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Patterns of foot examination in a diabetes clinic
CLINICAL STUDIES
Patterns of Foot Examination in a Diabetes Clinic
TIMOTHY SILLECK BAILEY, HILMA M. YU, M.D. ELLIOT J. RAYFIELD, M.D.
M.D.
New York. New York
From the D&betas Research Laboratory, Division of Arteriosclerosis and Metabolism, Department of Medfclne, Mount Sinai Schcol of Medicine, New York, New York. This work was submitted as partial fulfillment of the clerkship requirement in Community Medicine while Timothy S. Bailey and Hllma M. Yu were thiiyear students at the Mount Sinai School of Medicine. This work was supported in part by grants from the American Diabetes Association, New York Affiliate, Kroc Foundation, Juvenile Diabetes Foundation, and donatlons in honcr of Dr. Gerald J. Friedman, New York, New York. Requests for reprints should be addressed to Dr. Elliot J. Rayfield, Diabetes Section, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029. Manuscript accepted August 16, 1984.
Peripheral vascular disease is a well-known source of morbldlty and potential mortality In dlabetlc patients. Sixty-flve subjects with dlabetes were studled in order to describe the contributions of the patlent, the physlclan, and the health care system to the performance of a preventive foot examination. The Incidence8 of foot examlnatlon on the day of study (12.3 percent) and during the previous year (49.2 percent) were slmllar to those found by other Investlgators. The feet of patlents at higher risk for limb amputation were not examlned wlth greater frequency at the cllnlc, although such patlents were more often referred to a podiatrist. The most slgnlflcant determinants of physlclan foot examlnatlon were patient recall of foot-related education received at the cllnlc and Interphyslclan varlablllty. These data suggest that the patlent, physician, and cllnlc routine all play an Important role In the success of a foot screening program for patients wlth diabetes. The documented yearly expense of diabetic peripheral vascular disease and its complications in the United States is in excess of 200 million dollars [ 1,2] for direct hospital costs alone. Foot lesions account for 20 percent of all diabetic hospitalizations [3,4]. It is estimated that 20,000 to 30,000 amputations are performed per year (50 to 70 percent of all nontraumatic amputations) [5] for diabetic foot lesions that have progressed to gangrene. The development and implementation of cost-effective strategies in preventing complications of diabetic peripheral vascular disease should be a high priority for the physicians who care for these patients. One recent recommendation would require diabetic patients to remove their shoes at each visit to the physician [6]. The effectiveness of frequent foot examination among diabetic patients coupled with intensive patient education was shown, by Davidson et al [7] of Grady Memorial Hospital, to have a sustained decrease of nearly 50 percent in the amputation rate and, by Miller et al [8] of the Los Angeles County Hospital, to significantly lower the rate of hospital admissions for diabetic foot complications [8]. Despite the consensus among physicians on the importance of foot examination in the care of diabetic patients, this screening measure is often neglected in the clinic setting. The following study was undertaken to assess the prevalence and determinants of physician foot examination in the setting of a major metropolitan diabetes clinic. PATIENTS
AND
METHODS
The study was conducted at the Mount Sinai Hospital diabetes clinic, which serves approximately 1,000 adult diabetic patients (85 percent non-insulindependent) with nearly 5,000 patient visits annually. Each patient is assigned
March
1985
The American
Journal
of Medicine
Volume
78
371
FOOT
EXAMINATION
TABLE I
IN A DIABETES
CLINIC-BAILEY
ET AL
Prevalence of Known and Putallve Risk Factors Associated with Limb Amputation in the Study Population
RiskFactor
Prevalence
Relerencrs
Neuropathy 40.0 percent (26)’ [W Peripheralvasculardiseases 18.5 percent (12) Previousamputation 7.7 percent (5) [‘7i:? Smoking 18.5 per cent (12) Age (65 yearsor older) 37.0 percent (24) [?? Durationof disease(greater 43.1 percent (28) [I91 than 15 years) Generalfoot problems 63.0 percent (41) Hypertension 35.4 percent (23) Poorglucosecontrol 15.4 percent (10) Foot-relatedhospitalizations 15.4 percent (10) (excludingamputations) Retinopathy 26.2 percent (17) Nephropathy 0 percent (0) ’ Numbersin parenthesesindicatenumbersof patients.
