Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting

Understanding how and why upskilling programmes for unregulated care providers can support health equity in underserved communities: a realist review protocol

INTRODUCTION

Foot ulcers are one of the most devastating complications of diabetes mellitus leading to leg amputations. In Canada, systematically marginalised and racialised populations are more prone to developing foot ulcers and at higher risk of limb amputations. Shortages of regulated healthcare have hindered efforts to provide foot care. Upskilling unregulated care providers (UCPs) to deliver foot screening seems a reasonable solution to reduce limb loss. UCPs can advocate for health equity and deliver appropriate care. There is a need, however, to understand how and why an educational intervention for UCPs providing foot screening for these high-risk groups may or may not work.

METHODS AND ANALYSIS

This realist review will follow the Realist And Meta-narrative Evidence Syntheses: Evolving Standards standards. First, we will develop an initial programme theory (PrT) based on exploratory searches and discussions with experts and stakeholders. Then, we will search MEDLINE, Embase, PsycINFO, ERIC, CINAHL and Scopus databases along with relevant sources of grey literature. The retrieved articles will be screened for studies focusing on planned educational interventions for UCPs related to diabetic foot assessment. Data regarding contexts, mechanisms and outcomes will be extracted and analysed using a realist analysis through an iterative process that includes data reviewing and consultation with our team. Finally, we will use these results to modify the initial PrT.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. The main output of this research will be an evidence-based PrT for upskilling programmes for UCPs. We will share our final PrT using text, tables and infographics to summarise our results and draw insights across papers/reports. For academic, clinical, social care and educational audiences, we will produce peer-reviewed journal articles, including those detailing the process and findings of the realist review and establishing our suggestions for effective upskilling programmes.

PROSPERO REGISTRATION NUMBER

CRD42022369208.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: a national multicenter study

BACKGROUND AND PURPOSE

The lack of timely foot care among individuals with diabetics often lead to ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening practices among patients with type 2 diabetes in various cities across Iran.

METHODS

The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, and diabetic foot self-care (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow's 60-Second Screen.

RESULTS

The study included 1094 diabetic patients with, with a majority being female (64.8%) and married (92.5%). The average age of the participants was 57.6 ± 10.21 (mean ± SD), and the mean duration of diabetes was 11.56 ± 7.41 years. Based on Inlow's 60-Second Screen criteria, 58% of the patients should undergo yearly foot ulcer screening, 47% exhibited peripheral neuropathy, and 37% were found to have inappropriate footwear.

CONCLUSION

The high prevalence of peripheral neuropathy observed in approximately half of the participants across different regions of Iran underscores the importance of continuous patient education regarding foot care and appropriate footwear. Furthermore, regular foot ulcer screenings, following the recommended intervals outlined in Inlow's screening protocol, should be implemented to effectively manage diabetic foot complications.

Comparison of Endocrinologists' Physical Examination Documentation for In-person vs Video Telehealth Diabetes Visits

Objective

Outpatient diabetes mellitus (DM) care over video telehealth (TH) requires modifications to how endocrinologists complete physical examinations (PEs). But there is little guidance on what PE components to include, which may incur wide variation in practice. We compared endocrinologists' documentation of DM PE components for in-person (IP) vs TH visits.

Methods

Retrospective chart review of 200 notes for new patients with DM from 10 endocrinologists (10 IP and 10 TH visits each) in the Veterans Health Administration between April 1, 2020, and April 1, 2022. Notes were scored from 0 to 10 based on documentation of 10 standard PE components. We compared mean PE scores for IP vs TH across all clinicians using mixed effects models. Independent samples t-tests were used to compare both mean PE scores within clinician and mean scores for each PE component across clinicians for IP vs TH. We described virtual care-specific and foot assessment techniques.

Results

The overall mean (SE) PE score was higher for IP vs TH (8.3 [0.5] vs 2.2 [0.5]; P < .001). Every endocrinologist had higher PE scores for IP vs TH. Every PE component was more commonly documented for IP vs TH. Virtual care-specific techniques and foot assessment were rare.

Conclusions

Our study quantifies the degree to which Pes for TH were attenuated among a sample of endocrinologists, raising a flag that process improvements and research are needed for virtual Pes. Organizational support and training could help increase PE completion via TH. Research should examine reliability and accuracy of virtual PE, its value to clinical decision-making, and its impact on clinical outcomes.

Evaluation of foot self-care status and foot screening problems in patients with diabetes in Iran: A national multicenter study.. [DOI: 10.21203/rs.3.rs-2880691/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Background and Purpose Lack of timely foot care in diabetics result in ulceration followed by infection and amputation. This study aimed to evaluate the foot self-care status and foot screening of patients suffering from diabetes around the country of Iran. Methods The cross-sectional descriptive study was performed on patients with type 2 diabetes in 10 main cities of Iran. The information about demographic and lifestyle factors, diabetes history, diabetic foot self-care situation (DFSQ) was assessed. Additionally, the neurological and vascular condition of the foot were screened by Inlow’s 60-Second Screen. Results Participants were 1094 diabetic patients. Most of the participants were female (64.8%) and married (92.5%) with the average age of 57.6 ± 10.21 (mean ± SD). The mean duration of DM was 11.56 ± 7.41 years. According to the Inlow’s 60-Second Screen criteria, 58% of patients should have foot ulcer screened yearly and 47% of the patients had peripheral neuropathy, 37% of population had inappropriate foot wear. Conclusion Considering the prevalence of peripheral neuropathy among about than half of participants in this study across Iran, it is essential to have continuous patients’ education about foot care and foot wear. Additionally, foot ulcer screening would be performed in recommended interval of Inlow screen.

