The American Diabetes Association guidelines for management of diabetes include a series of general recommendations for foot care.1 Their first recommendation is that the “feet should be inspected at every visit for patients with evidence of sensory loss or prior ulceration or amputation and comprehensive foot evaluation for others at least annually to identify risk factors for ulcers and amputations.”1
The recommendation is clear, especially to podiatrists, that regardless of the patient’s level of risk, every patient with diabetes should have at least an annual comprehensive foot evaluation. The reality is that this recommendation is easier said than done. While podiatrists have a strong awareness of the importance of a comprehensive diabetic foot examination, including the use of this exam for patients with pre-diabetes, statistics suggest that these exams often fall under the purview of primary care providers (PCPs).2,3 Primary care physicians treat at least 90 percent of the 34.2 million patients with diabetes in the United States and are considered the “gatekeepers” when it comes to referrals to specialists.3
However, there is substantial research documenting the issues of PCPs with respect to diabetes. When it comes to PCPs evaluating and managing the diabetic foot, many patients never receive a foot exam, not even a quick look at their feet. In my experience, the reasons for this vary and usually include: not enough time to do the exam; not enough training to do the exam; and not enough interest to do the exam. I have observed all too often, when a PCP identifies a foot ulcer, the treatment is application of a topical antibiotic like Neosporin and advice to “watch it.” This is a woefully inappropriate response to what could be a life-threatening medical problem.
What The Research Reveals About PCPs And Screening For The Diabetic Foot
In a 2017 article in BMJ Open Diabetes Research & Care, Mehta and colleagues noted a disconnect between PCP perceptions of adherence to screening guidelines and actual practice as well as limited referrals to diabetes prevention/diabetes self-management education programs.4
In 2019, researchers from Johns Hopkins University showed that approximately 25 percent of physicians misdiagnosed people with diabetes as having pre-diabetes.5,6 In addition, Tseng and coworkers found that the average doctor lacked familiarity with the prevention or management of pre-diabetes, and overall under-screened for the condition.5,6 Specifically, the authors noted that PCPs did not know one-third of the risk factors for prediabetes.5,6 Tseng noted “… implications for changing national guidelines and policies regarding type 2 diabetes prevention, including establishing measures of quality for diagnosing and managing pre-diabetes."5
In a previous 2017 publication, Tseng and coworkers surveyed over 1,000 primary care physicians to determine how well they could help patients avoid diabetes.7,8 The researchers found that many of the doctors who responded to the survey were not up-to-date on the latest diabetes risk factors or prevention measures. Their survey results also suggest that 25 percent of these physicians may identify people as having prediabetes when they actually have diabetes, which could lead to delays in getting those patients proper diabetes care and management.7,8
What About Patients With Prediabetes?
It is obvious that this “knowledge gap” affects more than people with diagnosed diabetes. This is disheartening news for the nearly 88 million Americans estimated to have prediabetes. Researchers have demonstrated that the prevalence of diabetic peripheral sensory neuropathy is higher in those with pre-diabetes in comparison to those with normal glucose tolerance and people with recently diagnosed diabetes.9 In 2015, Schieszer noted that prediabetes carries similar risks for peripheral neuropathy and severity of nerve dysfunction as new-onset diabetes.10 Schieszer also pointed out an independent association between pre-diabetes for peripheral neuropathy and severity of nerve dysfunction.10
If providers have difficulty diagnosing diabetes and pre-diabetes, how can we expect them to appropriately evaluate and manage the comorbidities of the conditions?
A Potential PCP Shortage?
These issues may be compounded by recent projections from the Association of American Medical Colleges (AAMC) that the U.S. could see an estimated shortage of between 21,400 and 55,200 primary care physicians by 2033.11 Those figures are part of an overall predicted shortfall of physicians (primary and specialty) ranging between between 54,100 and 139,000 by 2033. This will only complicate patient access to the recommended yearly comprehensive diabetic foot exam from primary care physicians.9
Potential Strategies For Improving ‘Throughput’ For The Diabetic Foot
Is it any wonder that patients with diabetes or pre-diabetes fail to get a legitimate yearly comprehensive diabetic foot exam from their primary care providers? There must be a better way to facilitate the evaluation and management process of the comorbidities of diabetes. Throughput may be part of the solution.
For patients with diabetes, we can define the issue of “throughput” as an inability to obtain proper evaluation and management in a timely fashion to prevent the onset of complications caused by the comorbidities of the condition: foot ulcers, amputations, retinopathy, cardiovascular dysfunction and renal disease.
The objective of addressing throughput as it relates to the diabetic foot is to minimize the amount of time necessary for a patient to be evaluated and facilitate treatments for any pathology noted. In a “best of all possible worlds” scenario, the following would represent the steps appropriate for throughput to be useful as a successful strategy for preventing diabetic foot ulcers and amputations.
Standardization of care. There is currently no standardization of care despite published guidelines. Providers either use templates they find on the web, a “do it yourself” method (what they have learned from reading journals, etc.) or fail entirely to provide any serious care. The lack of addressing and using “best practices” for patient care could improve with implementation of a standardized, evidence-based, universally-accepted comprehensive foot exam. Using internationally accepted, standardized screening and risk stratification methods, providers can help ensure identification of, care for and prevention of recurrence of foot pathology.
This standard foot exam would ideally exist on a computer-based program available via the Internet. The results of the exam should automatically enter into the patient’s electronic medical record. A dashboard displaying the history and exam results for ease of review would also be beneficial.