to a specific physician, and a dietitian and nurse educator are available for patient education. A cross-sectional survey was performed using the methods of patient interview, chart review, and physician questionnaire. The presence or absence of risk factors for limb amputation (Table I) was determined. Risk factors-tha proposed independent variables in the determination of physician behavior-were correlated with the outcomes of (1) performance of a foot examination (as judged by the minimal criterion of shoe removal in the physician’s presence) and (2) podiitric referral in the previous year. Patient interviews were conducted during three consecutive clinic sessions in March 1983. The interviews immediately followed the patients’ visit to the physician, and data were collected on each patient’s smoking history, age. duration and therapy of diabetes, foot problems, vascular disease, neuropathy, and previous amputations. Interview criteria for tha diagnosis of vascular disease were m&lad after those of the World Health Organization [9]. Charts were reviewed for evidence of poor glucose Control (defined a.stwo or more fasting values greater than 300 mg/dl), treated hypertension, foot examinations and podiatric consultations within the previous year, and documentation of any of the following: peripheral vascular disease, neuropathy, retinopathy, or nephropathy. Other potential predictors explored included patient concern (as reflected in the frequency of Self-examination and recall of patient education received at the clinic) and physician variability (as reflected by the Screening of blood pressure rnaaSurarnan&-anothar im@rtant preventive measure) [lo]. Data were analyzed by chi-square tests with continuity adjustment for small Sample size. In addition, the frequency of foot examination (defined as tha number of times the feet ware examined diiided by tha number of visits in the previous year) was plotted versus the sum of risk factors present to detect any correlation. A questionnaire was distributed to each physician in the clinic. it requested a ranking be made of the risk factors as-
372
March 1995
sociated with limb amputation on the basis of their Significance alone and in combination with the others. Also, physicians were questioned with regard to their referral patterns.
The American Journal cf Medlclne
RESULTS
Seventy patients (62 percent) of a total of 112 patients who were seen during the three days of study were interviewed. Of these 70 patients, five were excluded from the study, two because it was their first visit and three others because their charts were unavailable. The patients (69 percent male and 31 percent female) had a mean age of 58 years and an average duration of diabetes of 13.2 years. The percentage of patients possessing the risk factors investigated in this study is presented in Table I. The incidence of foot examination during the study was 12.3 percent. The prevalence of foot examination in the previous year was 49.2 percent. Of the 65 patients, 45 (69.2 percent) said that they examined their feet daily. Three of the 13 physicians (who saw 24 percent of all the patients) accounted for 73 percent of the examinations performed during the study and 53 percent of examinations performed during the entire year. Blood pressure was recorded for 76.9 percent of the patients during the duration of the investigation. A referral to the podiatrist (most commonly for a corn, callus, or foot deformity) was made in 18.5 percent of the cases. (Overall, 37 percent of patients were seen by a podiatrist; the additional 18.5 percent were self-referred.) Overall, 65 percent of the patients’ feet were examined by either an M.D. or a D.P.M. in the previous year. Each of the risk factors associated with limb amputation (Table I) was compared with the prevalence of foot examination, and podiatric referral in those patients having general foot problems (such as corn, callus, or foot deformity) and previous foot-related hospitalizations had statistical significance (p <0.05). There was no single risk factor that predicted the performance of a foot examination, and those patients with a greater number of risk factors were not examined more frequently in the diabetes clinic. Those patients who examined their feet daily demonstrated no difference in frequency of either foot examination or podiatric referral at the clinic. The feet of those patients whose blood pressure was recorded were not examined more frequently than those in whom blood pressure was not recorded. However, those patients who were able to recall any education they had received at the clinic (an index of patient concern) were examined to a greater extent in this time period (p <0.05). The first portion of the physician questionnaire confirmed the hierarchy of risk factor severity (Table
Volume 79
FOOT
II). The second portion presented a consensus of appropriate referral patterns. Thus, the podiatrist was entrusted with screening and caring for an early neuropathic ulcer, whereas the vascular or orthopedic surgeon was consulted almost exclusively as the severity of the lesion increased.
