Clinical and radiographic findings that lead to intervention in diabetic patients with foot ulcers. A nationwide survey of primary care physicians.
OBJECTIVE
To determine which elements of clinical history, physical examination, and diagnostic tests are important to primary care physicians in their management of foot ulcers in diabetic patients.


METHODS
We conducted a national mail survey of 600 primary care physicians to determine which patient characteristics and diagnostic test results were important in their decisions to seek radiographic studies, surgical referrals, and hospitalization for diabetic patients with foot ulcers.


RESULTS
The case characteristics most likely to influence physicians to order advanced diagnostic or therapeutic interventions are the presence of osteomyelitis on plain radiographs, the failure of the ulcer to improve with conservative therapy, and the presence of visible bone, crepitus, or necrosis within the ulcer (P < 0.001). Information from the initial clinical history was less likely to influence physicians to order advanced diagnostic or therapeutic interventions (P < 0.001) than was information from the physical examination.


CONCLUSIONS
We conclude that 1) the patient's history is relatively unimportant to primary care physicians in their management of diabetic foot ulcers; 2) the failure of conservative management is a major reason that primary care physicians order surgical referral, hospitalization, or radiographic testing for diabetic patients with foot ulcers; and 3) primary care physicians rely heavily on plain X ray of the foot, a test with poor sensitivity and specificity, in deciding whether to order further interventions for their diabetic patients with foot ulcers.
Edelman
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Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, NC 27705, USA. dedelman@acpub.duke.edu
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Oddone
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D003625:Data Collection; D048909:Diabetes Complications; D003920:Diabetes Mellitus / Q000628:therapy; D017719:Diabetic Foot / Q000175:diagnosis / Q000601:surgery / Q000628:therapy*; D019468:Disease Management; D005194:Family Practice; D006801:Humans; D011859:Radiography; D011795:Surveys and Questionnaires; D014481:United States