Screening and risk stratification. Patients should undergo screening and stratification into risk groups such as those developed by the International Working Group on the Diabetic Foot. By using criteria agreed upon by international foot health specialists, one may determine the severity of a patient’s comorbidity related to his or her diabetes by correlating the number and type of identified risk factors evaluated and documented in the presence of, or in advance of, the development of foot pathology.
Use of qualified adjunct medical personnel. The issue of adequate numbers of current providers who can assess and treat patients with diabetes combined with the predictions of a dwindling number of providers in the future is troubling. Another variable complicating the number of provider issues affecting throughput is time constraints, which limit foot exams for patients with diabetes. Limited time constraints cause “competition” between a myriad of medical problems primary care physicians treat.
The solution to the issue of decreasing numbers of providers and time constraints is to use qualified adjunct medical personnel, such as nurse practitioners, nurses or trained medical assistants, to perform the tasks, including the patient history, of administering the foot exam. This would be similar to performing an electrocardiogram (EKG) test. In this scenario, the PCP does not perform the foot exam but evaluation for medical care and consults stem from the results of the exam. The decision-making process (including possible referrals to podiatrists) would remain in the hands of the primary physician or PCP. Developing care management processes that shift the responsibilities of higher-level PCPs to lower-level primary care providers can materially reduce patient length of wait and increase throughput.
Centers of excellence. The last portion of my “best of all possible worlds” scenario for accelerating throughput and preventing foot ulcers, infections and amputations is to establish centers of excellence. These facilities would focus on the task of evaluation and management of the comorbidities of diabetes, thus facilitating throughput. In this scenario, by using 15 minutes for each patient foot exam, each examiner could evaluate 25 patients every day. Estimating 250 working days in a year, each examiner could process 6,250 patient visits each year. Ten examiners could process 62,500 patient visits, many more than might be done at any PCP office.
This scenario is not a dream. Graham Leese, MD, devised and implemented the concept by developing centers of excellence for retinal screening for the National Health Service of Scotland.12
The ultimate benefit of improved throughput will be that the providers will more closely meet the guidelines of the American Diabetes Association. The evaluation and management of the diabetic foot will change from being reactive to proactive. The number of people who present with ulcerated and infected feet would decrease significantly as could the number of ulcers, infections and amputations. This will engender a better quality of life for patients and help reduce the costs of health care.
Dr. Hinkes is President and Chief Medical Officer of ePrevenir, Inc. He is board-certified by the American Board of Foot and Ankle Surgery, and is a Fellow of the American College of Foot and Ankle Surgeons and the American Professional Wound Care Association. Dr. Hinkes is the author of the books “Healthy Feet for People With Diabetes” and “Keep the Legs You Stand On” that are available at www.amazon.com.
1. American Diabetes Association. Microvascular complications and foot care. Diabetes Care. 2017; 40(Suppl 1); S88-S98.
2. Fisher TK, Armstrong DG. Your annual comprehensive foot exam. Diabetes Self-Management. Available at: https://www.diabetesselfmanagement.com/managing-diabetes/complications-prevention/your-annual-comprehensive-foot-exam/ . Published June 16, 2017. Accessed December 14, 2020.
3. Davidson JA. The increasing role of primary care physicians in caring for patients with type 2 diabetes mellitus. Mayo Clin Proc. 2010;85(12 Suppl):S3-S4.
4. Mehta S, Mocarski M, Wisniewski T, Gillespie K, Narayan KMV, Lang K. Primary care physicians’ utilization of type 2 diabetes screening guidelines and referrals to behavioral interventions: a survey-linked retrospective study. BMJ Open Diab Res Care. 2017;5:e000406.
5. Dyson T. Many primary care doctors underscreen, misdiagnose diabetes. UPI. https://www.upi.com/Health_News/2019/09/10/Many-primary-care-doctors-underscreen-misdiagnose-diabetes/1951568133331/ . Published September 10, 2019. Accessed December 14, 2020.
6. Tseng E, Greer C, O’Rourke P, et al. National survey of primary care physicians’ knowledge, practices, and perceptions of prediabetes. J Gen Intern Med. 2019;34(11):2475-2481.
7. PCPS lack knowledge of prediabetes risk. Diabetes in Control. Available at: http://www.diabetesincontrol.com/pcps-lack-knowledge-of-prediabetes-risk/ . Published September 9, 2017. Accessed December 28, 2020.
8. Tseng E, Greer RC, O’Rourke P, et al. Survey of primary care providers’ knowledge of screening for, diagnosing and managing prediabetes. J Gen Intern Med. 2017;32(11):1172-1178.
9. Lee CC, Perkins BA, Kayaniyil S, et al. Peripheral neuropathy and nerve dysfunction in individuals at high risk for type 2 diabetes: the PROMISE cohort. Diabetes Care. 2015;38:793–800.
10. Schieszer J. The growing problem of peripheral neuropathy in prediabetes. Endocrinology Advisor. Available at: https://www.endocrinologyadvisor.com/home/topics/diabetes/the-growing-problem-of-peripheral-neuropathy-in-prediabetes/ . Published July 2, 2015. Accessed December 14, 2020.
11. American Association of Medical Colleges. New report confirms growing shortage of primary care physicians. Primary Care Collaborative. Available at: https://www.pcpcc.org/2020/07/10/new-report-confirms-growing-shortage-primary-care-physicians . Published July 10, 2020. Accessed December 14, 2020.
12. Leese GP, Morris AD, Olson J. A national retinal screening programme for diabetes in Scotland. Diabet Med. 2003;20(12):962-964.