TABLE II
EXAMINATION
IN A DIABETES
CLINIC-BAILEY
ET AL
Severity of Risk Factors as Ranked by Clinic Physicians in Order of Decreasing Importance Vascular -I- neuropathy -I- smoking Vascular + hypertension + smoking Hypertension + neuropathy + smoking Vascular + neuropathy Vascular + smoking Amputation Neuropathy + smoking Smoking Neuropathy + foot deformity Neuropathy Duration of disease (greater than 15 years) Foot deformity Age (65 years or older) Nephropathy Retinopathy Hypertension
COMMENTS The low rate of foot examination and podiatric referral that was found in the study population is consistent with the rate of foot examination among diabetic patients in general medical clinics (15 to 19 percent of those who entered the examining room wearing shoes) as reported by Cohen [ 1 l] in Diabetes Care. This finding corroborates the observation of other researchers that preventive measures of welldocumented efficacy are often among those measures that are consistently underutilized [ 121. To explain this phenomenon, Carter et al [ 131 reviewed three major elements in the implementation of a preventive measure: the patient, physician, and the health care system. It is believed that patient education and attitudes influence both patient acceptance and physician delivery of preventive care. The physician’s practice is affected by the patient’s characteristics and expectations, the physician’s assessment of the cost-benefit ratio of the measure in question, the physician’s values and educational experience, and the limitations imposed by the health care system. These system constraints include the element of time, staffing, funding, and physical plant as well as the formulation of a well-accepted preventive protocol. A salient finding of this investigation was that a patient’s set of risk factors did not predict the frequency of foot examination. Although those patients who examined themselves at home daily did not have significantly different outcomes, the feet of those who were able to recall previous foot-related education at the clinic were examined more frequently. This finding suggests that a patient’s learned concern for his or her vulnerable feet, paralleling the health belief model [ 141, effected foot examination by a health care provider. The habits of the individual physician proved the strongest influence on foot examination, borne out by the observation that three physicians (of 13), seeing a number of patients comparable with the others, accounted for 73 percent and 53 percent of all feet examined during the study and entire year, respectively. Interestingly, the patient interview revealed that 58 percent of all patients whose feet were examined had no symptoms referable to the foot itself at the time of the examination, indicating that a high percentage of the examinations were indeed preventive in nature. This practice is very important because the vulnerable condition of diabetic feet can progress to a serious state
nearly asymptomatically [8]. The discovery that those patients with a callus or foot deformity were referred to a podiatrist more often appears to represent a tendency to delegate to podiatrists follow-up care of these patients. The results of the physician questionnaire, however, indicated that patients with needs greater than routine footcare would be referred to orthopedic or vascular surgeons. The last important variable in effective foot care for diabetic patients is that of the clinic system itself. The value of checklists in increasing the level of preventive care has been demonstrated [ 151. In addition, Cohen [ 1 l] recently reported that patients presenting with bare feet to physicians in a general medical clinic were more than three times as likely to have their feet examined as were those who presented wearing shoes and socks. In anticipation of this system cue, all of our patients presented with footwear in order to detect other potential determinants of physician behavior. Thus, our study complements that of Cohen by considering the contributions of patient and physician variables in addition to those of the clinic routine. In summary, foot examination in a diabetes clinic is an important, but commonly under-utilized, preventive measure. The complex determinants of this practice can be resolved into patient, physician, and system components. Our findings indicate that each of these three elements must be addressed in order to establish an effective routine foot examination program in the care of patients with diabetes. ACKNOWLEDGMENT We are indebted to Dr. Edward Speedling for his review of the manuscript.