Association of Risk Factors with Receiving a Foot Check in People With Diabetes: NHANES 2013-2016

AIMS

The American Diabetes Association (ADA) recommends annual foot examinations for those with diabetes. The factors related to who receives an annual examination is not completely understood. This study aims to identify factors that influence whether individuals with diabtes had their feet checked for sores or irritations.

METHODS

Data from the National Health and Nutrition Examination Survey (NHANES), were analyzed to determine the factors that influence whether an annual foot check was performed.

RESULTS

Participants with abnormal A1C (> 6.5%) had higher odds of having their feet checked compared to those with a normal A1C (adjusted odds ratio [AOR] = 2.61; 95% confidence interval (CI): 1.28-5.30). The presence of retinopathy (AOR = 2.76; 95% CI:1.13-6.73) or kidney disease (AOR = 2.37; 95% CI:1.11-5.03) also increased the odds of a foot check. Finally, the number of risk factors for diabetic complications was significantly associated with having a foot check when modeled as a continuous variable (AOR = 1.36; 95% CI: 1.14-1.63).

CONCLUSIONS

Whether an individual received an annual foot check for sores or irritations was influenced by the number of risk factors they had, especially an elevated A1C value, and the presence of retinopathy or kidney disease.

Knowledge, Attitude and Practice on Diabetic Wound Care Management among Healthcare Professionals and Impact from A Short Course Training in Sabah, Borneo

Objective

Healthcare professionals with an advanced level of knowledge and skills on diabetic wound care management are needed to effectively manage complex wounds. This study aimed to determine the effects of an educational intervention to enhance the management of wound care among healthcare professionals.

Method

This study was part of a quasi-experimental pre-post research design where 82 healthcare professionals were recruited and assigned to intervention and control groups. The participants in the intervention group attended two days of educational intervention training on diabetic wound care management, while there was no intervention in the control group. A questionnaire on knowledge, attitude, and practice was applied before and one-month post-intervention to both groups.

Results

Pre-test resulted in a low level of knowledge 72.1% and 74.4%, negative level of attitude 67.4% and 66.7%, and a moderate level of practice 79.1% and 76.9% in both intervention and control groups respectively. Post-test resulted in increasing levels of knowledge (76.7%), positive attitude (100%), and practice (76.7%) in the intervention group. At the same time, there was no significant change in the control group. Repeated Measure ANOVA for within-subject and between-subject effects resulted in a statistically significant p-value of 0.001 for knowledge, attitude, and practice after the educational intervention.

Conclusion

Health professionals have only a moderate level of knowledge on diabetic wound care management. It is important to improve this level by specific trainings and by using a good training module.

Polyneuropathy is inadequately treated despite increasing symptom intensity in individuals with and without diabetes (PROTECT follow-up study)

AIMS/INTRODUCTION

Despite its major clinical impact, distal symmetric polyneuropathy remains frequently undiagnosed and undertreated in clinical practice. We previously reported in the PROTECT Study that 70% of type 2 diabetes patients with distal symmetric polyneuropathy were unaware of having the latter condition.

MATERIALS AND METHODS

In the present follow up after 2.5 ± 0.7 years, 122 and 85 participants with and without type 2 diabetes, respectively, completed questionnaires to obtain information about the further course of disease and its management.

RESULTS

At follow up, 49 and 48% of the respondents with type 2 diabetes and without diabetes, respectively, reported that the intensity of paresthesia or numbness in the feet increased, whereas for burning and pain in the feet the corresponding percentages were 56 and 61%. However, 33 and 40% of the respondents with type 2 diabetes and without diabetes, respectively, reporting neuropathic symptoms at follow up did not receive any pharmacotherapy. Pharmacotherapy of neuropathic symptoms at follow up among participants with type 2 diabetes and without diabetes included mainly World Health Organization Step 1 analgesics (17% each; excluding acetylsalicylic acid), pregabalin/gabapentin (20 and 12%), vitamin B complex (13 and 22%), benfotiamine (13 and 2%), opioids (7 and 12%), antidepressants (4 and 5%) and α-lipoic acid (4 and 2%).

CONCLUSIONS

These findings point to insufficient care, inadequate treatment adherence or limited efficacy of treatments in patients with polyneuropathy, suggesting that effective measures should be implemented to correct these healthcare deficits.

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical-scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at-risk patient about appropriate foot self-care and treat any pre-ulcerative sign on the foot. Instruct moderate-to-high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non-surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high-risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer-free days, and to reduce the patient and health care burden of diabetic foot disease.

