Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial. Diabetes education and care management significantly improve patient outcomes in the dialysis unit. Improving foot care for people with diabetes mellitus--a randomized controlled trial of an integrated care approach. Evaluation of the impact of podiatrist care in the primary prevention of foot problems in diabetic subjects. Screening for patients at risk of diabetic foot ulceration in a general diabetic outpatient clinic.
To evaluate the effect of a patient, health care provider, and systems intervention on the prevalence of risk factors for lower extremity amputation in patients with non-insulin-dependent diabetes.
                Blinded, randomized, controlled trial.
                Academic general medicine practice.
                Of the 395 patients with non-insulin-dependent diabetes who underwent the initial patient assessment, 352 completed the study.
                The 12-month intervention was multifaceted. Patients received foot-care education and entered into a behavioral contract for desired self-foot care, which was reinforced through telephone and postcard reminders. Health care providers were given practice guidelines and informational flow sheets on foot-related risk factors for amputation in diabetic patients. In addition, the folders for intervention patients had special identifiers that prompted health care providers to: 1) ask that patients remove their footwear, 2) perform foot examinations, and 3) provide foot-care education.
                Patients receiving the intervention were less likely than control patients to have serious foot lesions (baseline prevalence, 2.9%; odds ratio, 0.41 [95% CI, 0.16 to 1.00]; P = 0.05) and other dermatologic abnormalities. Also, they were more likely to report appropriate self-foot-care behaviors, to have foot examinations during office visits (68% compared with 28%; P < 0.001), and to receive foot-care education from health care providers (42% compared with 18%; P < 0.001). Physicians assigned to intervention patients were more likely than physicians assigned to control patients to examine patients' feet for ulcers, pulses, and abnormal dermatologic conditions and to refer patients to the podiatry clinic (10.6% compared with 5.0%; P = 0.04).
                An intervention designed to reduce risk factors for lower extremity amputations positively affected patient self-foot-care behavior as well as the foot care given by health care providers and reduced the prevalence of lower extremity clinical disease in patients with diabetes. The incidence of diabetes mellitus, particularly type 2, is increasing in the general population. Similarly, the incidence of patients with diabetes mellitus who develop end-stage renal disease has increased concomitantly in the dialysis facility to 44% of patients starting dialysis therapy with diabetes mellitus as their primary diagnosis. The aim of this study is to determine whether intensive education and care management of diabetes could improve glycemic control, alter patient behavior, and reduce complications in the setting of the dialysis unit.
                Eighty-three patients were allocated to either the control group or study group based on their day of dialysis treatment. All patients were followed up for a year. Patients in the study group underwent a diabetes education program and were followed up by a care manager who provided self-management education, diabetes self-care monitoring/management, motivational coaching, and foot checks.
                The control group baseline foot risk category worsened from 2.7 to 3.3 (P < 0.05), whereas it was unchanged in the study group (2.2 to 2.0). There were no amputations in the study group versus five amputations in the control group (P < 0.05). Ten patients in the control group were hospitalized with diabetes- or vascular-related admissions versus one patient in the study group (P < 0.002). Hemoglobin A(1c) levels declined from 6.9 to 6.3 in the study group, whereas results of the control group were unchanged (P < 0.005). Diabetes-related quality-of-life scores increased in the study group from 76 to 86 (P < 0.001 versus the control group). There was a significant improvement in self-management behavior in all six categories evaluated in the study group versus the control group. Dialysis centers were recognized by the American Diabetes Association to provide diabetes education.
                A program of intensive diabetes education and care management in a dialysis unit is effective in providing significant improvements in patient outcomes, glycemic control, and better quality of life in patients with diabetes mellitus.
                Copyright 2002 by the National Kidney Foundation, Inc. To evaluate a model of integrated diabetic footcare, for identification and clinical management of the high risk diabetic foot, centred on the primary care-based diabetic annual review.
                A pragmatic randomized controlled study was undertaken with matched cluster randomization of practices from 10 towns drawn from mid and east Devon responsible for the care of 1,939 people with diabetes (age > or =18 years). Outcome measures were patients' attitudes regarding the value and importance of footcare, patients' footcare knowledge, healthcare professionals' footcare knowledge and pattern of service utilization.
                Attitudes towards footcare improved in both intervention and control groups (mean percentage change 3.91, 0.68) with a significant difference in change of 3.18 (95% confidence interval (CI) 1.29-5.07) between the groups. Patients' knowledge about diabetic foot problems improved significantly in both groups (mean percentage change 1.09, 1.32) but with no significant difference in change: -0.09 (95% CI -1.81-1.63) between groups. Health professionals' knowledge scores improved in the intervention group (mean percentage change 13.2; P < 0.001). No improvement was seen in the control group (mean percentage change -0.2; P = 0.1) with a significant difference in change of 13.46 (95% CI 8.30-18.62) between groups. Appropriate referrals from intervention practices to the specialized foot clinic rose significantly (P = 0.05) compared with control practices (P = 0.14).
                Provision of integrated care arrangements for the diabetic foot has a positive impact on primary care staffs' knowledge and patients' attitudes resulting in an increased number of appropriate referrals to acute specialist services. To evaluate the influence of podiatrist activities on the outpatient care of diabetic patients in terms of knowledge of diabetic foot care, self-care, and minor foot problems.
                There were 733 patients, aged 10-79 years, identified from the national diabetes register. Patients without recent visits to a podiatrist and without an obvious need for foot care were randomized into a podiatric care group (education and primary prevention measures, n = 267) and a control group (written instructions only, n = 263). The patients were examined by an independent study podiatrist at baseline and after 1 year.
                Patients in the podiatrist group had greater improvement in knowledge of diabetic foot care (P = 0.004) and self-care (P < 0.001) scores compared with control subjects. The prevalence of callosities in regions other than the calcaneal region decreased more (P = 0.009) in the podiatrist group (from 54.5 to 39.5%) than in the control group (from 51.3 to 48.2%), and the size of the callosities decreased more (P < 0.001) in the podiatrist group than in the control group. Reduction in the prevalence of callosities was associated with younger age (< 50 years).
                Education and primary preventive measures provided individually by a podiatrist result in significant improvements in knowledge and foot self-care scores and in improvements in the prevalence of some minor foot problems. Long-term studies are needed to evaluate whether the intervention of podiatrists starting at an early phase would lead to a reduction in major foot problems. An examination of the reproducibility of three tests for identifying patients at risk of diabetic foot complications is reported. One thousand and one patients attending a general diabetic outpatient clinic at the Royal Liverpool University Hospital underwent screening using the Semmes-Weinstein monofilaments, the biothesiometer, and palpation of pedal pulses. Two hundred and fifty-nine patients who were found to have a deficit on at least one of these tests were given a second appointment where the tests were repeated. Two hundred and twenty-nine patients attended for their second appointment. The expected range of variation in readings for the biothesiometer was 5 log hertz, sufficient variation to make the biothesiometer unacceptable as a screening instrument. The range of reproducibility for the four pedal pulses was from 68% to 81%, also an unacceptable level of variation. Over 85% of the results for the Semmes-Weinstein monofilaments were the same on the first and second measurement. Of the three instruments examined in this study, only the Semmes-Weinstein monofilaments have sufficient reproducibility in the clinical setting for them to be recommended for general use as a screening test for risk of diabetic foot complications.