Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons.
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We examined charge data for health insurance claims paid in 1992 for persons under age 65 covered by a large California managed care plan. Charge and utilization comparisons between podiatrists and orthopedic surgeons were made for all foot care and for two specific foot problems, acquired toe deformities and bunions. Podiatrists provided over 59% of foot care services for this commercial population of 576,000 people. Podiatrists charged 12% less per individual service than orthopedists. However, podiatrists performed substantially more procedures per episode of care and treated patients for longer time periods, resulting in 43% higher total charges per episode. Hospitalization was infrequent for all providers, although podiatrists had the lowest rates. In a managed care setting in which all providers must adhere to a preestablished fee schedule, regardless of specialty, the higher utilization by podiatrists should lead to higher overall costs. In some cases, strong utilization controls could offset this effect. We do not know if the utilization difference is due to actual treatment or billing differences. Further, we were unable to determine from the claims data if one specialty had better outcomes than the other. (+info)
Amputation prevention by vascular surgery and podiatry collaboration in high-risk diabetic and nondiabetic patients. The Operation Desert Foot experience.
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OBJECTIVE: To describe a unique multidisciplinary outpatient intervention for patients at high risk for lower-extremity amputation. RESEARCH DESIGN AND METHODS: Patients with foot ulcers and considered to be high risk for lower-extremity amputation were referred to the High Risk Foot Clinic of Operation Desert Foot at the Carl T. Hayden Veterans Affairs' Medical Center in Phoenix, Arizona, where patients received simultaneous vascular surgery and podiatric triage and treatment. Some 124 patients, consisting of 90 diabetic patients and 34 nondiabetic patients, were initially seen between 1 October 1991 and 30 September 1992 and followed for subsequent rate of lower-extremity amputation. RESULTS: In a mean follow-up period of 55 months (range 3-77), only 18 of 124 patients (15%) required amputation at the level of the thigh or leg. Of the 18 amputees, 17 (94%) had type 2 diabetes. The rate of avoiding limb loss was 86.5% after 3 years and 83% after 5 years or more. Furthermore, of the 15 amputees surviving longer than 2 months, only one (7%) had to undergo amputation of the contralateral limb over the following 12-65 months (mean 35 months). Compared with nondiabetic patients, patients with diabetes had a 7.68 odds ratio for amputation (95% CI 5.63-9.74) (P < 0.01). CONCLUSIONS: A specialized clinic for prevention of lower-extremity amputation is described. Initial and contralateral amputation rates appear to be far lower in this population than in previously published reports for similar populations. Relative to patients without diabetes, patients with diabetes were more than seven times as likely to have a lower-extremity amputation. These data suggest that aggressive collaboration of vascular surgery and podiatry can be effective in preventing lower-extremity amputation in the high-risk population. (+info)
Benefits of a multidisciplinary approach in the management of recurrent diabetic foot ulceration in Lithuania: a prospective study.
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OBJECTIVE: To assess the ability of a multidisciplinary approach to diabetic foot care to reduce the incidence of recurrent ulceration and amputations compared with standard care in a 2-year prospective study. RESEARCH DESIGN AND METHODS: A total of 145 patients with a past history of neuropathic foot ulcers but no evidence of peripheral vascular disease entered the study. Subjects were screened for their neuropathic and vascular status at baseline, and all received identical foot care education. The intervention group (n = 56) was followed by the multidisciplinary team of physicians, nurses, and podiatrists with regular podiatry and reeducation every 3 months and the provision of specialty footwear as required. The standard treatment group was followed in local clinics on a trimonthly basis and received identical screening and education at baseline. RESULTS: There were no significant differences at baseline in age (intervention 59.2+/-13.4, standard treatment 58.5+/-11.5 years), duration of diabetes (14.0+/-7.1 vs. 15.6+/-7.8 years), or neuropathic status (vibration perception threshold [VPT]: 31.1+/-12.1 vs. 33.9+/-11.3 V, neuropathy disability score [NDS]: 8.1+/-1.4 vs. 7.9+/-1.7). All patients had an ankle brachial pressure index (ABPI) of >0.9 and at least one palpable foot pulse. Significantly fewer recurrent ulcers were seen in the intervention group than in the standard treatment group during the 2-year period (30.4 vs. 58.4%, P < 0.001). CONCLUSIONS: This prospective study has demonstrated the effectiveness of a multidisciplinary approach to diabetic foot care together with the provision of specialty footwear in the long-term management of high-risk patients with a history of neuropathic foot ulcers. (+info)
Foot screening technique in a diabetic population.
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Foot complications are a well known factor which contribute to the morbidity of diabetes and increases the chance of amputation. A total of 126 consecutive diabetic patients were evaluated by diabetic foot screening. Forty-one patients showed an impaired protective sense when tested with Semmes-Weinstein monofilament 5.07 (10 g), and 92% of them showed peripheral polyneuropathy in nerve conduction study (NCS). The mean vibration score of the Rydel-Seiffer graduated tuning fork in patients with peripheral polyneuropathy in nerve conduction (NCV) study was 5.38+/-2.0, which was significantly different from that of patients without polyneuropathy in NCS. Among the deformities identified on examination, callus, corn, and hallux valgus were the greatest. While checking the ankle/ brachial index (ABI), we also evaluated the integrity of vasculature in the lower extremities. After extensive evaluation, we classified the patients into eight groups (category 0,1,2,3,4A,4B,5,6). The result of this study suggested that the Semmes-Weinstein monofilament test, Rydel-Seiffer graduated tuning fork test, and checking the ankle/brachial index were simple techniques for evaluating pathologic change in the diabetic foot by office screening, and that this screening based on treatment-oriented classification helps to reduce pedal complications in a diabetic population. (+info)
Diabetes services in the UK: third national survey confirms continuing deficiencies.