March
1985
The American
Journal
of Medicine
Volume
79
373
FOOT
EXAMINATION
IN A DIABETES
CLINIC-BAILEY
ET AL
REFERENCES 1. 2.
3. 4. 5. 6.
7.
8.
9. 10.
374
11.
West KM: Epidemiology of diabetes and its vascular lesions. New York: Elsevier North-Holland, 1978; 351-440. The treatment and control of diabetes: a national plan to reduce morbidity and mortality-a report of the National Diabetes Advisory Board. Washington: United States Department of Health and Human Services, 1980: NIH publication no. 81-2284; 25. Levin MD: Saving the diabetic foot. Medical Times 1980; 108: 56-62. Bessman AN: Foot problems in the diabetic. Compr Ther 1982; 8: 32-37. West KM: Epidemiology of diabetes and its vascular lesions. New York: Elsevier North-Holland, 1978; 351-440. Brand PW: The diabetic foot. In: Ellenberg M, Rifkin R, eds. Diabetes meltitus: theory and practice. New York: McGraw-Hill, 1983; 829-849. Davklson JK, Alogna M, Goldsmith M, Borden J: Assessment of program effectiveness at Grady Memorial Hospital, Atlanta. In: Steiner G, Lawrence PA, eds. Educating diabetic patients. New York: Springer, 1981; 329-348. Miller LV, Goldstein J, Kumar D, Dye L: Assessment of program effectiveness at the Los Angeles County-University of Southern California Medical Center. In: Steiner G, Lawrence PA, eds. Educating diabetic patients. New York: Springer, 1981; 349-359. Rose GA, Blackburn H: Cardiovascular survey methods. WHO Monograph Series 56 1968: 173-175. Bass JL, Mehta KA, Gordon MI, et al: Pediatric ambulatory care evaluation-record review using objective criteria. Q Rev Bull 1981; 7: 9-12.
March
1985
The American
Journal
of Medlclne
Volume
12.
13.
14.
15.
10. 17. 18.
19.
20. 21.
79
Cohen SJ: Potential barriers to diabetes care. Diabetes Care 1983; 6: 499-500. Room FJ, Fletcher SW, Hulka BS: The periodic health examination: cornpark3cn of r ecommendations and intemists performance. South Med J 1981; 74: 265-271. Carter WB, Belcher DW, lnui TS: implementing preventive care in clinical practice: problems for managers, clinicians, and patients. Med Care Rev 1981; 38: 195-216. Becker MH, Maiman L, Kirscht JP, et al: Patient perceptions and compliance: recent studies of the health belief model. In: Haynes RB, Sackett DL, Taylor DW, eds. Compliance in health care. Baltimore: Johns Hopkiis University Press, 1979; 78-109. Cohen DI, Littenberg B, Wetzel C, Neuhauser DL: Improving physic&n compliance with preventive medicine guklellnes. bled Care 1982; 20: 1040-1045. Ellenberg M: Diabetic neuropathy-c@‘&alaspects Compr Ther 1982; 8: 21-31. Ganda OP: Review-pathogenesis of macrovascular disease in the human diabetic. Diabetes 1980; 29: 931-942. Delbrii L, Appleberg M, Reeve TS: Factors associated with development of foot lesions in the diabetic. Sugery 1983; 93: 78-82. Beach KW, Strandness DE Jr: Arteriosclerosis obliterans and associated risk factas in insulindependent and ncn-fnsulin dependent diabetes. Diabetes 1980; 29: 882-888. Levin ME: The diabetic foot. Angiology 1980; 31: 375-385. Rosen AJ, DePalma RS, Victor Y: Risk factors in peripheral atherosclerosis. Arch Surg (Chicago) 1973; 107: 303308.