Treatment of modifiable risk factors for foot ulceration in persons with diabetes: a systematic review

BACKGROUND

Prevention of diabetic foot ulcers is important. Preventative treatment mostly targets and aims to improve modifiable risk factors of foot ulceration. While effectiveness of interventions in ulcer prevention has been systematically reviewed, their effectiveness in improving modifiable risk factors is unknown.

METHODS

The available medical scientific literature in PubMed, Excerpta Medica Database, and the Cochrane database was searched for original research studies on six interventions to treat modifiable risk factors for diabetic foot ulceration (ie, education for patients; education for professionals; self-management; pre-ulcer treatment; orthotic interventions; and foot- and mobility-related exercises). We assessed interventions for eight outcomes (ie, patients' knowledge; treatment adherence; professionals' knowledge; pre-ulcers; mechanical stress; neuropathy symptoms; foot/ankle joint mobility; and foot function). Both controlled and noncontrolled studies were selected. Data from controlled studies were assessed for methodological quality by two independent reviewers and extracted and presented in evidence and risk of bias tables.

RESULTS

We included 72 publications (26 with a controlled study design and 46 noncontrolled). We found that structured education may improve foot self-care behaviour of patients, yearly foot examinations, and foot disease knowledge of health care professionals. Callus removal reduces peak plantar pressure. Custom-made therapeutic footwear can be effective in reducing plantar pressure and may reduce callus. Foot- and mobility-related exercises may improve neuropathy symptoms and foot and ankle joint range of motion, while they do not seem to reduce peak plantar pressure; evidence for their effect on foot strength is conflicting.

CONCLUSIONS

Structured education for patients and health care professionals, callus removal, custom-made therapeutic footwear, and foot- and mobility-related exercises may be beneficial for improving modifiable risk factors for foot ulceration. However, we generally found low quality of evidence for interventions targeting modifiable risk factors for ulceration in persons with diabetes, with frequently inconsistent or limited results available per intervention and outcome.

Choosing a Vibratory Test to Pair With Semmes Weinstein Monofilament Testing for Evaluating Lower Extremity Sensation in Patients With Diabetes: A Comparison of Three Vibratory Methodologies

BACKGROUND

Numerous guidelines recommend pairing Semmes-Weinstein monofilament (SWM) testing with a secondary clinical test when screening for diabetic peripheral neuropathy, yet time is very limited in clinical practice. This study compared the time to complete and the diagnostic agreement of three vibratory sensation tests.

METHODS

Sixty-five individuals (42% male; aged: 61 ± 12 years) were recruited. A single investigator administered the following tests bilaterally: 10-site SWM, traditional tuning fork (TTF), electronic tuning fork (ETF), and vibration perception threshold (VPT) via biothesiometer. Times to physically administer the tests were compared with a one-way repeated measures ANOVA. Cochran's Q test was used to compare the varied tests' diagnostic agreement.

RESULTS

The ANOVA indicated there were significant (P < .001, partial eta squared = .442) differences in time to complete the varied tests. Sidak post hoc comparisons indicated the VPT (21.2 ± 14.3) testing took an intermediate time to complete, while the ETF (9.7 ± 6.5) and TTF (10.1 ± 7.5) tests took the least amount of time, and the SWM (28.6 ± 8.4) test took the longest time. There were also numerous significant differences (P ≤ .001) between the different tests in regards to neuropathy diagnoses.

CONCLUSIONS

Tuning fork methods required 11 seconds less to administer than VPT testing. Although that may seem trivial, it is worth noting peripheral neuropathy screening often fails to occur in the precious few minutes clinicians are allotted per patient. Considering ETF's intrinsic control of stimulus amplitude and its ease of use with an embedded timer, the ETF is recommended over the TTF. Clinicians should also be mindful that different tests yield different diagnostic conclusions.

Identifying and Addressing Language Needs in Primary Care: a Pilot Implementation Study

BACKGROUND

Medical interpreters improve care for patients with Limited English Proficiency but are underused. Protocols to improve interpreter use in primary care are needed.

METHODS

Medical Assistants (MAs) screened patients for language needs and arranged for telephone interpreters during rooming in two pilot clinics (PCs). We interviewed MAs and providers and analyzed interviews using modified grounded theory, linking themes to the Promoting Action on Research Implementation in Health Services (PARiHS) framework categories of Context, Evidence, and Facilitation. Providers in PCs and four comparison clinics were surveyed.

RESULTS

Context themes included issues with the telephone interpreter vendor; having established teams, roles and workflows; and difficulty incorporating time-sensitive tasks. Evidence themes included engagement in language screening; preferring in-person interpreters; improving the patient experience; and having mixed responses to the protocol. Facilitation themes included MAs needing more support. PC providers were more satisfied with care (OR = 12.7) and communication (OR = 7.6) than comparison clinic providers.

CONCLUSIONS

The protocol may improve patient care and communication, but implementation was inconsistent. Language screening is a complex process and further research is needed to improve screening questions and procedures. Future interventions should capitalize on team members' drives to improve patient care and control costs but also need to consider the impacts of health system changes, and to consider the culture, training needs, roles, and relationships of team members.

Painful and painless neuropathies are distinct and largely undiagnosed entities in subjects participating in an educational initiative (PROTECT study)

AIMS

We conducted a nationwide educational initiative to determine the prevalence and risk factors of diagnosed and undiagnosed painful and painless distal sensory polyneuropathy (DSPN).

