Population-based screening for the prevention of lower extremity complications in diabetes

Diabetes-related foot disease is a major health problem leading to significant morbidity and cost. If high-risk populations could be identified and treated before they develop complications, a significant reduction in the burden of foot disease and number of amputations might be expected. We examined the evidence to support population-based screening programs. MEDLINE and EMBASE databases were searched from January 1970 to February 2012 to identify studies assessing the impact of screening on lower limb complications in diabetes. Foot screening was defined as combined risk stratification and intervention to prevent foot complications in a population of people with diabetes mellitus. Articles reporting singularly on stratification of risk factors to predict subsequent complications but not reporting effect on minor, major and/or combined major and minor (total) amputation were excluded. Two randomized control trials were identified. These demonstrated patient benefit from screening in the setting of a general secondary care diabetes clinic and renal dialysis unit. Four before and after studies suggested benefit from primary care or regional screening. One study tried to address confounding from general improvements in the provision of diabetes foot care separately from screening. All the observational studies were prone to confounding. The evidence base for formal national primary care-based foot screening of all patients with diabetes is weak. Focused research is needed to confirm that general population-based screening in the community is effective and cost-effective. Limited evidence suggests that screening of high-risk populations of patients may be justified.