Diabetes-related foot conditions like ulcers and amputations can be very serious, but these complications are preventable when comprehensive foot exams are prioritized. Podiatrist Dr. Mark Hinkes joined The Huddle to talk about the importance of foot health and comprehensive foot exams for people with diabetes, and how we can use data collected from these foot exams to predict potential future risk. Learn more about the International Working Group on the Diabetic Foot here: Home - IWGDF Guidelines View Mark's book "Healthy Feet for People with Diabetes" here: Healthy Feet for People With Diabetes: Hinkes DPM, Dr. Mark: 9780985628604: Books - Amazon.ca Learn more about diabetes-related foot complications: Foot Complications | ADA Five year mortality and direct costs of care for people with diabetic foot complications are comparable to cancer | Journal of Foot and Ankle Research | Full Text
Diabetes-related foot conditions like ulcers and amputations can be very serious, but these complications are preventable when comprehensive foot exams are prioritized. Podiatrist Dr. Mark Hinkes joined The Huddle to talk about the importance of foot health and comprehensive foot exams for people with diabetes, and how we can use data collected from these foot exams to predict potential future risk.
Learn more about the International Working Group on the Diabetic Foot here: Home - IWGDF Guidelines
View Mark's book "Healthy Feet for People with Diabetes" here: Healthy Feet for People With Diabetes: Hinkes DPM, Dr. Mark: 9780985628604: Books - Amazon.ca
Learn more about diabetes-related foot complications:
Kirsten Yehl
Hello, and welcome to ADCES's podcast, The Huddle: Conversations with the diabetes care team. In each episode, we speak with guests from across the diabetes care space to bring you perspectives, issues, and updates that elevate your role, inform your practice, and ignite your passion. I'm Kirsten Yehl, Director of Research and Development at the Association of Diabetes Care and Education Specialists. Today, I'm joined by Dr. Mark Hinkes who's going to be talking about the importance of comprehensive foot exams and how we can use data collected in these exams to better diabetes management and care in the future. Dr. Hinkes, welcome to The Huddle.
Mark Hinkes
Thank you, Kirsten. It's a pleasure to be here with you today.
Kirsten
Well, we are so glad that you're here with us today. And one of the reasons you're here is, I loved our conversations around really making the DCES an ambassador for amputation prevention. That's been one of the drivers of your work. Am I right?
Mark
Yes. In fact, it's a vital portion of giving people with diabetes a better quality of life and reduce the cost of health care for them.
Kirsten
And that is absolutely fantastic. And you also have an amazing book that I keep up on my bookshelf and handy at all times. It's the “Healthy Feet for People with Diabetes”. It's a great reference for people. So you're an expert in this space. So happy that you're here. But before we dive into this, because this is a really important topic for our guests to hear about, I'm wondering, can you share a little bit about your background, where you came from, what drives you, what got you into the space?
Mark
Thanks, Kirsten. I'd be happy to do that. First of all, please call me Mark. I'm just a regular guy who happens to be podiatrist.
Kirsten
Awesome.
Mark
With that in mind, I started my career in Florida, where I did my residency. And from that, I'm now board certified in surgery and wound care. It's a big jump there. I started my practice 20 years ago in Miami and left it after that due to Hurricane Andrew. Hurricanes are in the news a lot, so I feel like I'm justified in talking about them. I spent 20 years in service to veterans in several Department of Veterans Affairs medical centers. In my 40-year career, I've seen nearly 200,000 patient visits. At the VA, where I worked in Roanoke, Virginia and Nashville, I was the chief of the podiatry section and chairman of the Preservation, Amputation, Care, and Treatment program, which is a government program focused on preventing foot ulcers and amputations. Also at the VA, I developed and managed a five-year research project. The project used evidence-based medicine as the basis for patient care. The data from the effort revealed a 40% decrease in amputations and a 62% decrease in costs. I have tried very hard to educate both patients and caregivers and I've written two books. One book is out of print, so we're not going to talk about it. The other one is called “Healthy Feet for People with Diabetes” and it has a focus on prevention and foot health. I'm also writing blogs for Podiatry Today magazine and on LinkedIn. Well, when I'm not fooling with people's feet, for fun I like to make stained glass art. I grow fragrant roses. I enjoy traveling. I cook a little bit, not very much, and I like to play bad gammon. So that's a quick thumbnail.
Kirsten
Another thing we are here to talk about is data collection and technology, especially as it relates to podiatry and the feet. So I'm super excited to jump into that. But before we do, we should talk a little bit more about the why foot care is so important. What goes into that. We started talking a little bit about that, what the stats you gave us, but maybe dive in a little deeper here.