METHODS

Among 1850 participants, 781 had no history of diabetes (ND), 126 had type 1 diabetes (T1D), and 943 had type 2 diabetes (T2D). Painful DSPN was defined as polyneuropathy detected by bedside tests with pain and/or burning in the feet, while painless DSPN was defined as polyneuropathy with paresthesias, numbness, or absence of symptoms.

RESULTS

DSPN was detected in 48.2% of ND, 44.3% of T1D, and 55.3% of T2D subjects. DSPN was painful, painless, or atypical in 62.1, 24.8, and 13.1% of the participants. Painful DSPN was more severe than painless DSPN. Painful and painless DSPN were previously undiagnosed in 61.5 and 81.1% of the participants, respectively. In T2D subjects, painful and painless DSPN were associated with a higher and lower BMI, respectively. Among ND participants 39.2% had HbA1c levels indicating prediabetes/diabetes.

CONCLUSIONS

Around half of participants in an educational initiative had DSPN, 62% of whom had the painful entity that correlated with BMI in T2D. Since many cases of neuropathy and diabetes remain undiagnosed, effective strategies to timely detect both conditions should be implemented.

Impact of an educational intervention on medical records documentation

BACKGROUND

Inaccurate and incomplete documentation can lead to poor treatment and medico-legal consequences. Studies indicate that teaching programs in this field can improve the documentation of medical records. The study aimed to evaluate the effect of an educational workshop on medical record documentation by emergency medicine residents in the emergency department.

METHODS

An interventional study was performed on 30 residents in their first year of training emergency medicine (PGY1), in three tertiary referral hospitals of Tehran University of Medical Sciences. The essential information that should be documented in a medical record was taught in a 3-day-workshop. The medical records completed by these residents before the training workshop were randomly selected and scored (300 records), as was a random selection of the records they completed one (300 records) and six months (300 records) after the workshop.

RESULTS

Documentation of the majority of the essential items of information was improved significantly after the workshop. In particular documentation of the patients' date and time of admission, past medical and social history. Documentation of patient identity, requests for consultations by other specialties, first and final diagnoses were 100% complete and accurate up to 6 months of the workshop.

CONCLUSION

This study confirms that an educational workshop improves medical record documentation by physicians in training.

Germain A, Egede LE. Trends in sex differences in the receipt of quality of care indicators among adults with diabetes: United States 2002-2011

BACKGROUND

Evidence suggests disparities in quality of care (QoC) indicators based on sex exist in adults diagnosed with diabetes; however, this research is limited. Therefore, the objective of this research study was to assess differences in QOC indicators in a nationally representative sample of men and women with diabetes.

METHODS

Cross-sectional study of 17,702 men and women (≥18 years of age) with diabetes from the 2002-2011 Medical Expenditure Panel Survey Household Component. Sex was the main predictor variable, and the dependent variables were five binary indicators to measure QOC, which included testing of hemoglobin A1c, examining feet annually, getting eyes dilated, checking blood pressure, and visiting the doctor annually. Sample demographics by sex were assessed. Unadjusted analyses were computed for descriptive statistics by sex and proportions of QOC indicators over time. Logistic regression evaluated associations between QOC indicators and sex, while controlling for sociodemographic characteristics, time, and comorbid conditions.

RESULTS

Approximately 44% and 56% of the sample was comprised of men and women, respectively. Unadjusted analyses showed significant differences in A1c testing (p < 0.001) and foot examinations (p = 0.002) for the entire sample, and significant differences in A1c testing (p = 0.027), foot examinations (p = 0.01), and dilated eye exams (p = 0.026) among men and A1c testing (p < 0.001) among women overtime. Adjusted analyses found women to be significantly more likely to have dilated eye examinations during a given year (OR = 1.14; 95% CI 1.04, 1.24), to get their blood pressure checked by a doctor in a given year (OR = 1.44; 95% CI 1.13, 1.84), and to visit a doctor annually (OR = 1.39; 95% CI 1.22, 1.58) compared to men.

CONCLUSIONS

In this sample of adults with diabetes, women had significantly higher odds of receiving quality of care compared to men. These findings suggest the importance of educating patients about appropriate metrics of diabetes management, especially men, and the need for continuous empowerment of women to receive proper and optimal care. Additional research is needed to identify causes and reduce sex and gender disparities associated with diabetes quality of care.

Delay between Onset of Symptoms and Seeking Physician Intervention Increases Risk of Diabetic Foot Complications: Results of a Cross-Sectional Population-Based Survey

We present a post hoc analysis of 17,530 questionnaires collected as part of the 2012 screening for neuropathy using Norfolk Quality of Life tool in patients with diabetes in Romania, to assess the impact on foot complications of time between the onset of symptoms of diabetes/its complications and the physician visit. Odds ratios (ORs) for self-reporting neuropathy increased from 1.16 (95% CI: 1.07-1.25) in those who sought medical care in 1-6 months from symptoms of diabetes/its complications onset to 2.27 in those who sought medical care >2 years after symptoms onset. The ORs for having a history of foot ulcers were 1.43 (95% CI: 1.26-1.63) in those who sought medical care in 1-6 months and increased to 3.08 (95% CI: 2.59-3.66) in those who sought medical care after >2 years from symptoms of diabetes/its complications onset. The highest ORs for a history of gangrene (2.49 [95% CI: 1.90-3.26]) and amputations (2.18 [95% CI: 1.60-2.97]) were observed in those who sought medical care after >2 years following symptoms onset. In conclusion, we showed that waiting for >1 month after symptoms onset dramatically increases the risk of diabetic foot complications. These results show the need for accessible educational programs on diabetes and its chronic complications and the need to avoid delays in reporting.