Patterns of Foot Examination in a Diabetes Clinic
TIMOTHY SILLECK BAILEY, HILMA M. YU, M.D. ELLIOT J. RAYFIELD, M.D.
M.D.
New York. New York
From the D&betas Research Laboratory, Division of Arteriosclerosis and Metabolism, Department of Medfclne, Mount Sinai Schcol of Medicine, New York, New York. This work was submitted as partial fulfillment of the clerkship requirement in Community Medicine while Timothy S. Bailey and Hllma M. Yu were thiiyear students at the Mount Sinai School of Medicine. This work was supported in part by grants from the American Diabetes Association, New York Affiliate, Kroc Foundation, Juvenile Diabetes Foundation, and donatlons in honcr of Dr. Gerald J. Friedman, New York, New York. Requests for reprints should be addressed to Dr. Elliot J. Rayfield, Diabetes Section, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029. Manuscript accepted August 16, 1984.
Peripheral vascular disease is a well-known source of morbldlty and potential mortality In dlabetlc patients. Sixty-flve subjects with dlabetes were studled in order to describe the contributions of the patlent, the physlclan, and the health care system to the performance of a preventive foot examination. The Incidence8 of foot examlnatlon on the day of study (12.3 percent) and during the previous year (49.2 percent) were slmllar to those found by other Investlgators. The feet of patlents at higher risk for limb amputation were not examlned wlth greater frequency at the cllnlc, although such patlents were more often referred to a podiatrist. The most slgnlflcant determinants of physlclan foot examlnatlon were patient recall of foot-related education received at the cllnlc and Interphyslclan varlablllty. These data suggest that the patlent, physician, and cllnlc routine all play an Important role In the success of a foot screening program for patients wlth diabetes. The documented yearly expense of diabetic peripheral vascular disease and its complications in the United States is in excess of 200 million dollars [ 1,2] for direct hospital costs alone. Foot lesions account for 20 percent of all diabetic hospitalizations [3,4]. It is estimated that 20,000 to 30,000 amputations are performed per year (50 to 70 percent of all nontraumatic amputations) [5] for diabetic foot lesions that have progressed to gangrene. The development and implementation of cost-effective strategies in preventing complications of diabetic peripheral vascular disease should be a high priority for the physicians who care for these patients. One recent recommendation would require diabetic patients to remove their shoes at each visit to the physician [6]. The effectiveness of frequent foot examination among diabetic patients coupled with intensive patient education was shown, by Davidson et al [7] of Grady Memorial Hospital, to have a sustained decrease of nearly 50 percent in the amputation rate and, by Miller et al [8] of the Los Angeles County Hospital, to significantly lower the rate of hospital admissions for diabetic foot complications [8]. Despite the consensus among physicians on the importance of foot examination in the care of diabetic patients, this screening measure is often neglected in the clinic setting. The following study was undertaken to assess the prevalence and determinants of physician foot examination in the setting of a major metropolitan diabetes clinic. PATIENTS
AND
METHODS
The study was conducted at the Mount Sinai Hospital diabetes clinic, which serves approximately 1,000 adult diabetic patients (85 percent non-insulindependent) with nearly 5,000 patient visits annually. Each patient is assigned
March
1985
The American
Journal
of Medicine
Volume
78
371
FOOT
EXAMINATION
TABLE I
IN A DIABETES
CLINIC-BAILEY
ET AL
Prevalence of Known and Putallve Risk Factors Associated with Limb Amputation in the Study Population
RiskFactor
Prevalence
Relerencrs
Neuropathy 40.0 percent (26)’ [W Peripheralvasculardiseases 18.5 percent (12) Previousamputation 7.7 percent (5) [‘7i:? Smoking 18.5 per cent (12) Age (65 yearsor older) 37.0 percent (24) [?? Durationof disease(greater 43.1 percent (28) [I91 than 15 years) Generalfoot problems 63.0 percent (41) Hypertension 35.4 percent (23) Poorglucosecontrol 15.4 percent (10) Foot-relatedhospitalizations 15.4 percent (10) (excludingamputations) Retinopathy 26.2 percent (17) Nephropathy 0 percent (0) ’ Numbersin parenthesesindicatenumbersof patients.
