Are Type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics Giorgia De Berardis a , Fabio Pellegrini a , Monica Franciosi a , Maurizio Belfiglio a , Barbara Di Nardo a , Sheldon Greenfield b , Sherrie H. Kaplan b , Maria C.E. Rossi a , Michele Sacco a , Gianni Tognoni a , Miriam Valentini a , Antonio Nicolucci a, T The QuED Study Group-Quality of Care and Outcomes in Type 2 Diabetes 1 a Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, S. Maria Imbaro, CH, Italy b Center for Health Policy Research, University of California Irvine, Irvine, CA, USA Received 13 February 2004; received in revised form 24 January 2005; accepted 15 February 2005 Abstract In the context of a nationwide outcomes research program on Type 2 diabetes, we investigated physician and patient practices related to foot care. Patients filled in a questionnaire investigating whether they had received information about foot care, how often they had had their feet examined in the last year, and how often they usually checked their feet. Analyses were adjusted for patient case-mix and physician-level clustering. Overall, 3564 patients were recruited by 125 diabetes outpatient clinics (DOCs) and 103 general practitioners (GPs), of whom 6.8% suffered form lower limb complications. The presence of foot complications was correlated with insulin treatment, cigarette smoking, low levels of school education, and the presence of other diabetic complications. More than 50% of the patients reported that they had not had their feet examined by their physician and 28% referred that they had not received foot education. Patients with lower levels of school education and income, as well as overweight individuals, were less likely to receive foot education. Physicians tended to perform foot examination more often in males, low-income patients, those with foot complications, and those treated with insulin, but not in patients with the highest risk of foot complications, that is, those with diabetic neuropathy or peripheral vascular disease (PVD). GPs tended to perform foot examination less frequently than diabetologists do. Foot self-examination was not performed by 33% of the patients. Those individuals who had received foot education or had had their feet examined were more likely to check their feet regularly. A substantial proportion of Type 2 diabetic patients is not offered adequate foot care, even in the presence of major risk factors for lower limb complications. Patient knowledge and practices are strongly related to physicians’ attitudes. D 2005 Elsevier Inc. All rights reserved. Keywords: Type 2 diabetes; Foot care; Physician attitudes; Questionnaire; Patients practices 1. Introduction Lower limb complications in diabetes are a frequent and seriously disabling condition, affecting both quality of life and health care utilization (Bild et al., 1989; Humphrey, Dowse, Thoma, & Zimmet, 1996; Lehto, Ronnemaa, Pyorala, & Laakso, 1996; Moss, Klein, & Klein, 1996; Ragnarson Tennvall & Apelqvist, 2000). Diabetes is the leading cause of lower limb amputation, generally preceded by foot ulcers and gangrene. Foot ulceration may occur in up to 15% of diabetic patients during their lifetime and 1056-8727/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jdiacomp.2005.02.005 T Corresponding author. Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Via Nazionale, 66030 S. Maria Imbaro (CH), Italy. Tel.: +39 0872 570260; fax: +39 0872 570263. E-mail address: nicolucci@negrisud.it (A. Nicolucci). 1 The QuED Study Group-Quality of Care and Outcomes in Type 2 Diabetes is composed of the Writing committee and Coordinating center (Authors); the Scientific Committee: Vittorio Caimi MD, Fabio Capani MD, Andrea Corsi MD, Roberto Della Vedova MD, Massimo Massi Benedetti MD, Antonio Nicolucci MD, Claudio Taboga MD, Massimo Tombesi MD, Giacomo Vespasiani MD; and Investigators (Appendix A). Journal of Diabetes and Its Complications 19 (2005) 319 – 327