High prevalence of diagnosed and undiagnosed polyneuropathy in subjects with and without diabetes participating in a nationwide educational initiative (PROTECT study)

AIMS

Since neuropathy screening may be underutilized in primary care practice, we conducted a nationwide educational initiative to determine the prevalence of diagnosed and previously undiagnosed polyneuropathy.

METHODS

Among 1017 individuals participating in the initiative, 983 with complete data were analyzed, 359 of whom had no diabetes by history (ND), 80 had type 1 diabetes, and 544 had type 2 diabetes. Polyneuropathy was assessed by history and foot examination including pressure, temperature, and vibration perception and was classified as possible, probable, and severe. Foot pulses and HbA1c were determined in subsets of participants.

RESULTS

Polyneuropathy was detected in 53.8% of ND, 43.8% of type 1, and 55.6% of type 2 diabetes subjects and was associated with higher age. In a subset of participants with polyneuropathy, the latter was declared as previously undiagnosed by 79.1% of ND, 35.7% of type 1, and 61.5% of type 2 diabetes participants. After adjustment for age and sex, prevalent polyneuropathy was associated with peripheral arterial disease.

CONCLUSIONS

More than half of subjects with and without diabetes participating in an educational initiative had polyneuropathy which was reported as previously undiagnosed by two thirds. Effective strategies to avoid underdiagnosis of neuropathy and to improve preventive foot care should be implemented.

Diabetic Foot Disease, Self-Care and Clinical Monitoring in Adults with Type 2 Diabetes: The Alberta's Caring for Diabetes (ABCD) Cohort Study

OBJECTIVE

To examine the prevalence and predictors of foot disease, self-care and clinical monitoring in adults with type 2 diabetes in Alberta, Canada.

METHOD

Baseline data from a prospective cohort of adults with type 2 diabetes were used. Assessment of foot disease included self-reported peripheral neuropathy, peripheral vasculopathy, foot or leg ulcer/infection or gangrene/amputation. Foot self-care was assessed using the Summary of Diabetes Self-Care Activities, and clinical monitoring using patients' reports of having feet checked for lesions or sensory loss.

RESULTS

The mean age of respondents (N=2040) was 64 (SD 10.7) years; 45% were female, and 91% were Caucasian. Peripheral neuropathy was reported by 18% of the respondents, peripheral vasculopathy by 28%, ulcer/infection by 6% and gangrene/amputation by 1.4%. Only 14% of respondents performed foot self-care behaviours ≥6 days per week, and only 41% and 34% had their feet clinically checked for lesions or sensory loss, respectively. Predictors of foot disease included longer duration of diabetes, smoking, depressive symptoms, low self-efficacy and a history of cardiovascular diseases. Predictors of good self-care included older age, female sex, longer duration of diabetes and no report of hyperlipidemia. Predictors of clinical monitoring included female sex, current smoking, residing in urban areas, longer duration of diabetes, and histories of heart disease or hyperlipidemia.

CONCLUSIONS

Peripheral neuropathy and vasculopathy were the most common reported foot problems in this population. Foot self-care is generally infrequent, and clinical monitoring is performed for less than half of these patients, with significant variations by patient demographics and clinical presentation.

A clinical screening score for diabetic polyneuropathy: KORA F4 and AusDiab studies

AIMS

Since screening for distal sensorimotor polyneuropathy (DSPN) in individuals with diabetes is being underused, our aim was to develop a clinical screening score for identifying individuals with DSPN.

METHODS

All participants with type 2 diabetes and aged 61-82 years from the German population-based KORA F4 Study (n=177) and the Australian population-based AusDiab Study (n=244) were combined into one study sample. Risk indicators of DSPN were identified and entered into a stepwise model-selection procedure, constructing two consecutive scores with increasing complexity (a base and clinical model).

RESULTS

The prevalence of DSPN was 18.2% (95% confidence interval (CI): 14.7-22.3). The base model comprised age (years), height (cm), weight (kg), pain or discomfort in the feet and/or legs (yes/no), and duration of diabetes (years), yielding an area under the receiver operating characteristics curve (AUC) of 0.80 (95% CI: 0.76-0.85). The clinical model additionally included diastolic blood pressure (mmHg) and serum creatinine levels (mmol/l). The AUC increased only marginally to 0.82 (0.77-0.87) (p for AUC comparison=0.188). The internal validation of the scores produced similar AUCs.

CONCLUSIONS

The screening scores developed in this study are a simple tool to differentiate between a high and low likelihood of having DSPN among individuals with type 2 diabetes.

