Can Diabetes Care Teams Improve Patient Outcomes and Value?

The 38 million people in the United States living with diabetes are at an elevated risk of requiring some type of lower limb amputation, often after a diabetic foot ulcer (DFU) develops and doesn’t heal. These amputations are associated with a 5-year survival rate of only 43% — dramatically less than the average 5-year survival rates of breast cancer, testicular cancer, or colorectal cancer.
Yet few people with diabetes experience anywhere near the same level of coordinated care from expert-level providers that people with cancer can access. Too often, patients are subject to a flurry of conflicting opinions from each of their specialists, none of whom are coordinating with each other to align their recommendations. 
It’s time to prioritize diabetes care just like cancer care by borrowing well-established concepts from our colleagues in oncology.
What if teams of specialists from primary care, podiatry, endocrinology, infectious disease, vascular surgery, behavioral health, and other disciplines as needed routinely met as a “limb preservation board” or a “high-risk limb board” to discuss their shared patients, identify risks, and develop a unified plan of action that could prevent an avoidable amputation in people with lower limb complications?
The benefits to people with complex diabetes could accrue rapidly by coordinating services; reducing preventable costs to the health system; and fostering more ulcer-free, hospital-free, activity-rich days for people with diabetes.
Hospitals and health systems already use a variety of methods to ensure their most acute patients can benefit from the collective wisdom of expert clinicians across disciplines.
For people with complex cancers, for example, this often includes getting their case in front of a tumor board. The group of multidisciplinary specialists reviews test results and discusses treatment options to ensure delivery of the best possible care.
Tumor board review is strongly associated with longer survival rates for people with certain types of cancers. It’s an effective strategy for providing the best possible options to people with serious disease. 
People with diabetes usually don’t have access to these collaborative resources until something goes very wrong for them and they end up admitted after a crisis event. 
That’s because primary care, where most diabetes services take place, hasn’t yet adopted these principles due to ongoing shortages of healthcare providers, the overwhelming number of people in need, and, often, a lack of awareness around the potential severity of DFUs and their complications.
Currently, acute care providers amputate limbs every 4 minutes. Payers shoulder the financial burdens, including up to $58,000 per year in routine care costs for a person with DFUs and up to $100,000 for an amputation.
But as value-based care brings the acute care and primary care communities closer together, there are increasing opportunities for early intervention to reduce confusion around complex clinical cases while preventing overly expensive care and poor-quality outcomes. 
The high-risk limb board model solves for these problems by bringing specialized knowledge to the primary care setting while reducing the need for acute care providers to perform such costly procedures.
To put this concept into action, care providers, payers, and other stakeholders must first rethink how people move through the diabetes care process.
At what point do patients move from the primary care environment into specialty care? What complications tend to trigger the transition, and whom are they seeing next? What are the barriers to accessing this enhanced care, including capacity challenges and socioeconomic barriers, that may cause conditions to deteriorate due to delays?
The answers to these questions can help clinicians decide on the best home base for a high-risk limb board, whether that’s in a local community hospital in a rural region or an academic medical center in a larger city, as well as the most appropriate specialties to participate in the cross-disciplinary program.
Next, healthcare providers and payers need to address how they can use technology, including remote patient monitoring devices and advanced analytics, to identify candidates for personalized management. These devices can combine with clinical data, claims, socioeconomic data, and other information to feed artificial intelligence algorithms to predict the likelihood of DFU development and progression to the point where amputation may be considered.
Patients who fall into high-risk categories could benefit from early referral to collaborative care initiatives, which can preemptively reduce poor outcomes and the associated spending.
Lastly, stakeholders must make the business case to participating care providers and payers, especially in the value-based care environment, that this approach can help all parties meet their clinical and financial goals.
It may take time to generate sufficiently detailed evidence to bring high-risk limb boards into diabetes care at scale, but we must commit to devoting the time, energy, and resources to efforts like these if we want to make progress against the rising tide of chronic disease.
Inertia can be a powerful force in healthcare, especially as care provider shortages and other challenges threaten to sap our energy. But with proven success in cancer care and with much to gain in patient outcomes, this proactive coordinated approach could be the key to accelerating the industry into a new era of precision care for people with diabetes.
Dr David Armstrong is professor of surgery at the University of Southern California. He has produced more than 480 peer-reviewed research papers in dozens of scholarly medical journals, as well as over 80 book chapters. He is co-editor of the American Diabetes Association’s (ADA) Clinical Care of the Diabetic Foot now in its third edition. Armstrong is past chair of scientific sessions for the ADA’s Foot Care Council, and a past member of the National Board of Directors of the American Diabetes Association. He sits on the Infectious Disease Society of America’s (IDSA) Diabetic Foot Infection Advisory Committee and is the US-appointed delegate to the International Working Group on the Diabetic Foot (IWGDF). 
Dr Gary Rothenberg is a board-certified podiatrist, a certified diabetes care and education specialist, and certified wound specialist who currently holds an associate professor of internal medicine appointment within the Endocrinology Division at the University of Michigan School of Medicine. He also is the director of medical affairs at Podimetrics. In addition, Rothenberg is also the Director of Fellowship Training for the two-year research-based fellowship at that institution where he helps train the next generation of leaders in preventive, academic podiatric medicine. Prior to academia, he served the veteran population as an attending physician and director of resident training at the Miami VA Healthcare System for 11 years.