to a specific physician, and a dietitian and nurse educator are available for patient education. A cross-sectional survey was performed using the methods of patient interview, chart review, and physician questionnaire. The presence or absence of risk factors for limb amputation (Table I) was determined. Risk factors-tha proposed independent variables in the determination of physician behavior-were correlated with the outcomes of (1) performance of a foot examination (as judged by the minimal criterion of shoe removal in the physician’s presence) and (2) podiitric referral in the previous year. Patient interviews were conducted during three consecutive clinic sessions in March 1983. The interviews immediately followed the patients’ visit to the physician, and data were collected on each patient’s smoking history, age. duration and therapy of diabetes, foot problems, vascular disease, neuropathy, and previous amputations. Interview criteria for tha diagnosis of vascular disease were m&lad after those of the World Health Organization [9]. Charts were reviewed for evidence of poor glucose Control (defined a.stwo or more fasting values greater than 300 mg/dl), treated hypertension, foot examinations and podiatric consultations within the previous year, and documentation of any of the following: peripheral vascular disease, neuropathy, retinopathy, or nephropathy. Other potential predictors explored included patient concern (as reflected in the frequency of Self-examination and recall of patient education received at the clinic) and physician variability (as reflected by the Screening of blood pressure rnaaSurarnan&-anothar im@rtant preventive measure) [lo]. Data were analyzed by chi-square tests with continuity adjustment for small Sample size. In addition, the frequency of foot examination (defined as tha number of times the feet ware examined diiided by tha number of visits in the previous year) was plotted versus the sum of risk factors present to detect any correlation. A questionnaire was distributed to each physician in the clinic. it requested a ranking be made of the risk factors as-
372
March 1995
sociated with limb amputation on the basis of their Significance alone and in combination with the others. Also, physicians were questioned with regard to their referral patterns.
The American Journal cf Medlclne
RESULTS
Seventy patients (62 percent) of a total of 112 patients who were seen during the three days of study were interviewed. Of these 70 patients, five were excluded from the study, two because it was their first visit and three others because their charts were unavailable. The patients (69 percent male and 31 percent female) had a mean age of 58 years and an average duration of diabetes of 13.2 years. The percentage of patients possessing the risk factors investigated in this study is presented in Table I. The incidence of foot examination during the study was 12.3 percent. The prevalence of foot examination in the previous year was 49.2 percent. Of the 65 patients, 45 (69.2 percent) said that they examined their feet daily. Three of the 13 physicians (who saw 24 percent of all the patients) accounted for 73 percent of the examinations performed during the study and 53 percent of examinations performed during the entire year. Blood pressure was recorded for 76.9 percent of the patients during the duration of the investigation. A referral to the podiatrist (most commonly for a corn, callus, or foot deformity) was made in 18.5 percent of the cases. (Overall, 37 percent of patients were seen by a podiatrist; the additional 18.5 percent were self-referred.) Overall, 65 percent of the patients’ feet were examined by either an M.D. or a D.P.M. in the previous year. Each of the risk factors associated with limb amputation (Table I) was compared with the prevalence of foot examination, and podiatric referral in those patients having general foot problems (such as corn, callus, or foot deformity) and previous foot-related hospitalizations had statistical significance (p <0.05). There was no single risk factor that predicted the performance of a foot examination, and those patients with a greater number of risk factors were not examined more frequently in the diabetes clinic. Those patients who examined their feet daily demonstrated no difference in frequency of either foot examination or podiatric referral at the clinic. The feet of those patients whose blood pressure was recorded were not examined more frequently than those in whom blood pressure was not recorded. However, those patients who were able to recall any education they had received at the clinic (an index of patient concern) were examined to a greater extent in this time period (p <0.05). The first portion of the physician questionnaire confirmed the hierarchy of risk factor severity (Table
Volume 79
FOOT
II). The second portion presented a consensus of appropriate referral patterns. Thus, the podiatrist was entrusted with screening and caring for an early neuropathic ulcer, whereas the vascular or orthopedic surgeon was consulted almost exclusively as the severity of the lesion increased.
