Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations

Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN


Wounds. 2003;15(4) 

In This Article

Diabetic Ulcer Overview

There are at least 16 million people with diabetes in the United States,[7] and approximately 800,000 new cases are diagnosed each year.[8] Fifteen percent of all patients with diabetes may be expected to develop foot ulcers during their lifetimes.[9]

Significant morbidity and mortality is associated with diabetic ulcers. Persons with diabetes have an increased risk of developing infections with subsequent complications secondary to impaired macrophage and cellular immune responses.[10,11] Nonhealing ulcers may become infected ulcers and are a major cause of lower-extremity amputation, which is 15 times more likely to occur in people with diabetes versus people without diabetes.[4] Approximately 67,000 amputations were performed each year between 1993 and 1995 among people with diabetes.[8] Once amputation occurs, approximately 50 percent of the people with amputations will develop ulceration with associated infection on the contralateral limb within 18 months of the amputation; fifty-eight percent have contralateral amputations three to five years subsequent to the first amputation.[9] The three-year mortality rate after the first amputation is between 20 and 50 percent.[9]

Significant healthcare costs are associated with ulceration of the diabetic foot. Routine ulcer care, infections, hospitalizations, amputations, and diabetes-related care cost billions of dollars. In 1997, inpatient, outpatient, and outpatient pharmaceutical medical expenditures incurred by the diabetic population totaled 77.7 billion dollars.[12] The total direct and indirect cost of care related to diabetes was estimated to be 98 billion dollars.[12] A recent manuscript by Weiman, et al.,[13] reported costs for a nonoperable treatment of a single ulcer to be 7,000 to 8,000 dollars. Infected ulcers cost 17,000 to 18,000 dollars while amputations were approximately 45,000 dollars, excluding rehabilitation costs.

Appropriate and advanced treatment may significantly reduce the high morbidity, mortality, and cost of care associated with diabetic foot ulcers by expediting wound closure. The longer an ulcer remains open, the greater the chance of colonization, infection, and amputation. Timely closure of an ulcer may be expected to reduce the probability of secondary complications.


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