Diabetes is a chronic and debilitating disease that has long-term consequences for those that 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 on anyone that must endure it. To avoid amputation, foot exams performed by a physician may help provide the kind of preventative care that may lead to a reduced risk for 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 the patient is facing in regards to foot ulceration and amputation. One such component is history of the patient. Another is assessment of peripheral/neuropathic vascular symptoms, possible renal replacement therapy, and impaired vision. Another part of foot examinations is determining if a patient’s tobacco use as this is a major risk factor both neuropathy and vascular disease.
Aside from patient history, foot exams require a general inspection and dermatological assessment. The next step is musculoskeletal assessment that includes assessment of any gross deformity. This is followed by a neurological assessment. The last step is vascular assessment. These steps can be achieved in as little as three minutes (Dorresteijn & Valk, 2012).
While research shows single preventative methods have not provided reduction of occurrence of foot ulceration to a major degree, 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. Research from three different articles will offer a look into which way is most effective in minimizing amputation and foot ulceration. The research will also highlight the consequences of performing foot exams frequently versus infrequently in relation to medical expenses.
Integration and Synthesis of the Evidence
Patient education is a big part of prevention. Patients can perform their own foot exams daily without the need of physician intervention and is the main 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 is an important part to understand when seeing the effectiveness of physician assisted foot exams frequently versus infrequently. Should the patient receive adequate education on performing their own daily foot exams, the need to employ 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 enable improved 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 sequence may help with delivering a higher quality of care for those experiencing complications from diabetes mellitus. The researchers also determined variation in regions in accordance with modified 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 other factors as well such as daily foot evaluations and 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). The results demonstrated that daily foot evaluations did not present with a decrease risk of amputation. Meaning there was no major impact in decreasing said risk for amputation for diabetes patients. Patient education and modification of physical examination sequence model does have a positive effect in decreasing risk for amputation. This helps provide further support for patient education being an important preventative measure.
Another study examined insulin-dependent beneficiaries with a history of foot ulcers to assess medical spending as well as whether higher spending reduced mortality or not. “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 or in the case of the article, Medicare spending, increases with inclusion of foot exams each time a patient attends a medical appointment with a physician. If foot examinations become part of standard clinical practice for insulin-dependent patients, this may increase overall medical spending for patients and insurance companies.
The results of the 2013 study suggest higher medical spending did not promote a major 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). What the results of the study suggest is that higher levels of medical spending provide no real positive impact on patient mortality. Including foot examinations for diabetes mellitus patients to prevent amputation and foot ulceration may not provide a significant positive effect for insulin-dependent patients. It may just increase medical spending and not provide the kind of decrease in risk patients need.
The evidence presented favored two conclusions. The first conclusion is there is no need to increase frequency of foot exams. The second is patient education may be a better preventative measure than adding foot examinations to every office visit. The three articles highlighted from different perspectives, why frequent foot exams may not be as important as imagined. From the education perspective, patients can learn to perform foot examinations by themselves at home. This can be taught at an annual foot examination and carried out by the patient at home.
The second perspective came from efficacy. Patients that experienced daily foot examinations saw no significant difference in amputation risk. If a clinical practice is not effective, then it is not necessary. The third came from a financial perspective. Higher medical spending does not provide a significant positive impact on patient mortality. If medical spending can be kept at a certain range while achieving the same efficacy, this means annual foot examinations may be the best option overall.
The overall theme of the three articles is efficacy, whether more or less works. Each article suggested less is the better option. At times something can be effective when it is performed infrequently versus frequently. Foot examinations have seen efficacy through annual practice rather than during each office visit. Patients need to be educated on what they need to do to prevent diabetes-related complications rather than have the physician perform unnecessary actions each office visit.
Comparative Evaluation of the Evidence to Practice
In relation to my own practice, I have seen no major difference when patients increase the foot examination frequency. Patients have stated they perform daily foot examinations and they still do not see any reduction in risk for foot ulceration or amputation. The main problem with preventative efforts is the lack of patient education that leads to continued bad habits on the part of the patient. These bad habits contribute to the symptoms and effects that lead to foot ulceration and amputation.
Patients saw the same outcomes from having an annual foot exam versus having one every office visit. What impact was seen related to the additional time and medical expenses of performing a foot examination each visit. Patients saw on average a doctor visit extended by a minimum of 15 minutes as patient history played an important part of the foot examination. This outcome supports the outcomes for the research.