TABLE II
EXAMINATION
IN A DIABETES
CLINIC-BAILEY
ET AL
Severity of Risk Factors as Ranked by Clinic Physicians in Order of Decreasing Importance Vascular -I- neuropathy -I- smoking Vascular + hypertension + smoking Hypertension + neuropathy + smoking Vascular + neuropathy Vascular + smoking Amputation Neuropathy + smoking Smoking Neuropathy + foot deformity Neuropathy Duration of disease (greater than 15 years) Foot deformity Age (65 years or older) Nephropathy Retinopathy Hypertension
COMMENTS The low rate of foot examination and podiatric referral that was found in the study population is consistent with the rate of foot examination among diabetic patients in general medical clinics (15 to 19 percent of those who entered the examining room wearing shoes) as reported by Cohen [ 1 l] in Diabetes Care. This finding corroborates the observation of other researchers that preventive measures of welldocumented efficacy are often among those measures that are consistently underutilized [ 121. To explain this phenomenon, Carter et al [ 131 reviewed three major elements in the implementation of a preventive measure: the patient, physician, and the health care system. It is believed that patient education and attitudes influence both patient acceptance and physician delivery of preventive care. The physician’s practice is affected by the patient’s characteristics and expectations, the physician’s assessment of the cost-benefit ratio of the measure in question, the physician’s values and educational experience, and the limitations imposed by the health care system. These system constraints include the element of time, staffing, funding, and physical plant as well as the formulation of a well-accepted preventive protocol. A salient finding of this investigation was that a patient’s set of risk factors did not predict the frequency of foot examination. Although those patients who examined themselves at home daily did not have significantly different outcomes, the feet of those who were able to recall previous foot-related education at the clinic were examined more frequently. This finding suggests that a patient’s learned concern for his or her vulnerable feet, paralleling the health belief model [ 141, effected foot examination by a health care provider. The habits of the individual physician proved the strongest influence on foot examination, borne out by the observation that three physicians (of 13), seeing a number of patients comparable with the others, accounted for 73 percent and 53 percent of all feet examined during the study and entire year, respectively. Interestingly, the patient interview revealed that 58 percent of all patients whose feet were examined had no symptoms referable to the foot itself at the time of the examination, indicating that a high percentage of the examinations were indeed preventive in nature. This practice is very important because the vulnerable condition of diabetic feet can progress to a serious state
nearly asymptomatically [8]. The discovery that those patients with a callus or foot deformity were referred to a podiatrist more often appears to represent a tendency to delegate to podiatrists follow-up care of these patients. The results of the physician questionnaire, however, indicated that patients with needs greater than routine footcare would be referred to orthopedic or vascular surgeons. The last important variable in effective foot care for diabetic patients is that of the clinic system itself. The value of checklists in increasing the level of preventive care has been demonstrated [ 151. In addition, Cohen [ 1 l] recently reported that patients presenting with bare feet to physicians in a general medical clinic were more than three times as likely to have their feet examined as were those who presented wearing shoes and socks. In anticipation of this system cue, all of our patients presented with footwear in order to detect other potential determinants of physician behavior. Thus, our study complements that of Cohen by considering the contributions of patient and physician variables in addition to those of the clinic routine. In summary, foot examination in a diabetes clinic is an important, but commonly under-utilized, preventive measure. The complex determinants of this practice can be resolved into patient, physician, and system components. Our findings indicate that each of these three elements must be addressed in order to establish an effective routine foot examination program in the care of patients with diabetes. ACKNOWLEDGMENT We are indebted to Dr. Edward Speedling for his review of the manuscript.
