Preventing amputations from diabetes mellitus: the Indian Health Service experience

With the heavy burden of diabetes mellitus among American Indians and Alaskan Natives, lower-extremity amputation (LEA) has become a common complication. Rates of diabetes-related LEA are 2-3 times those observed in other diabetic populations. During the past 12 years, the Indian Health Service (IHS) has made LEA prevention a public health priority. From 1988 to 1992 screening criteria based on simple examinations were developed and validated in primary care Settings. Prevention efforts have focused on targeting high-risk individuals for self-care foot education, provision of protective footwear, and routine podiatry care. Follow-up studies in Alaska and northern Minnesota saw 25-50% reductions in LEA rates associated with these interventions. In settings where these efforts were augmented with system changes, such as team coordination, patient-tracking systems, comprehensive footcare practice guidelines, flowsheets, and outreach programmes, LEA incidence was reduced by 50-75%. Efforts are currently underway to disseminate system-based approaches for comprehensive diabetic footcare and to expand the availability of foot care resources to tribal communities served by the IHS.