Prevalence and risk factors of neuropathy in newly diagnosed type 2 diabetes in primary care practices: a retrospective database analysis in Germany and U.K

AIMS

To estimate the prevalence and risk factors of diabetic neuropathy in newly diagnosed type 2 diabetes in general practices.

METHODS

Longitudinal data from nationwide general practices in Germany (n=630) and U.K. (n=100) (Disease Analyzer) were analyzed. Patients with newly diagnosed (<1 year) type 2 diabetes (2008-2012) were identified including 45,633 patients (age: 66, SD: 12 years) in Germany and 14,205 patients (age: 63, SD: 13 years) in U.K. Neuropathy was identified by ICD code (E11.4) or the original diagnosis. Associations of potential risk factors with neuropathy were investigated using logistic regression.

RESULTS

The prevalence of diagnosed neuropathy was 5.7% (95% CI: 5.5-5.9%) in Germany and 2.4% (1.9-2.9%) in U.K. In Germany, factors independently associated with neuropathy in stepwise logistic regression were age (>70 years: OR; 95% CI 2.1; 1.6-2.8), retinopathy (3.0; 2.1-4.2), peripheral artery disease (PAD: 1.9; 1.4-2.5), insulin treatment (4.6; 3.5-6.2) and oral antidiabetic drugs (OAD: 1.6; 1.2-2.0). In UK, male sex (1.4; 1.01-1.9), nephropathy (1.7; 1.2-2.5), PAD (1.5; 1.1-2.1), antihypertensives (1.7; 1.1-2.5), insulin (2.1; 1.1-3.8) and OAD (1.4; 1.01-1.8) were identified.

CONCLUSIONS

The prevalence of diabetic neuropathy at time of type 2 diabetes diagnosis was low in primary care (Germany, UK). Neuropathy was associated with age, PAD and microvacular complications.

The Effect of Educational Intervention on Medical Diagnosis Recording among Residents

Introduction:

Studies indicate that using interventions including education may improve medical record documentation and decrease incomplete files. Since physicians play a crucial role in medical record documentation, the researchers intend to examine the effect of educational intervention on physicians’ performance and knowledge about principles of medical diagnosis recording among residents in Hormozgan University of Medical Sciences(HUMS).

Methods:

This quasi-experimental study was conducted in 2010 on 40 specialty residents (from internal medicine, obstetrics and gynecology, pediatrics, anesthesiology and surgery specialties) in Hormozgan University of Medical Sciences. During a workshop, guidelines for recording diagnostic information related to given specialty were taught. Before and after the intervention, five medical records from each resident were selected to assess physician performance about chart documentation. Using a questionnaire, physicians’ knowledge was investigated before and after intervention. Data were analyzed through one-way ANOVA test.

Results:

Change in physicians’ knowledge before and after education was not statistically significant (p = 0.15). Residents’ behavior did not have statistically significant changes during three phases of the study.

Conclusion:

Diversity of related factors which contributes to the quality of documentation compels portfolio of strategies to enhance medical charting. Employing combination of best practice efforts including educating physicians from the beginning of internship and applying targeted strategy focus on problematic areas and existing gap may enhance physicians’ behavior about chart documentation.

The system of care for the diabetic foot: objectives, outcomes, and opportunities

Most cases of lower extremity limb loss in the United States occur among people with diabetes who have a diabetic foot ulcer (DFU). These DFUs and the associated limb loss that may occur lead to excess healthcare costs and have a large negative impact on mobility, psychosocial well-being, and quality of life. The strategies for DFU prevention and management are evolving, but the implementation of these prevention and management strategies remains challenging. Barriers to implementation include poor access to primary medical care; patient beliefs and lack of adherence to medical advice; delays in DFU recognition; limited healthcare resources and practice heterogeneity of specialists. Herein, we review the contemporary outcomes of DFU prevention and management to provide a framework for prioritizing quality improvement efforts within a resource-limited healthcare environment.

Effect of an educational intervention in primary care physicians on the compliance of indicators of good clinical practice in the treatment of type 2 diabetes mellitus [OBTEDIGA project]

AIM

To evaluate the effect of an educational intervention among primary care physicians on several indicators of good clinical practice in diabetes care.

METHODS

Two groups of physicians were randomly assigned to the intervention or control group (IG and CG). Every physician randomly selected two samples of patients from all type 2 diabetic patients aged 40 years and above and diagnosed more than a year ago. Baseline and final information were collected cross-sectionally 12 months apart, in two independent samples of 30 patients per physician. The educational intervention comprised: distribution of educational materials and physicians' specific bench-marking information, an on-line course and three on-site educational workshops on diabetes. External observers collected information directly from the physicians and from the medical records of the patients on personal and family history of disease and on the evolution and treatment of their disease. Baseline information was collected retrospectively in the control group.

RESULTS

Intervention group comprised 53 physicians who included a total of 3018 patients in the baseline and final evaluations. CG comprised 50 physicians who included 2868 patients in the same evaluations. Measurement of micro-albuminuria in the last 12 months (OR = 1.6, 95% CI: 1.1-2.4) and foot examination in the last year (OR = 2.0, 95% CI: 1.1-3.6) were the indicators for which greater improvement was found in the IG. No other indicator considered showed statistically significant improvement between groups.

