REDUCING LOWER-EXTREMITY AMPUTATIONS DUE TO DIABETES - APPLICATION OFTHE STAGED DIABETES MANAGEMENT APPROACH IN A PRIMARY-CARE SETTING

BACKGROUND. While lower-extremity amputation (LEA) is a frequent compl ication of diabetes, effective strategies for the prevention of LEA in primary care settings have not been extensively studied. METHODS. Thi s prospective study of American Indians with diabetes in a rural prima ry care clinic was divided into three periods: the standard care perio d (1986 to 1989), during which patients received foot care at the disc retion of the primary care provider; the public health period (1990 to 1993), during which patients were screened for foot problems and high -risk individuals received foot care education and protective footwear ; and the Staged Diabetes Management (SDM) period (1994 to 1996), duri ng which comprehensive guidelines for diabetic foot management were ad apted by the primary care clinicians to their practices and were syste matically implemented. RESULTS. A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation. P atient sex distribution, mean age, and mean duration of diabetes were similar in the three periods. The average annual LEA incidence was 29/ 1000 diabetic person-years for the standard care period (n=42), 21/100 0 for the public health period (n=33), and 15/1000 for the SDM period (n=20), an overall 48% reduction (P=.016). Overall, the incidence of a first amputation declined from 21/1000 to 6/1000 (P<.001). CONCLUSION S. The customization and systematic implementation of practice guideli nes by local primary care providers was associated with improved diabe tic foot care outcomes, SDM has relevance to primary care organization s seeking to improve outcomes for patients with diabetes.