 to the public payer.9 This implies that direct expenditures for treatment of DFUs within the VHA exceeds $3 billion annually.