Foot Exam Frequency and Amputation Prevention in Diabetes

Introduction to Diabetic Foot Complications

Diabetes mellitus is a chronic and debilitating disease that has long-term consequences for those who become insulin-dependent. One of those long-term consequences is the formation of foot ulcers. Foot ulcers can lead to amputation of an insulin-dependent patient's legs and feet. Amputation is a serious and expensive economic burden for anyone who must endure it. To avoid amputation, foot exams performed by a physician may help provide the kind of preventative care that leads to a reduced risk of amputation in diabetes mellitus patients.

Foot ulceration develops as a result of trauma, neuropathy, and deformity (Scott, 2013). Foot exams have various components that allow for effective assessment of any potential problems a patient is facing with regard to foot ulceration and amputation. One such component is the patient's medical history. Another involves assessment of peripheral and neuropathic vascular symptoms, possible renal replacement therapy, and impaired vision. An additional part of foot examinations is determining whether a patient uses tobacco, as this is a major risk factor for both neuropathy and vascular disease.

Aside from patient history, foot exams require a general inspection and dermatological assessment. The next step is a musculoskeletal assessment that includes evaluation of any gross deformity. This is followed by a neurological assessment, and the last step is vascular assessment. These steps can be completed in as little as three minutes (Dorresteijn & Valk, 2012).

While research shows that single preventative methods have not produced a major reduction in the occurrence of foot ulceration, clinical practice in the form of foot examinations may offer some positive results. The objective of this essay is to determine whether frequent foot examinations versus annual foot examinations minimize the rate of amputations and foot ulcerations. Evidence from three articles will offer a look into which approach is most effective in minimizing amputation and foot ulceration. The research also highlights the consequences of performing foot exams frequently versus infrequently in relation to medical expenses.

Integration and Synthesis of the Evidence

Patient education is a significant part of prevention. Patients can perform their own foot exams daily without physician intervention, and this self-examination is the primary means of reducing potential amputation and foot ulceration complications. "Teaching diabetes patients the principles of self-examination of the feet and foot care has since long been advocated as an essential attribute of prevention strategies and is widely implicated in clinical practice" (Dorresteijn & Valk, 2012, p. 101). This point is important when evaluating the effectiveness of physician-assisted foot exams performed frequently versus infrequently. Should a patient receive adequate education on performing daily foot exams at home, the need for frequent physician-assisted foot exams would be considered unnecessary.

In a 2013 article, researchers discuss modifying a physical examination sequence model that can be employed to improve preventative efforts for patients at risk for amputation and foot ulceration. "The modified sequence should reduce physician time while improving efficiency and effectiveness, utilizing a physical examination sequence model with which the physicians are familiar and can easily adopt and apply in a consistent manner" (Scott, 2013, p. 73). Physicians perform regular physical examinations during an annual physical, and modification of the examination sequence may help deliver higher quality care for those experiencing complications from diabetes mellitus. Researchers also examined regional variation in accordance with modified preventative efforts: "We used regression models to determine whether previously described regional variation in LEA incidence was associated with responses to the Behavioral Risk Factor Surveillance System. Regions were created using Dartmouth Atlas Health Referral Regions" (Margolis, Hoffstad, & Weibe, 2014, p. 2296).

The researchers assessed additional factors, including daily foot evaluations, and examined whether these actions led to a decreased occurrence of amputation. "Statistically significant inverse associations were found between LEA and the rate of patients reporting colorectal screening (P < 0.0001) or the participation in diabetes management classes (P = 0.018). Most other factors, including daily foot evaluations, were not associated with a decreased risk of LEA" (Margolis, Hoffstad, & Weibe, 2014, p. 2296). These results demonstrated that daily foot evaluations were not associated with a decreased risk of amputation, meaning there was no major impact in reducing said risk for diabetes patients. Patient education and modification of the physical examination sequence model, however, did show a positive effect in decreasing amputation risk, providing further support for patient education as an important preventative measure.

Another study examined Medicare beneficiaries who were insulin-dependent and had a history of foot ulcers, assessing medical spending and whether higher spending reduced mortality. "Insulin-dependent beneficiaries with foot ulcers and lower extremity amputations were enrolled in Medicare Parts A and B during the calendar year 2007. We used ordinary least squares regression to explain geographic variation in per capita Medicare spending, one-year mortality rates" (Sargen, Hoffstad, & Margolis, 2013, p. 128). Medical spending — in this case Medicare spending — increases with the inclusion of foot exams at each patient visit. If foot examinations become part of standard clinical practice for insulin-dependent patients, this may increase overall medical spending for both patients and insurance companies.

The results of the 2013 study suggest that higher medical spending did not promote a meaningful decrease in mortality rates. "However, higher spending was not associated with a statistically significant reduction in one-year patient mortality (P=.12 for DFU, P=.20 for LEA). Macrovascular complications for amputees were more common in parts of the country with higher mortality rates (P<.001)" (Sargen, Hoffstad, & Margolis, 2013, p. 128). These results suggest that higher levels of medical spending provide no real positive impact on patient mortality. Including foot examinations for diabetes mellitus patients at every office visit to prevent amputation and foot ulceration may not provide a significant positive effect for insulin-dependent patients — it may simply increase medical spending without delivering the reduction in risk that patients need.

Patient Education as a Preventative Strategy

The evidence presented supports two primary conclusions. First, there is no demonstrated need to increase the frequency of foot exams. Second, patient education may be a more effective preventative measure than adding foot examinations to every office visit. The three articles examined — from the perspectives of education, clinical efficacy, and medical spending — each offer reasons why frequent foot exams may not be as important as commonly assumed. From the educational perspective, patients can learn to perform foot examinations at home, a skill that can be taught during an annual foot examination and then carried out independently.

The second perspective concerns efficacy. Patients who underwent daily foot examinations showed no significant difference in amputation risk. If a clinical practice does not demonstrate effectiveness, it is not a necessary addition to routine care. The third perspective is financial. Higher medical spending does not produce a significant positive impact on patient mortality. If medical spending can be maintained at a moderate level while achieving the same clinical outcomes, annual foot examinations emerge as the most practical option.

The overall theme across all three articles is efficacy — whether more frequent intervention or less frequent intervention produces better results. Each article suggested that less is the better option. Foot examinations have demonstrated efficacy through annual practice rather than through inclusion at each office visit. Patients need to be educated on what they can do to prevent diabetes-related complications, rather than relying on physicians to perform additional actions at every appointment.

References

Dorresteijn, J. & Valk, G. (2012). Patient education for preventing diabetic foot ulceration. Diabetes/Metabolism Research and Reviews, 28, 101–106. http://dx.doi.org/10.1002/dmrr.2237

Margolis, D., Hoffstad, O., & Weibe, D. (2014). Lower-extremity amputation risk is associated with variation in Behavioral Risk Factor Surveillance System responses. Diabetes Care, 37(8), 2296–2301. http://dx.doi.org/10.2337/dc14-0788

Sargen, M., Hoffstad, O., & Margolis, D. (2013). Geographic variation in Medicare spending and mortality for diabetic patients with foot ulcers and amputations. Journal of Diabetes and Its Complications, 27(2), 128–133. http://dx.doi.org/10.1016/j.jdiacomp.2012.09.003

Scott, G. (2013). The diabetic foot examination: A positive step in the prevention of diabetic foot ulcers and amputation. Osteopathic Family Physician, 5(2), 73–78. http://dx.doi.org/10.1016/j.osfp.2012.08.002

White, K., Dudley-Brown, S., & Terhaar, M. (2016). Translation of evidence into nursing and health care. Springer Publishing Company.