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Diabetic Foot Ulcers — Effects on QOL, Costs, and Mortality and the Role of Standard Wound Care and Advanced-Care Therapies
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38 Abstract: Diabetic foot ulcers (DFUs) are a common and serious complication of diabetes mellitus. A review of the literature confirms that the presence of an unhealed DFU negatively affects several domains of patient quality of life (daily and social activities) and increases the risk of infection, amputation, and death. Patients with diabetes mellitus and DFUs also have higher healthcare utilization rates than patients without DFUs and reported healing rates vary from 24% to 82% after 12 weeks of care. Guidelines for the expeditious healing of DFUs are available and include debridement, infection control, offloading, and the use of dressings that maintain a moist wound bed. Wound measurements to determine progress toward healing must be obtained because percent reduction in wound area during the first 4 weeks of care is a predictor of treatment outcome. If a wound fails to respond to standard care, the use of advanced treatment approaches such as cytokines, negative pressure therapy, and living skin equivalents may be beneficial. Clinical studies to further elucidate the effects of topical, systemic, and supportive regimens of care on outcomes and costs are needed.
Please address correspondence to: Robert J. Snyder, DPM, CWS, 7301 N. University Drive, Suite 305, Tamarac, FL 33321; email:drwound@aol.com.
Potential Conflicts of Interest: Dr. Snyder and Dr. Hanft disclose they have received speaker honoraria and served as a consultant or paid advisory board member, Advanced BioHealing, LaJolla, CA. Editorial assistance in the writing of this article, funded by Advanced BioHealing, Inc, was provided by Tracey Fine, MS, ELS, and Amy Horton, PharmD, CMPP, The JB Ashtin Group, Inc., Plymouth, MI.
The prevalence of diabetes mellitus is increasing worldwide; by the year 2025, an estimated 300 million people will have diabetes.1 Diabetic foot ulcers (DFUs), one of the most common complications of diabetes, have an annual incidence rate of 1% to 4% and a lifetime risk of 15% to 25%.2-5 Peripheral neuropathy is a major contributing factor in the development of DFUs, along with deformity, callus, trauma, and vascular insufficiency.1,3,4,6,7 DFUs are often recalcitrant to treatment and associated with serious medical complications, such as osteomyelitis and lower limb amputation. Approximately 15% of DFUs result in lower extremity amputation.5,7 More than 85% of lower extremity amputations in patients with diabetes are precipitated by a foot ulcer.6,8
The ultimate goal of DFU management is complete wound healing. Standard management strategies for healing DFUs typically have included debridement, infection control, offloading, and the use of dressings to maintain a moist wound bed. Despite the use of standard management strategies, healing rates of DFUs remain low. 
The purpose of this review is to enhance understanding of the effect of DFUs on quality of life (QoL), costs, morbidity, and mortality and to describe current management approaches to optimize outcomes of care.
The Effects of Diabetic Foot Ulcers
Quality of life. DFUs can be painful and limit daily and social activities, leading to reduced QoL. Goodridge et al9 compared QoL parameters in 104 patients with healed and unhealed DFUs (defined as having a history of DFU ≥6 months) who received care in a tertiary foot care clinic. The results of each DFU group also were compared with patients with diabetes and no history of a foot ulcer, patients with hypertension, and persons in the general population.
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Excellent article, but I didn't see any mention of hyperbaric oxygen therapy. After 4 weeks of conventional wound care with unsatisfactory response, I use engineered stem cell tissue grafts and 4 weeks of hyperbarics.
Don Sprague,MD
Reply to this comment »San Antonio, TX
In the article I saw no mention of hypoxia in diabetic foot wounds and hyperbaric oxygen therapy as a modality used in treating DFU.
Reply to this comment »On August 30, 2002 the Center for Medicare and Medicaid Services announced in CAG-00060N, Coverage Decision Memorandum for Hyperbaric Oxygen Therapy in the Treatment of Hypoxic Wounds and Diabetic Wounds of the Lower Extremities and in Transmittal AB-02-183 Program Memorandum for Intermediaries / Carriers its decision to cover treatment of diabetic wounds of the lower extremities with hyperbaric oxygen effective April 1, 2003 if certain criteria was met -
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