The research offered a preventative effort of patient education to help decrease occurrence of amputation and foot ulcerations. It also offered the option of intensive follow-ups and support hosiery, rather than simply adding foot examinations to every office visit.
The intensive intervention comprised more intensive follow-up, a weekly diabetic foot clinic, podiatry care, provision of support hosiery and protective footwear and introduction of appointment reminder letters to patients. A significant and cost-effective reduction of lower-extremity amputations (RR 0.30; 95% CI 0.13 to 0.71) was achieved and also a non-significant reduction of the number of foot ulcerations (RR 0.69; 95% CI 0.41 to 1.14) (Dorresteijn & Valk, 2012, p. 105).
Even with the complex intervention method, the 2012 study showed non-significant reduction in the occurrence of foot ulcerations. If a complex intervention method does not significantly decrease foot ulceration occurrence, then a simpler method like frequent foot examinations would also have the same effect. This brings up the topic of feasibility.
Annual foot examinations are much easier to perform and comply with compared to foot examinations every visit. Realistically, physicians must see several patients each day. To spend time on an unnecessary action like foot exams and also charge more for the extra service may make this an unviable option. To implement a change that involves an extra action every office visit means changing standard practice, which is more often than not more expensive and less feasible.
This is a potential barrier to change. Changing standard practice in a clinical setting is met often with strong resistance (White, Dudley-Brown, & Terhaar, 2016). It takes more communication and adaptation to implement a change that must occur frequently. Compliance must come from the part of both the patient and the physician. The physician must implement a protocol for the foot examinations. The patients must comply to the standard protocol (White, Dudley-Brown, & Terhaar, 2016).
When it came to seeing compliance of changes in my own practice setting, compliance was often met with strong resistance, especially if the change had to be implemented frequently and cost more time and money to perform. When it came to foot examinations, especially as they relate to Medicare patients, they needed to be billed along with an additional service. Medicare only covers foot examinations once every six months. If foot examinations were implemented for every office visit in the case of Medicare patients, they would not be able to have them due to the restriction.
This presents another important barrier to implementation of frequent foot examinations. Health insurance companies and Medicare will not pay for frequent foot examinations. Therefore, this is an important barrier to recognize in the feasibility of frequent foot examinations. Foot examinations are not important in providing higher quality care to insulin-dependent patients. They will not be approved by Medicare for more than once every six months. They have no positive effect on preventing foot ulcerations and amputations.
Diabetes mellitus comes with many potential complications. Two such complications are amputations and foot ulceration. LEA or lower extremity amputations are costly and can lead to significant financial burdens to insulin-dependent patients. Assessment of efficacy in frequency of foot examinations provided several important conclusions. The first conclusion is frequent foot examinations provided no real benefit to patients. It did not decrease the occurrence of foot ulcerations or amputations.
Foot ulcerations and amputations may be prevented more effectively with patient education and a more complex intervention. The second conclusion is frequent foot examinations versus infrequent foot examinations lead to higher medical costs. Higher medical costs are not associated with improved patient health. Medicare patients cannot have more than one-foot examination every six months. Even if implementation of frequent foot exams became standard, Medicare diabetes patients would be unable to see these changes applied to them due to the insurance restriction.
Research should lean towards efficacy of patient education and improvement of patient education as it relates to chronic and debilitating diseases like diabetes mellitus. Patients informed of what they can do at home can help them prevent complications such as amputation and foot ulcerations. Physicians and nurses may teach patients diabetic foot care, daily at home foot examinations, and lifestyle choices. These options may improve patient health and quality of life.
It cannot be stressed the common occurrence of diabetic foot complications and the importance of screening and prevention. While screening is important, it can be performed without the assistance of a physician by a patient in his or her own home. Annual foot examinations provide the basis from which physicians and patients can assess and determine health outcomes. By increasing frequency of these foot examinations, the only increases will be seen in medical costs.
Patient education is the main means of preventing health complications for chronically ill patients. Standard practice includes annual foot examinations for insulin-dependent patients. Improvements in diabetes care management have not included an increase in these foot examinations. They have included a more complex intervention, from weekly foot care programs and increased patient education. Even with complex intervention, amputation has not seen a major decline through these preventative efforts. In conclusion, diabetes mellitus is a chronic illness and patients can properly manage it with education and annual foot examinations. Frequent foot examinations have no significant positive impact on prevention of foot ulceration and amputation.
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.
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