CONCLUSIONS

The identification of indicators with very low level of compliance and the implementation of a simple intervention in physicians to correct them is effective in improving the quality of care of diabetic patients.

Factors contributing to diabetes patients not receiving annual dilated eye examinations

PURPOSE

Early detection of diabetic eye disease by dilated eye exam can limit potential vision loss from diabetic retinopathy. The purpose of this study was to examine what variables contribute to diabetes patients not receiving annual dilated eye examinations.

METHODS

This study used national 2009 Behavioral Risk Factor Surveillance System survey data. Variables used in the analysis included sociodemographics, insurance status, mentally unhealthy days, receipt of annual dilated eye exams, insulin dependence, a history of diabetes education classes, timely annual diabetic foot exams, and history of cardiovascular disease. Survey proportions were calculated, and survey logistic regression was performed with the consideration of survey strata and weight to correct for biases.

RESULTS

The likelihood of receiving annual dilated eye exams was correlated with eight statistically significant variables. These variables included age category, income level, education level, health insurance status, mentally unhealthy days within the past month, insulin dependence, a history of diabetic education classes, and timeliness of annual diabetic foot examinations.

CONCLUSIONS

This study provides a snapshot of variables that may have a bearing on diabetes patients seeking annual dilated retinal examinations. Eight variables were statistically significant in affecting the timeliness of diabetic eye examinations. Thus, resolutions for these factors could be implemented for future improvement of comprehensive health care provided to those with diabetes.

Older subjects with diabetes and prediabetes are frequently unaware of having distal sensorimotor polyneuropathy: the KORA F4 study

OBJECTIVE

Distal sensorimotor polyneuropathy (DSPN) is a severe complication of type 2 diabetes. This study aimed to assess the prevalence of unawareness of DSPN in prediabetes and diabetes in a sample of the older population of Augsburg, Germany.

RESEARCH DESIGN AND METHODS

Glucose tolerance status was determined in 61- to 82-year-old participants of the population-based KORA F4 Study (2006-2008) (n = 1,100). Clinical DSPN was defined as the presence of bilaterally impaired foot-vibration perception and/or bilaterally impaired foot-pressure sensation. DSPN case subjects were considered unaware of their condition when answering "no" to the question, "Has a physician ever told you that you are suffering from nerve damage, neuropathy, polyneuropathy, or diabetic foot?"

RESULTS

Clinical DSPN was prevalent in 154 (14%) participants, 140 of whom were unaware of their disorder. At a prevalence of 23.9% (95% CI 12.6-38.8), participants with combined impaired fasting glucose and impaired glucose tolerance had the highest prevalence of DSPN. Of these, 10 of 11 (91%) were unaware of having clinical DSPN. Participants with known diabetes had an equally high prevalence of DSPN [22.0% (16.2-28.9)], with 30 of the 39 (77%) DSPN case subjects unaware of having the disorder. Among subjects with known diabetes who reported to have had their feet examined by a physician, 18 of 25 (72%) clinical DSPN case subjects emerged unaware of having DSPN.

CONCLUSIONS

Our findings showed a high prevalence of unawareness of having clinical DSPN among the prediabetic and diabetic groups and an insufficient frequency of professional foot examinations, suggesting inadequate attention to diabetic foot prevention practice.

Nurses' role in diabetic foot prevention and care; a review

Diabetes as one of Non-communicable diseases has allocated a large proportion of cost, time and human resources of health systems. Now, due to changes in lifestyle and industrial process, incidence of diabetes and its complications have been increased. Accordingly diabetic foot considered as a common complication of diabetes.Nurses are health care providers who actively involved in prevention and early detection of diabetes and its complications. The nurses' role could be in health care, health, community education, health systems management, patient care and improving the quality of life.Diabetes Nurses play their educating role in the field of prevention of diabetic foot, foot care and preventing from foot injury. In care dimension, nurses responsible for early detection of any changes in skin and foot sensation, foot care, dressing and apply novel technology.In the area of rehabilitation, help patient sufferings from diabetic foot ulcer or amputation, to have movement are diabetes nurse's duties.Consequently, nurses need to attend in special training to use the latest instructions of diabetic foot care in order that provides the effective services to facilitate promote diabetic patients health.

Effectiveness of diabetes resource nurse case management and physician profiling in a fee-for-service setting: a cluster randomized trial

Nurses with advanced training-diabetes resource nurses (DRNs)-can improve care for people with diabetes in capitated payment settings. Their effectiveness in fee-for-service settings has not been investigated. We conducted a 12-month practice-randomized trial involving 22 practices in a fee-for-service metropolitan network with 92 primary care physicians caring for 1891 Medicare patients ≥65 years with diabetes mellitus. Each practice was randomized to one of three intervention groups: physician feedback on process measures using Medicare claims data; Medicare claims feedback plus feedback on clinical measures from medical record (MR) abstraction; or both types of feedback plus a practice-based DRN. The primary endpoint investigated was hemoglobin A(1c) level. Other measures were low-density lipoprotein (LDL) cholesterol level, blood pressure, annual hemoglobin A(1c) testing, annual LDL screening, annual eye exam, annual foot exam, and annual renal assessment. Data were collected from medical chart abstraction and Medicare claims. The number of patients with hemoglobin A(1c) <9% increased by 4 (0.9%) in the Claims group; 9 (2.1%) in the Claims + MR group (comparison with Claims: P = 0.97); and 16 (3.8%) in the DRN group (comparison with Claims: P = 0.31). Results were similar for the other clinical outcomes, with no differences significant at P = 0.10. For process of care measures, decreases were seen in all groups, with no significant differences in change scores. Quality improvement strategies must be evaluated in the appropriate setting. Initiatives that have been effective in capitated systems may not be effective in fee-for-service environments.

