Clinical and radiology findings that lead to intervention in diabetic patients with a foot ulcer: A nationwide survey of primary care physicians
We conducted a national mail survey of 600 primary care physicians to determine which elements of the clinical history and physical examination, and which diagnostic tests, influence their decisions to order radiology studies, surgical referral, and hospitalization for diabetic patients with a foot ulcer. Respondents graded the importance of items in the clinical history, physical exam findings, and laboratory data along a five-point Likert scale. We used ridit analysis as a non-parametric approach to compare the relative importance of diagnostic elements. The response rate among eligible physicians was 36%. The historical and physical examination 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 than information from the physical examination to influence physicians to order these advanced diagnostic or therapeutic interventions (p<0.001). We conclude that: 1) the initial history is relatively unimportant to primary care physicians in their management of the diabetic foot ulcer, 2) failure of conservative management is a major reason that primary care physicians seek referral, hospitalization, or radiology testing for patients with a diabetic foot ulcer, and 3) primary care physicians rely heavily on the plain x-ray of the foot, a test with poor sensitivity and specificity, in determining whether to order further radiology testing, referral, or hospitalization for their diabetic patients with a foot ulcer.
Edelman, D; Matchar, DB; Oddone, EZ
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