March
1985
The American
Journal
of Medicine
Volume
79
373
FOOT
EXAMINATION
IN A DIABETES
CLINIC-BAILEY
ET AL
REFERENCES 1. 2.
3. 4. 5. 6.
7.
8.
9. 10.
374
11.
West KM: Epidemiology of diabetes and its vascular lesions. New York: Elsevier North-Holland, 1978; 351-440. The treatment and control of diabetes: a national plan to reduce morbidity and mortality-a report of the National Diabetes Advisory Board. Washington: United States Department of Health and Human Services, 1980: NIH publication no. 81-2284; 25. Levin MD: Saving the diabetic foot. Medical Times 1980; 108: 56-62. Bessman AN: Foot problems in the diabetic. Compr Ther 1982; 8: 32-37. West KM: Epidemiology of diabetes and its vascular lesions. New York: Elsevier North-Holland, 1978; 351-440. Brand PW: The diabetic foot. In: Ellenberg M, Rifkin R, eds. Diabetes meltitus: theory and practice. New York: McGraw-Hill, 1983; 829-849. Davklson JK, Alogna M, Goldsmith M, Borden J: Assessment of program effectiveness at Grady Memorial Hospital, Atlanta. In: Steiner G, Lawrence PA, eds. Educating diabetic patients. New York: Springer, 1981; 329-348. Miller LV, Goldstein J, Kumar D, Dye L: Assessment of program effectiveness at the Los Angeles County-University of Southern California Medical Center. In: Steiner G, Lawrence PA, eds. Educating diabetic patients. New York: Springer, 1981; 349-359. Rose GA, Blackburn H: Cardiovascular survey methods. WHO Monograph Series 56 1968: 173-175. Bass JL, Mehta KA, Gordon MI, et al: Pediatric ambulatory care evaluation-record review using objective criteria. Q Rev Bull 1981; 7: 9-12.
March
1985
The American
Journal
of Medlclne
Volume
12.
13.
14.
15.
10. 17. 18.
19.
20. 21.
79
Cohen SJ: Potential barriers to diabetes care. Diabetes Care 1983; 6: 499-500. Room FJ, Fletcher SW, Hulka BS: The periodic health examination: cornpark3cn of r ecommendations and intemists performance. South Med J 1981; 74: 265-271. Carter WB, Belcher DW, lnui TS: implementing preventive care in clinical practice: problems for managers, clinicians, and patients. Med Care Rev 1981; 38: 195-216. Becker MH, Maiman L, Kirscht JP, et al: Patient perceptions and compliance: recent studies of the health belief model. In: Haynes RB, Sackett DL, Taylor DW, eds. Compliance in health care. Baltimore: Johns Hopkiis University Press, 1979; 78-109. Cohen DI, Littenberg B, Wetzel C, Neuhauser DL: Improving physic&n compliance with preventive medicine guklellnes. bled Care 1982; 20: 1040-1045. Ellenberg M: Diabetic neuropathy-c@‘&alaspects Compr Ther 1982; 8: 21-31. Ganda OP: Review-pathogenesis of macrovascular disease in the human diabetic. Diabetes 1980; 29: 931-942. Delbrii L, Appleberg M, Reeve TS: Factors associated with development of foot lesions in the diabetic. Sugery 1983; 93: 78-82. Beach KW, Strandness DE Jr: Arteriosclerosis obliterans and associated risk factas in insulindependent and ncn-fnsulin dependent diabetes. Diabetes 1980; 29: 882-888. Levin ME: The diabetic foot. Angiology 1980; 31: 375-385. Rosen AJ, DePalma RS, Victor Y: Risk factors in peripheral atherosclerosis. Arch Surg (Chicago) 1973; 107: 303308.