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Risk of foot amputation may be double for diabetes patients who don't obtain prescribed footwear and medicines

Patients with diabetes often develop blisters and cuts that do not heal, leading to infection and sometimes an amputation. The American Diabetes Association recommends a yearly foot exam for patients with diabetes to prevent the complications of foot ulcers and amputation, but there is little research to support this recommendation.

Robert G. Nelson, M.D., Ph.D., who was with the National Institute of Diabetes and Digestive and Kidney Disease at the time of this research, and his colleagues undertook a population-based, retrospective case-control evaluation to assess the value of foot exams. The study was supported by the Agency for Healthcare Research and Quality and conducted with the Pima Indians, a group in which the prevalence of diabetes and diabetes-associated amputation is among the highest in the world.

The researchers reviewed the medical records of 61 diabetic patients who had undergone amputation to assess the frequency of foot exams provided during the 3 years prior to the amputation. They also reviewed the medical records for 183 diabetic controls who had not undergone an amputation. Over the 3 years, the 244 diabetic patients received 1,857 foot examinations. Almost one-third of the foot exams were for wound care. The remainder were considered to be preventive and included foot screening, footwear fitting, debridement of callus and nails, and foot care education. After controlling for differences in health status and foot-risk conditions, the risk of amputation for people who received one or more preventive foot exams over the 3 years was 0.55, but the result was not statistically significant.

The researchers also assessed the number of times patients were prescribed foot wear and received the foot wear. The four patients who required molded shoes (a customized shoe required for severe foot deformities) received the footwear, but most of the other types of therapeutic footwear, including depth shoes and inserts, were not available at that time and thus were not obtained by the patients. The researchers suggest that the lack of statistical significance may have been due not only to the small sample size, but also to the lack of footwear availability at the time of the study for people with high-risk foot conditions.

The researchers also noted any record of compliance problems with diabetes care for foot care. Notations in the chart regarding poor compliance were associated with a two-fold increased risk of amputation, but again, the results were not statistically significant. The findings from this study suggest that foot exams may be associated with a decrease in amputation risk. Identification of a foot problem should be followed by appropriate treatments in order to prevent serious complications. The necessary footwear is now available for this patient population.

See "Do foot examinations reduce the risk of diabetic amputation?" by Jennifer Mayfield, M.D., M.P.H., Gayle E. Reiber, M.P.H., Ph.D., Dr. Nelson, and Tom Greene, Ph.D., in the June 2000 Journal of Family Practice 49(6), pp. 499-504.

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