08/03/2023    John V. Guiliana, DPM, MS

Comprehensive Evaluation of Diabetic Patients ( Allen Jacobs, DPM

Kudos to Dr. Jacobs, who always seems to have his
finger on the pulse of professional challenges. He
has again accurately identified a problem that
translates into needless infections,
hospitalizations, amputations, and death in our
diabetic population, estimated to cost
approximately $80 billion annually.

As a profession, we have become so preoccupied with
the worry of audits that many forget to look beyond
just the nail and callus care in this “at risk”
population. Attacking the $80 billion annual price
tag involves comprehensive chronic care management,
and paramount to our role in this initiative
involves maintaining skin integrity. Without skin
integrity, the unfortunate and costly “chain of
consequences” (fissure, ulceration, infection,
amputation, death) ensues. The root cause of
compromised skin integrity is frequently because of
skin dryness from neuropathic sudomotor
deficiencies, as well as pressure from poorly
fitted shoe gear.

Dr. Jacobs accurately pointed out that without the
medical necessity needed for appropriately being
compensated for an evaluation and management
service, we are financially limited to attending to
only the nail and callus care and ignoring the real
“elephant in the room.” This not only serves as a
grave injustice for patients with diabetes, but it
also has created a great deal of professional
fungibility for podiatry, as other
paraprofessionals have begun taking over those nail
and callus care tasks.

We don’t have to succumb to this challenge,
however! If my colleagues would change their
approach to how they view the at-risk foot care
visit for patients with diabetes, many ethical and
financial challenges can be resolved, particularly
when we are facing a healthcare system shifting
towards value-based care. We need to expand our
current philosophy on what constitutes “podiatric
vital signs” specifically for the diabetic foot to
extend beyond the measurement of height, weight,
blood pressure, etc.,and quickly, efficiently, and
quantitatively assess the diabetic foot for its
skin moisture index (SMI) and “hot spots.”

Very inexpensive tools and innovations are now
available to identify the medical necessity needed
for the additional chronic care management for our
patients with diabetes, as well as compensation for
our role in this critical lower extremity
amputation prevention (LEAP) initiative to prevent
the “chain of consequences” for many patients. I
encourage my colleagues to explore using DermaStat®
and IRStat® as part of their “LEAP Vitals” to
measure skin moisture index and hot spots,
respectively, in our patients with diabetes. It can
ultimately change our role in the healthcare
system, as well as have a very positive impact on
our practice’s economy.

John V. Guiliana, DPM, MS, Little Egg Harbor, NJ

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