American Diabetes Month: How foot ulcers impact CAH operations

Normally, if someone injures their foot, they experience pain alerting them to the injury. They then take steps to treat it: clean the wound, apply a topical medication, and cover it with a bandage. Their body begins the healing process, and typically their foot heals. However, for the 38.4 million Americans who have diabetes, that’s not always the case.¹

One of the most dangerous complications of diabetes is a diabetic foot ulcer (DFU), an open sore on the foot related to diabetes that fails to heal. A DFU often occurs on the bottom of the foot but can happen anywhere the skin or tissue breaks down or is cut open. Once a patient has had one, they are more likely to develop another.

Having diabetes puts patients at a much greater risk for foot ulcers, as diabetes affects circulation in the legs and feet and raises blood sugar levels, which both slow healing. In addition, nerve damage in the legs and feet can cause numbness that does not allow the patient to feel the severity of a leg or foot injury, causing the blister, cut, or sore to go unnoticed. Left untreated, these small breaks in the skin may turn into larger, more problematic wounds.

DFUs can be dangerous for patients. In the best circumstances, it takes weeks to several months for the ulcer to heal. In some cases, a patient may need surgery to remove tissue that has died. If infection spreads throughout their body or severe ligament, muscle, and bone damage occurs, amputation may be necessary.

Putting hospitals at risk

Non-healing wounds like DFUs are also harmful to hospitals. Not only are they costly – perhaps 50 to 200 percent above the baseline annual cost for diabetes-related care – DFUs present incredibly high rates of hospital admissions, emergency department visits, and home health care utilization.² For hospitals, that may mean operational strain such as staffing and overcrowding, clinical strain, including reduced quality of care and limited resources, and financial strain or increased costs.

For critical access hospitals (CAH) specifically, these effects are amplified. Research shows that the prevalence of diabetes is 9 to 17 percent higher in rural areas than in urban areas.³ Because of this, issues with staffing and overcrowding can lead to decreased capacity, impacting a CAH’s ability to treat more patients. Reduced quality of care and limited resources negatively affect patient healing for a condition that already has high rates of recurrence. These consequences contribute to lost revenue, especially when time, resources, and treatments do not properly treat a patient’s DFU.

Ultimately, DFUs that are not properly treated compound, often until amputation is required, but this isn’t the final straw in a patient’s wound care treatment. Amputations bring on a new set of costs for the patient, not only financial but physical and mental. DFUs alone present a higher five-year mortality rate than many cancers, including prostate, breast, and Hodgkins Lymphoma. When paired with either a minor or major amputation, mortality rates soar to become comparable with lung and pancreatic cancers.^{4,5,6,7,8,9.10,11}

A unique opportunity for CAHs

Fortunately, CAHs have a unique opportunity to help patients in their community suffering from DFUs. An advanced wound care program can specifically treat patients with non-healing, diabetes-related wounds by focusing on limb salvage and wound prevention.

Advanced wound care is provider driven and procedure focused, offering a multidisciplinary approach to healing that may include a combination of wound care techniques and treatments, advanced products and dressings, lifestyle changes, and patient education as part of a patient’s personalized treatment plan designed by a team with specialized training in wound care. Offering a weekly advanced wound care program can help patients even more. One study shows that, with weekly appointments, it takes an average of 28 days for a DFU to heal versus 66 days with appointments every other week.¹² This could make a significant difference for patients potentially facing diabetes-related amputation.

Providing advanced wound care can benefit CAHs in multiple ways. First and foremost, advanced wound care keeps patients local. When patients are referred elsewhere for advanced care or surgical procedures, they often continue their follow-up and rehabilitation within that external health system. Offering comprehensive wound care within your CAH allows you to retain those patients, strengthen continuity of care, and position your hospital as a regional leader for diabetes-related wound complications. This can attract new patients, too. Because your hospital is providing the same care as the large system down the road, your offerings are strengthened, and people don’t need to travel as far to receive high-quality care.

Being part of the solution

It’s important to never underestimate a wound — even a minor one, as a simple callus could be the tip of the iceberg that leads to a serious non-healing wound. This American Diabetes Month, be a part of the solution for those in your community affected by diabetes-related non-healing wounds by raising awareness of DFUs in your community:

1. Ask hospital-affiliated podiatrists to hold a free foot screening to help identify members of the community who are at risk of developing a non-healing foot ulcer.
   
   
2. Connect local podiatrists with your hospital’s diabetes educator for senior and community education presentations.
   
   
3. Implement an advanced wound care program at your hospital to increase access to care for patients with diabetes.

NRHA adapted the above piece from Restorix Health, a trusted NRHA partner, for publication within the Association’s Rural Health Voices blog.
 

About the author: William H. Tettelbach, MD, is the chief medical officer of RestorixHealth where he is responsible for developing and implementing institutional health care policies and standards and evaluating new treatment modalities for the organization. He also supports medical research, medical director, and panel provider training and support to ensure quality of the medical care provided to patients across the country.

References

1. https://www.cdc.gov/diabetes/php/data-research/index.html
2. https://diabetesjournals.org/care/article/46/1/209/148198/Etiology-Epidemiology-and-Disparities-in-the 
3. https://www.cdc.gov/pcd/issues/2025/24_0199.htm 
4. https://www.cancer.org/cancer/prostate-cancer/detection-diagnosis-staging/survival-rates.html
5. https://www.cancer.org/cancer/breast-cancer/understanding-a-breast-cancer-diagnosis/breast-cancer-survival-rates.html
6. https://www.cancer.org/cancer/hodgkin-lymphoma/detection-diagnosis-staging/survival-rates.html
7. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092527/
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092527/
9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7092527/
10. https://www.cancer.org/cancer/lung-cancer/detection-diagnosis-staging/survival-rates.html
11. https://www.cancer.org/cancer/pancreatic-cancer/detection-diagnosis-staging/survival-rates.html
12. https://pubmed.ncbi.nlm.nih.gov/23080236/