Mark
Okay. We need to take a more global look at this before we take a deep close up look. Diabetes is a global health care crisis and we're spending over a trillion dollars annually on this problem and it's affecting 500 million adults and it's also affecting 500 million people with pre-diabetes. So these two groups together are more than a billion people on this planet that have this problem. And the number of people is projected to increase by 50% in the next 25 years. So what this really means is there's going to be a lot more foot pathology that needs to be dealt with. And my position is, we're farther ahead if we prevent it than if we have to try to deal with it. So the single most costly debilitating diabetes complication, which is responsible for infections, hospitalization, lower extremity amputations, and premature death in some cases, is the foot ulcer.
Kirsten
So why do people get these ulcers?
Mark
But it's kind of an interesting situation. The foot ulcer is the result of a triggering event of mechanical, chemical, or thermal trauma to the foot that's affected by PAD, arterial disease, and any combination of neuropathy. But it's usually sensory neuropathy.
Kirsten
All right. So this is the big problem. From some of the stats I've read, it's like 25% of all people with diabetes will develop a foot ulcer in their lifetime. Can you talk through like how bad is this problem?
Mark
It's a bad one. Here's some numbers to think about. Worldwide, a foot ulcer happens every second. And an amputation is performed every 20 seconds. Because what you mentioned, that 25% of people with diabetes will develop a foot ulcer in their lifetime. And 85% of all non-traumatic amputations in the diabetic population are preceded by a foot ulcer. What's really important, this is a big take home that everybody should remember. Preventing the foot ulcer prevents the infection, the hospitalization, the amputation, and the possible premature death. So we're not talking about just fixing a hole in somebody's foot. We're talking about some serious problems that are life-changing and expensive. 38% of the people who suffer an amputation are going to lose the other leg in three years and near 75% of those who suffer an amputation will not survive five years. So the mortality of a diabetes-related amputation is greater than all forms of cancers combined, excluding pancreatic and lung cancers. So let's just take a second here to reflect. Think about this. In the past minute, there have been 60 foot ulcers and three amputations.
Kirsten
Okay, so that's, that's actually pretty scary. It made me pause and think there. Let me ask you this. When you're thinking about prevention, there has to be factors or variables that can influence prevention or influence these amputations. Can you talk through maybe those big influencers, factors?
Mark
Thanks. That's a really good question. Pretty much the primary care provider and the business model of their practice influence the foot health of patients with diabetes. There's a shortage of doctors and endocrinologists in the US, and the ratio is about one to 4,000 of endocrinologists to adult people with diabetes. Primary care providers are not really diabetes specialists, yet they manage 90% of the patients with diabetes, and they are also charged with doing foot exams. Primary care providers are generalists, and many of them are not aware of the contents of a comprehensive foot exam. So, they perform what they call a partial foot exam or don't do a foot exam at all. So consequently, there are gaps in care that cause clinical mistakes and omissions. The result is a reactive treatment, which means we're going to be, instead of addressing a comorbidity before they occur, we're now trying to deal with it after they occur. Key indicators may not be noted, thus wrong decisions can be made for care.
Kirsten
You're bringing up some pretty important issues here, these issues that are affecting primary care providers. can't do it all, right?
Mark
You're right. Primary care providers are limited by the clock. They have 10 or 15 minutes to see a patient. Their training and interest may be limited. And they're probably not interested in doing foot exams. I'll ask each person that's listening to this now on your last visit to your primary care doctor, did they look at your feet? I think more people are going to probably say no than yes. And if I'm wrong, let me know. I want to say now that I think CDCES members are really important here because they not only have the time, but they have the education, the training, the motivation to do these exams. I personally see them as ambassadors of amputation prevention. Let me just go into a quick cul-de-sac. In India, the government has just started a program where they have recruited 19,000 medical people, doctors, nurses, and so forth. And they've established over 100 clinics for people with diabetes to have screening foot exams. My vision is that in this country, the CDCES can do the same thing, and I see them as ambassadors of amputation prevention.
Kirsten
Yeah, I think we're going to have to keep repeating that because I absolutely love that. I've heard you say it before, and I think it's something worth repeating over and over, this ambassadors of amputation prevention. I do want to get back to this business model of health care. And you and I have talked a little bit about this, how the health systems have changed over say the last 20 years as we've moved towards the larger conglomerates, the large academic medical centers. And instead of being run by physicians, they're run by, really business people. Can you talk about the impact that has on the primary care model and the time that patients have with their physicians?
