New data from Singapore is challenging long-held assumptions about the role of podiatric care in diabetic foot management.
Researchers in Singapore just dropped a bombshell — and it’s the kind of data that should be required reading for every health system administrator, policymaker, and insurance company executive who has ever questioned the value of podiatric care.
Led by Wen Zhe Leo and senior author Joseph Lo, a multidisciplinary team from Singapore’s National Healthcare Group just published findings from the DEFINITE Care program in the Journal of the American Podiatric Medical Association.
The headline: podiatric care was associated with a 69% reduction in the odds of death and a 26% increase in amputation-free survival among patients with diabetic foot ulcers (DFUs).
Traditionally viewed as a component of wound care and limb preservation, podiatry may also play a critical role in improving survival.
In this Q&A, Joseph Lo, MD, and Chelsea Law, discuss the findings of how early intervention, multidisciplinary coordination, and a shift toward proactive care.
This study is impressive. What were two findings that surprised you most?
First, we were struck by the magnitude of the mortality benefit. After adjusting for comorbidities, podiatric follow up was associated with a 69 percent reduction in one year mortality. This is despite these patients being more clinically complex, with higher HbA1c, more chronic kidney disease, retinopathy, and greater cardiovascular burden. This suggests podiatric care may extend beyond local wound management to function as an early detection and escalation gateway within a multidisciplinary limb salvage system.
Second, we observed higher rates of minor amputations alongside improved survival and amputation free survival. While this may seem counterintuitive, early podiatric involvement often enables earlier identification of infection or tissue compromise, prompting timely surgical source control. In this context, minor amputations may be limb preserving interventions that prevent progression to sepsis or major amputation.
Together, these findings reinforce that timely, proactive foot care can shift patients from catastrophic to controlled trajectories, improving both limb and survival outcomes.
Many of us remember your insights about DEFINITE shared at DFCon 2024. Has your research, program, or thinking evolved since then, particularly in light of this new data?
Yes, meaningfully.
At DFCon, we framed DEFINITE as a multidisciplinary pathway to reduce major amputations through better access, triage, and system integration.
This new data shifts our perspective in two key ways.
First, we now think beyond amputation prevention toward mortality modification. The 69 percent reduction in one year mortality suggests limb preservation programs influence systemic outcomes, reframing them as population health interventions rather than purely procedural care.
Second, we are more comfortable viewing increased minor amputations as appropriate, limb saving escalation rather than failure. Early intervention appears to prevent catastrophic progression.
The data also highlight areas for improvement, particularly in preventing ulcer recurrence through sustained longitudinal care. This includes stronger podiatry follow up, surveillance clinics, offloading, orthotics, rehabilitation, and mobility support.
Operationally, this pushes us to strengthen risk stratification, enable earlier referral and prevention, expand offloading strategies, integrate health economics, and track longer term outcomes.
In short, DEFINITE is evolving into a broader population health strategy focused on recurrence prevention and long term survival, not just limb salvage.
This model appears both clinically effective and cost effective. What is the strongest pushback you have encountered from systems that have not integrated podiatric care, and how does this data address it?
Pushback is mainly structural and financial, not philosophical.
Three concerns recur. Limited podiatry workforce, higher upfront utilization, and the perception that podiatry is ancillary.
This data addresses each. Despite greater clinical complexity, podiatry follow up was associated with a 69 percent reduction in one year mortality and improved amputation free survival. This reframes podiatry as a risk modifying intervention rather than supportive care.
Although utilization increased, length of stay fell by 17 percent and major amputations did not rise. Earlier minor interventions likely prevent more severe and costly outcomes.
Podiatry also functions as an early escalation gateway within coordinated care. It is not extra care, but care that changes trajectory.
The key shift is from asking whether we can afford podiatry to whether we can afford not to intervene early.
Singapore’s data shows a significant mortality benefit associated with podiatric care. How does this reinforce or potentially challenge the broader multidisciplinary Toe and Flow model of team based limb preservation?
It strongly reinforces and expands it.
Our findings support the importance of coordinated collaboration between toe specialists such as podiatry, wound care, and surgical teams, and flow specialists focused on vascular intervention. Outcomes reflect integration rather than podiatry in isolation, with important contributions from endocrinology and primary care.
Primary care referral pathways and care coordination, especially through diabetic foot coordinators, are critical to ensuring timely access and follow up.
Importantly, the data expand the model beyond limb outcomes. Podiatric engagement appears to influence systemic survival, acting as an early gateway for risk stratification and multidisciplinary optimization.
Higher minor amputation rates alongside better outcomes reinforce that early, decisive intervention can prevent catastrophic progression.
Rather than challenging the model, the data deepen it and position podiatry as a key entry point that activates the broader system, with increasing emphasis on earlier upstream intervention.
What feedback have you received from the limb preservation community since publication, particularly regarding workforce models and the practical realities of scaling podiatric integration?
Feedback has been encouraging but pragmatic.
The mortality signal has strengthened the case for podiatry as foundational rather than ancillary. However, much of the discussion focuses on workforce and scalability.
Systems with established podiatry pathways are working to optimize referral timing and capacity. Others face structural barriers, including limited workforce, gaps in training, and unclear reimbursement models.
Common themes include task sharing through nurse led surveillance, tiered referral pathways, colocating podiatry within limb salvage teams, and the need for stronger health economics data.
There is also increased emphasis on prevention, including offloading, appropriate footwear, orthotics, and long term surveillance to reduce recurrence.
Finally, coordination infrastructure is critical. Roles such as diabetic foot coordinators help ensure timely, reliable care.
The conversation has shifted from whether podiatry matters to how to scale it effectively.
If you had to give clinicians one thing they could implement tomorrow to move closer to the Singapore model, what would it be?
Create a simple, non negotiable trigger for early podiatric referral in any patient with a diabetic foot ulcer and embed it into routine workflow.
When referral is discretionary, patients are often seen too late. A structured trigger removes that variability. It can be simple, such as any ulcer below the malleolus, a recurrent ulcer, neuropathy with callus, or a patient following minor amputation.
Once triggered, referral becomes automatic.
Early podiatric engagement often serves as the entry point into coordinated care, prompting offloading, infection control, vascular evaluation, and multidisciplinary management.
Even without a fully developed system, a reliable early referral gateway moves care closer to the Singapore model. Identify risk early, intervene decisively, and coordinate care before deterioration occurs.
Reference: Leo WZ, Ge L, Law C, Chew T, Lim JA, Tan E, Liew H, Hoe J, Lin J, Lo ZJ. Podiatric care associated with reduced mortality and enhanced amputation-free survival. J Am Podiatr Med Assoc. 2026;116:11. doi:10.3390/japma116010011
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