The lived experience of a foot burn injury from the perspective of seven Jordanians with diabetes: a hermeneutic phenomenological study

Poor vision and poor pain sensation expose sufferers of diabetes to foot burn injuries. A phenomenological approach was used to illuminate the lived experience of those with diabetes who sustained foot burn injuries. Face-to-face unstructured interviews were conducted with seven patients recruited from health care facilities throughout Jordan. The interviews were digitally recorded, transcribed verbatim into Arabic, checked for accuracy and then analysed using thematic analysis. Our study highlights that household appliances are a major cause of foot burn injuries among the studied population and that culturally specific risk factors predispose Jordanians with diabetes to foot burn injuries, namely ablution for males and cooking activities for females. Participants sought health care when home remedies failed. Inconsistent management practices were identified among health care providers. Culturally specific health education programs should be made to raise patients' awareness towards avoiding possible risks at home.

Patient computer use to prompt doctor adherence to diabetes management guidelines

RATIONALE, AIMS AND OBJECTIVES

Doctor compliance with diabetic care guidelines is low and may be improved with system-wide changes that include patient involvement. The objective of this study was to determine if patients in an internal medicine teaching clinic would use a touch-screen computer to receive personalized information regarding their need for diabetes care. Outcomes included determining if this intervention would improve resident doctor compliance with diabetic guidelines.

METHODS

In this prospective study a computer was available for patients to use independently in one clinic, while another computer was placed in a second clinic with nursing support. Patients responding they were diabetic to the first screen received screens covering HbA1c, blood pressure, cholesterol, foot, eye examinations and compliance with having labs drawn. Non-diabetic patients received three general health screens. A response-based report was printed for patients to share with their doctor. Chart reviews were conducted to assess diabetic health care delivery.

RESULTS

The computer was used voluntarily by 20.6% of patients in the primary clinic and by 100% of patients in the nurse-assisted clinic. A total of 104 patients from both clinics responded they were diabetic; over 50% did not know what HbA1c meant and a minority responded their HbA1c, blood pressure and cholesterol were at good levels. Significantly more HbA1c tests conducted within 6 months were documented in patients' charts.

DISCUSSION

Patients used the computer effectively without direction in the primary clinic. In this initial study, implementation of the computer program increased the number of HbA1c tests ordered. Future studies incorporating refinements may increase both usage and efficacy of this intervention.

Assessing diabetes practices in clinical settings: precursor to building community partnerships around disease management

Many recommended best practices exist for clinical and community diabetes management and prevention. However, in many cases, these recommendations are not being fully utilized. It is useful to gain a sense of currently utilized and needed practices when beginning a partnership building effort to ameliorate such practice problems. The purpose of this study was to assess current practices in clinical settings within the Brazos Valley in preparation for beginning a community-based participatory research project on improving diabetes prevention and management in this region. Fifty-seven physicians with admission privileges to a regional health system were faxed a survey related to current diabetes patient loads, knowledge and implementation of diabetes-related best practices, and related topics. Both qualitative and quantitative examination of the data was conducted. Fifteen percent of responding providers indicated they implemented diabetes prevention best practices, with significant differences between primary-care physicians and specialists. Respondents indicated a need for educational and counseling resources, as well as an increased health-care workforce in the region. The utilization of a faxed-based survey proved an effective means for assessing baseline data as well as serving as a catalyst for further discussion around coalition development. Results indicated a strong need for both clinical and community-based services regarding diabetes prevention and management, and provided information and insight to begin focused community dialogue around diabetes prevention and management needs across the region. Other sites seeking to begin similar projects may benefit from a similar process.

Psychosocial and behavioral aspects of diabetic foot lesions

This article reviews key findings from recently conducted and ongoing studies into how patients adapt to diabetic foot complications by focusing on two areas. These areas include the role of psychological factors in guiding preventive foot self-care and the impact of diabetic foot ulceration and amputations on an individual's emotional state and quality of life.

Diabetic foot screening: why is it neglected?

Understanding reasons for the neglect of foot screening during the annual review of people with diabetes enables the development of solutions for this omission. This study explores the reasons within the context of health care delivery systems in terms of the professional, social, political and economic aspects of this screening. Information was obtained through reviewing publications on diabetic foot and health care reform. The omission of annual foot examination for people with diabetes is attributed to the nature of diabetes-related foot problems, people with diabetes, health care professionals and the current structure of health care delivery systems. Increasing the adherence to foot screening for those with diabetes requires short- and long-term strategies. Short- and long-term strategies for reminding patients and staff about foot screening are suggested.