Managed care for reducing lower extremity amputations in Type 2 diabetes: a systematic review

Background. There is limited evidence on the effect of organizational arrangements on foot complications in diabetes. We evaluated the effectiveness of different organizational arrangements in the delivery of care for the reduction of lower extremity amputations (LEA) among people with Type 2 Diabetes (T2D) affected by foot ulcers.Methods. We conducted a systematic review of the scientific literature published between 1999-2019 on Medline and Embase, using the following key terms as search criteria: people with T2D, diagnosed with diabetic foot ulcer, treated with specific processes and pathways of care, experiencing LEA as an outcome.Results. A total of 57 studies were eligible for the study, investigating the following organizational aspects: dedicated teams; care pathways and protocols; multidisciplinary teams; and combined interventions. Among the retrieved papers, only 7 could be used for binary outcome meta-analysis. Overall, intervention groups showed a 29% reduced risk of any type of LEA (OR = 0.71, 0.52- 0.96). The effect was larger when focusing on major LEA alone, leading to a 48% risk reduction (OR = 0.52, 0.30-0.91).Conclusions. Specific organizational arrangements may help reduce the burden of T2D among subjects affected by foot ulcers, particularly in terms of major amputations. Further studies should use standardized criteria for the investigation of care arrangements. Implications for practice are that organizational settings highlighted from the literature as potentially effective could be mapped to the local routine and continuously followed-up using data to verify their advantages in real world conditions.