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AIMS: To determine the current level of diabetes services and to compare the results with previous national surveys. METHODS: A questionnaire was mailed to all paediatricians in the UK identified as providing care for children with diabetes aged under 16 years. Information was sought on staffing, personnel, clinic size, facilities, and patterns of care. Responses were compared with results of two previous national surveys. RESULTS: Replies were received from 244 consultant paediatricians caring for an estimated 17 192 children. A further 2234 children were identified as being cared for by other consultants who did not contribute to the survey. Of 244 consultants, 78% expressed a special interest in diabetes and 91% saw children in a designated diabetic clinic. In 93% of the clinics there was a specialist nurse (44% were not trained to care for children; 47% had nurse:patient ratio >1:100), 65% a paediatric dietitian, and in 25% some form of specialist psychology or counselling available. Glycated haemoglobin was measured routinely at clinics in 88%, retinopathy screening was performed in 87%, and microalbuminuria measured in 66%. Only 34% consultants used a computer database. There were significant differences between the services provided by paediatricians expressing a special interest in diabetes compared with "non-specialists", the latter describing less frequent clinic attendance of dietitians or psychologists, less usage of glycated haemoglobin measurements, and less screening for vascular complications. Non-specialist clinics met significantly fewer of the recommendations of good practice described by Diabetes UK. CONCLUSIONS: The survey shows improvements in services provided for children with diabetes, but serious deficiencies remain. There is a shortage of diabetes specialist nurses trained to care for children and paediatric dietitians, and a major shortfall in the provision of psychology/counselling services. The services described confirm the need for more consultant paediatricians to receive specialist training and to develop expertise and experience in childhood diabetes. (+info)
Chiropody may prevent amputations in diabetic patients on peritoneal dialysis.
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BACKGROUND: A multidisciplinary approach has been shown to be of benefit in the prevention of lower limb ulceration and amputation in patients with diabetes, but there is less information on the role of such an approach in patients receiving dialysis treatment. OBJECTIVE: The purpose of the present study was to determine whether the institution of a chiropody program would result in fewer amputations in diabetic patients on peritoneal dialysis (PD). DESIGN: Retrospective chart review. SETTING: The PD program at a tertiary-care hospital. PATIENTS: Patients with diabetes that were enrolled in the PD program between January 1997 and December 1999, inclusive, that were offered the opportunity to see a chiropodist, and that agreed to be seen. A total of 132 patients were included. INTERVENTION: Education about foot care, assessment, and, in some instances, treatment by a chiropodist. RESULTS: Patients with an amputation were more likely to be male (p < 0.01) and have peripheral vascular disease (p < 0.001) compared to those without an amputation. They also had a lower average mean arterial pressure (p < 0.05), lower weekly creatinine clearance (p < 0.01), higher mean erythropoietin dose (p < 0.05), and longer duration of end-stage renal disease (p < 0.001). Factors that were predictive of shorter time to death or amputation were older age [hazard ratio (HR) = 1.03, p < 0.05], peripheral vascular disease (HR = 2.66, p< 0.01), and cerebrovascular disease (HR = 2.70, p< 0.01). Being seen by a chiropodist was protective (HR = 0.39, p < 0.01). CONCLUSION: The current study suggests that a chiropody program may help to prevent amputation in patients with diabetes on PD. (+info)
A multi-interface adaptive hypermedia system to promote consumer-provider partnership in chronic disease management.
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Much of chronic disease management depends on active partnership of consumer and provider. Our system promotes diabetes management through profiling and adaptive support of both consumer and provider. We use a University Podiatry Clinic and diabetes consumer information portal as inter-related contexts that share profile information. (+info)
A team approach to musculo-skeletal disorders.
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INTRODUCTION: The majority of patients with musculo-skeletal problems referred to hospitals in the UK have to wait for months, if not over a year, before finally seeing an orthopaedic surgeon. In Stobhill Hospital, Glasgow, the waiting time for an out-patient appointment was 182 days in 1995, with only 20% of the referrals requiring surgery. The aim of this paper was to reduce the out-patient waiting times based on a co-ordinated team approach. METHODS: An outpatient musculo-skeletal service was developed over a 7-year period at Stobhill Hospital. The traditional consultant-based model, in which the consultant and a trainee saw all new patients referred to the hospital, was gradually replaced with a team approach, based on continuous reconfiguration of the roles of the orthopaedic surgeon and rheumatologist and extending the roles of nurses, physiotherapists and podiatrists. This was achieved by: (i) protocol-based daily triage for all referrals to the most appropriate health professional in the team, by the senior out-patient nursing staff; (ii) allocation of appointments based on clinical priority, with a fast-track for urgent cases; and (iii) improvement of inter-disciplinary communication, facilitating the retraction as well as the extension of traditional roles. RESULTS: Despite the number of GP referrals to the orthopaedic out-patient department at Stobhill nearly doubling in a period of 5 years, the out-patient waiting time decreased by about 50% (90 days from 182 days). This reduction in waiting times improved patient and GP satisfaction levels. We also noticed an improved morale and personal development of the health professionals as they saw patients appropriate to their skills and expertise. CONCLUSION: The team's experience demonstrates the effectiveness of a team approach in tackling what is often seen as the insoluble problem of orthopaedic waiting times. This is based on excellent communication and collaboration, with a clear aim of improving patient care that is evidence based. (+info)