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Diabetics' infected feet may be overlooked (4/8/97)

Diabetic patients with acutely infected feet may not be getting adequate foot exams in some hospitals, according to a new study by two Texas podiatrists and a Michigan endocrinologist.

The study points to the need for having podiatrists on staff in hospitals or on call from nearby clinics. The authors are David Armstrong, DPM, and Lawrence Lavery, DPM, MPH, of The University of Texas Health Science Center at San Antonio and Gary Edelson, MD, of Wayne State University in Detroit.

In a four-year monitoring effort at a large university teaching hospital in the upper Midwest, the researchers found that diabetic patients admitted for acute foot infections were evaluated with even minimum competency less than 14 percent of the time. The facility in question was one without a dedicated podiatry, or foot, service in place. The results were published in *Archives of Internal Medicine*.

"The results were quite startling," said Dr. Armstrong, assistant professor in the Health Science Center's department of orthopaedics. "It has long been known that on a routine visit to a primary care physician, a diabetic patient's feet are evaluated only 10-20 percent of the time, but when a patient is admitted for a specific diabetic foot complication, we anticipate a far more concerted examination."

Drs. Armstrong, Lavery and Edelson reviewed the records of more than 250 diabetic patients, all of whom were admitted for diabetic foot infections to various medical services at the Midwest teaching hospital. In only about 35 cases did the patients receive even a minimally competent examination of their feet, and most of those evaluations were not up to standards set by the American Diabetes Association. These guidelines include feeling for a foot pulse; evaluating wound location, size and depth; and noting presence and severity of infection.

"We were searching for even the most cursory description of these things and in most cases did not find them," Dr. Armstrong said, noting that nearly 90 percent of the infected wounds were not evaluated for involvement of underlying structures such as bone or tendon, nearly half of patients did not have bacterial cultures taken of their wound and x-rays were not ordered in about a third of the cases.

"The real point that can be made here is that some physicians have gotten so used to treating laboratory values that they may have stopped looking at and laying hands on the place of interest, such as the foot," Dr. Armstrong said. "In many cases, it's to the patients' peril. In this era of high-tech gadgetry, something as low-tech as evaluating the wound or area of involvement can go a long way toward reducing the unnecessarily high number of leg amputations among our diabetic population."

More than 80 percent of leg amputations are performed on diabetic patients. Annually, at least 120,000 people in the United States must go through this procedure.

"We believe a systematic evaluation of the diabetic foot is absolutely vital," Dr. Armstrong said. "The Health Science Center's teaching hospitals and other facilities with dedicated diabetic foot care teams perform these sorts of evaluations, which not only have been shown to be cost-effective in the near term, reducing the length and number of hospital stays, but also perhaps in the long term by reducing the cost of rehabilitating many of these amputees and lowering the staggering cost to society in terms of lost productivity. With proper preventive care, diabetic patients can continue to be ambulatory and productive rather than debilitated and subsidized."

Diabetes is a major health problem in South Texas, especially among the region's large Hispanic population. In 1993, Drs. Lavery, Armstrong and Larry Harkless, DPM, director of podiatry residency training at the Health Science Center, looked at records from about 2,000 amputations performed at nearly every hospital in the region. "Anecdotally, we found very similar results to our present study," Dr. Armstrong said. "Not enough attention was paid to these patients' areas of concern, their feet."

Lack of foot care isn't just a problem in rural areas where podiatrists are few. "The facility we monitored for our present study is in a very large town with ample resources available but not being implemented," Dr. Armstrong noted. "That's the equivalent of having a number of great ballplayers in your area but not assembling them into a team to best utilize their talent. We need agreements among podiatrists, endocrinologists, vascular surgeons, orthopaedists, diabetes nurse educators, physical therapists, primary care physicians and rehabilitation medicine physicians. Getting the right professionals to the right patients and focusing on the problem is half the battle in amputation prevention."

Diabetic patients in the McAllen-Harlingen-Brownsville area of the Lower Rio Grande Valley of Texas are being helped by a clinic that opened a couple of years ago, he said. "This has shown very promising results in employing podiatry and several other medical disciplines in a team approach to limb salvage in diabetics. Only until that happens on the national level can we make a meaningful dent in the amputation rate."

One of the simplest things very frequently ignored is the extent of neuropathy (inability to sense pain), he said. "As patients progress with diabetes, a large percentage lose sensation to their hands and feet. This is very dangerous and really the precipitating factor in so many amputations. I tell patients that pain is a gift to them; it's one no one wants, yet it tells us when there are problems.

"I'm a diabetic foot specialist and quite frankly I never look at my feet unless they hurt. But then again, I'm not diabetic. If we could just get our diabetic patients to look at their feet every day just like they comb their hair or brush their teeth, then we'd win the other half of the battle. These patients have to be made aware that if they ignore their feet, they could lose them."

The researchers' newly published paper is a sort of "call to action," he said, for physicians and patients alike.

Contact: Will Sansom (210) 567-2570