Mark
Yes, that's a very good point. It used to be there was only one business model of medicine. It was called fee for service. There's a new business model that's coming out. It's called value-based care. In value-based care, it's based on capitation. So it's not the volume of people you see. It's the value that you do for each patient. So, value-based care strives to keep patients healthy by screening and promoting prevention. So it's a completely different way to look at health care. And I think that there's about 27% of the medical providers are in complete value-based care. There's about 12% that are partially based in value-based care. So we're looking at close to 50% of providers of health care being involved at some level on value-based care. And I think this is going to increase in the future and it's going to be only good for patients.
Kirsten
So value-based care kind of puts us in the position or the primary care physician in the position or the health system in the position to collect the right data to help navigate people through the system in the best way. And I know you're gonna talk about this a little more, but I think right now we could maybe take that turn into how you collect and use this information, because artificial intelligence and machine learning relies on data. And this value-based care is supporting us to collect the data and the information we're going to use. Am I on the right track there?
Mark
100%. 100% correct. So when we're looking at a patient's foot, especially a patient with diabetes, we're looking for components in the history of the physical exam that are necessary for us to stratify patients into risk groups that are associated with the International Working Group on the Diabetic Foot. And I would encourage everybody who's listening when we're done here, get on your computer and look up International Working Group on the Diabetic Foot because there is a tremendous amount of information there that's good for us as practitioners as well as for patients. So, what we're promoting here is the risk stratification method used by the International Working Group, which is evidence-based medicine, and then what's available in the literature. And we're putting these two together to develop data that gives us information that we will use to nourish the machine learning, which will help in the development of the artificial intelligence. So what are we looking for? Well, the components from the history that we're looking for are a previous or current foot ulcer and amputation, or is the patient on end stage for renal disease. And these of course are all problems of small vessel disease, which links all the comorbid conditions of the feet, eyes, kidneys, and cardiovascular systems together. From the physical exam, we're looking for PAD, neuropathy, and deformities of the bones, soft tissue, and nails.
Kirsten
So what are the benefits? I love the screening, and you've kind of laid it out for us really clearly there. Can you talk about the benefits of the screening?
Mark
Sure. Screening exams make a world of difference because they give us identification of each patient's unique risk factors for developing a foot ulcer. And when we detect these risks, that facilitates prevention at the earliest possible stage, which we can't do until we can screen and identify the patient's risks. So identifying the risks puts us upstream, if you will, of the development of an ulcer. The data that we collect from the history and the physical exam will allow us to do three things. One, it will identify the patient's risks. Two, it will help us to stratify patients into risk categories and three, actually four things. The third is it will make recommendations on how to mitigate the risks. And the fourth is it will give us information on how soon the patient needs to be reevaluated. And I'll put this in perspective. One of the things that happens when a patient comes to a physician for the first visit is, what do we know about this patient? Well, they're type one, they're type two, maybe they're type three, or maybe they have gestational diabetes. But that doesn't tell us anything about their risk. And so, PCPs are really operating blindly when it comes to identifying risks. So this is why the screening is so important because it gives a framework for a PCP not only to identify the glucose and the things that they normally would do, but now it adds another dimension because now we're able to look at risks and mitigate them. And this is a huge step forward in giving patients a better quality of life and decreasing the cost of care.
Kirsten
I love this. So now we can get into some of the techie stuff we love talking about. So if we're collecting the right data, if we have access to that data and maybe larger data sets, that's when we can start using and seeing the benefits of artificial intelligence in the health care network. Am I right there?
Mark
Absolutely. We're going to go into an area now that's previously probably never been discussed, and that is how we use data to prevent amputations. Artificial intelligence is absolutely amazing. In a phone call, they can tell if you have a respiratory problem, if you're pre-diabetes, and we can look at x-rays and so forth. What they're doing with data is incredible. But here before, nobody has really gone down the road of trying to figure out how we can do this to prevent amputations, and that's one of the things that I am doing. So what I want to share with you is that in a comprehensive foot exam, there's nearly 100 data points that we can collect. And the data that we collect from the history of the physical exam identifies the patient's risks for developing an ulcer that can lead to an amputation. So the data is also used to stratify patients in two risk groups, which I mentioned. It also gives the PCP suggestions on referrals to members of the interdisciplinary team for mitigation of identified risks. Let me just back up here. A patient that comes to a PCP that has a small ulcer on their foot, and if the PCP says, let's put a little Neosporin on it and watch it, well, that's the totally wrong thing to do. And yet it happens all the time. So the data that we get can change the care of patients from a population health model, which is what we're doing now, to a personalized medicine model. And the only way you can do personalized medicine is to understand each patient's unique risk factors. And that's what collecting data does.
Kirsten
So I love this. I made some notes while we were talking. So 100 data points allows us to move people, move our clients or patients into risk groups, make the right referrals. Let me back up to these 100 data points and thinking of the diabetes care and education specialist as the ambassador that you talked about. What can the diabetes care and education specialists do to move this work forward, begin to collect all of those data points to get them into the system so that they can be used so that we can actually do machine learning and create algorithms that can support prevention and support people with diabetes. Health systems are big, right? Like, how can the diabetes care and education specialist be that ambassador that you're talking about?
Mark
That's a really wonderful question. Thank you very much. The real issue we have here now is that the way we're managing people with diabetes is 19th through 20th century. Well we're in the 21st century now and we need to change how we're doing this. And change is kind of frightening to people and scary to people, and there's the financial aspects relative to change and so forth. So one of the things that, why I've identified the diabetes care and education specialist is, this is what they do. This is part of what they do. And the education is critical, just critical. And if you think about where can a patient with diabetes get a legitimate foot exam? Well, you can go to your PCP. We talked about the issues there. You can go to a podiatrist. There are some issues there. But ultimately, the person who has the time, the energy, the motivation, and the desire really is the diabetes education and care specialist. What I want to say about the collecting data is that it nourishes the machine learning and the artificial intelligence. And we need this data. And the more data we get, the better the machine learning will be because the machine learning is looking for correlations between data sets. For example, we'd look at a foot exam and then look at a CGM, a continuous glucose monitor device. And we can take those two databases and merge them and look for correlations. And we will find new information about foot health and foot pathology based on the time in range that a CGM will tell us about. So, data needs to be real, live, and comprehensive. And this is important point here. It's not just what's in the medical record that we need to use that data for machine learning. The data from the exam can be used with other data, like I mentioned, looking for correlations. So we need to look at what is the source of the data when we start talking about machine learning. And if it comes from the electronic health record by the PCP, we need to look really close at it because it may not be valid. So I think certified diabetes education specialists are the perfect professionals because they have what I call new eyes. And new eyes means that they'll be able to look at information from a patient's history, which contains data points, and any deformity identified from the exam, someone's foot, is a data point. And there's more than just what you see on the surface. The hammer toe is a data point. A corn is a data point. A deformed nail is a data point. Neuropathy and PAD are data points. So it's important that we know how to identify these risk factors, document them appropriately, and then move forward to mitigate the risk that they represent. So I guess in a closing moment, I would say my goal is that certified diabetes care and education specialists should be able to perform and document the results of a comprehensive foot exam. Now I know they're already doing foot exams. And so, I'm not saying you're not doing a good job, you're doing a good job. I want to make it easier and better and help you to collect the data that's 21st century valuable so that we can move into predictive analytics and personalized medicine. So, I’m really, I'm grateful for the time we had to spend together and I'm appreciative and thank you for the opportunity, actually the privilege to share some time and information with you.
Kirsten
Well, we were so happy that you could join us. This has been an incredible conversation. I mean, and just to sort of wrap things up a little bit, listening to you describe the DCES role in artificial intelligence. And it's so nice when we can talk about a specific area like podiatry, like the foot. I like to think of it as, the diabetes care and education specialist is the behavioral specialists, right? And maybe that's the human factor that influences machine learning and artificial intelligence. And the diabetes care and education specialist brings so much more to the table than maybe they're really aware of, right?
Mark
Absolutely. Absolutely. I think that they're an underappreciated group of folks who are doing a terrific job. And we need to support them and give them the tools so that they can be even more effective at what they're doing.
Kirsten
Yeah. I know we mentioned your books up front. I have your book on reference all the time. So, we can make sure that we put that in the show notes for you. Any other references for our listeners that you want to share?
Kirsten
Well, I am going to be speaking November 1st at the Maryland State Society CDCES meeting. And we'll be going into a lot of the information that I kind of talked about here in more depth. And I will have copies of the book available. And I want to take questions. I want to hear what the CDCES people are concerned about and help them to be better at what they're going to do. So if there's another state society that would like to have more information about this, I'm happy to do it.
Kirsten
Well, Mark, thank you so much for joining us.
Mark
It's my pleasure and my privilege to be with you, Kirsten. Thank you again.
Kirsten
Super. We'll do it again soon.
Thank you for listening to this episode of The Huddle. Make sure to download the resources discussed on today's episode. You can find them linked in the show notes. And remember, being an ADCES member gets you access to many resources, education, and networking opportunities. Learn more about the many benefits of ADCES membership at adces.org/join. The information in this podcast is for informational purposes only and may not be appropriate or applicable for your individual circumstances. This podcast does not provide medical or professional advice and is not a substitute for consultation with a health care professional. Please consult your health care professional for any medical questions.