The health status of diabetic patients receiving orthotic therapy

Race and Insurance Status Association With Receiving Orthopedic Surgeon-Prescribed Foot Orthoses

BACKGROUND

This study looked at the effect of patient demographics, insurance status, education, and patient opinion on whether various orthotic footwear prescribed for a variety of diagnoses were received by the patient. The study also assessed the effect of the orthoses on relief of symptoms.

METHODS

Chart review documented patient demographics, diagnoses, and medical comorbidities. Eligible patients completed a survey either while in the clinic or by phone after their clinic visit.

RESULTS

Of the 382 patients prescribed orthoses, 235 (61.5%) received their orthoses; 186 (48.7%) filled out the survey. Race and whether or not the patient received the orthosis were found to be significant predictors of survey completion. Race, type of insurance, and amount of orthotic cost covered by insurance were significant predictors of whether or not patients received their prescribed orthoses. Type of orthosis, diabetes as a comorbidity, education, income, sex, and diagnosis were not significant predictors of whether the patient received the orthosis. Qualitative results from the survey revealed that among those receiving their orthoses, 87% experienced improvement in symptoms: 21% felt completely relieved, 66% felt better, 10% felt no different, and 3% felt worse.

CONCLUSION

We found that white patients had almost 3 times the odds of receiving prescribed orthoses as black patients, even after controlling for type of insurance, suggesting race to be the primary driver of discrepancies, raising the question of what can be done to address these inequalities. While large, systematic change will be necessary, some strategies can be employed by those working directly in patient care, such as informing primary care practices of their ability to see patients with limited insurance, limiting blanket refusal policies for government insurance, and educating office staff on how to efficiently work with Medicare and Medicaid.

LEVEL OF EVIDENCE

Level III, comparative study.

Patient Reported Outcome Measures for Major Lower Limb Amputation Caused by Peripheral Artery Disease or Diabetes: A Systematic Review

OBJECTIVE

Most major lower limb amputations are related to peripheral artery disease (PAD) or diabetes. Just 40% of patients who undergo major lower limb amputation will use a prosthesis yet measures of surgical success commonly focus on prosthesis use. Patient reported outcome measures (PROMs) are valuable to comprehensively evaluate health related quality of life (HRQL) after surgery. This systematic review aimed to identify and describe PROMs available to assess HRQL in patients after amputation for PAD or diabetes.

METHODS

A search was conducted based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) for systematic reviews of PROMs. Ovid MEDLINE, Ovid EMBASE, PsycINFO, CINAHL, and Cochrane CENTRAL were also searched from inception until August 2019. Included were articles describing the development, measurement properties, or evaluation of HRQL via a PROM in adult patients after amputation for PAD or diabetes. Studies of amputation exclusively for trauma or malignancy were excluded. Data were collected on study characteristics, PROM characteristics (generic/disease specific), and properties of amputation specific PROMs.

RESULTS

Of 3 317 abstracts screened, 111 full text articles were assessed for eligibility and 64 included. Fifty-six studies evaluated HRQL, with 23 (46%) of these using an amputation specific PROM to do so. Eleven different amputation specific PROMs were identified, 10 (91%) of which were developed only for prosthesis users. One measure was suitable for use in all patients after amputation. This "Amputee single item mobility measure" includes a single item evaluating mobility. Nine studies reported some psychometric testing of an amputation specific PROM.

CONCLUSION

A well tested, multidimensional PROM applicable to wheelchair and prosthetic users after amputation is lacking and urgently needed for studies in this field. Future work to develop an appropriate measure is required.

Economic value of orthotic and prosthetic services among medicare beneficiaries: a claims-based retrospective cohort study, 2011-2014

Background

There are few studies of the economic value of orthotic and prosthetic services. A prior cohort study of orthotic and prosthetic Medicare beneficiaries based on Medicare Parts A and B claims from 2007 to 2010 concluded that patients who received timely orthotic or prosthetic care had comparable or lower total health care costs than a comparison group of untreated patients. This follow-up study reports on a parallel analysis based on Medicare claims from 2011 to 2014 and includes Part D in addition to Parts A and B services and expenditures. Its purpose is to validate earlier findings on the extent to which Medicare patients who received select orthotic and prosthetic services had less health care utilization, lower Medicare payments, and potentially fewer negative outcomes compared to matched patients not receiving these services.

Methods

This is a retrospective cohort analysis of 78,707 matched pairs of Medicare beneficiaries with clinical need for orthotic and prosthetic services (N = 157,414) using 2011–2014 Medicare claims data. It uses propensity score matching techniques to control for observable selection bias. Economically, a cost-consequence evaluation over a four-year time horizon was performed.

Results

Patients who received lower extremity orthotics had 18-month episode costs that were $1939 lower than comparable patients who did not receive orthotic treatment ($22,734 vs $24,673). Patients who received spinal orthotic treatment had 18-month episode costs that were $2094 lower than comparable non-treated patients ($23,560 vs $25,655). Study group beneficiaries receiving both types of orthotics had significantly lower Part D spending than those not receiving treatment (p < 0.05). Patients who received lower extremity prostheses had comparable 15-month episode payments to matched beneficiaries not receiving prostheses ($68,877 vs $68,893) despite the relatively high cost of the prosthesis.

Conclusions

These results were consistent with those found in the prior study and suggest that orthotic and prosthetic services provide value to the Medicare program and to the patient.

Measures of health-related quality of life in diabetes-related foot disease: a systematic review

AIMS/HYPOTHESIS

Patient-reported outcome measures (PROMs) are increasingly used as key performance indicators in chronic illness. We sought to review the value of these tools in assessing health-related quality of life (HRQOL) in patients with diabetes-related foot disease and identify the impact of each foot problem on life quality.

METHODS

A systematic review of literature on HRQOL PROMs in diabetes-related foot disease was performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The quality of eligible studies was evaluated within pre-existing criteria.

RESULTS

53 studies written between 1995 and 2010 met the inclusion criteria. A variety of HRQOL PROMs were used. Disease-specific tools were better than generic at quantifying temporal changes in life quality and showed greater sensitivity to ulcer/neuropathic severity. No studies have simultaneously evaluated disease-specific tools. Generic and utility HRQOL PROMs are frequently used as secondary outcome measures in randomised trials and cost-utility analysis. HRQOL is depressed in diabetes, further impaired by the presence of foot disease. Ulcer healing is associated with improvements in HRQOL. Patients with active ulceration report poorer HRQOL than those whom have undergone successful minor lower extremity amputation (LEA) but there is a paucity of quality data on HRQOL outcomes for diabetes-related LEA.

CONCLUSIONS/INTERPRETATION

No one PROM was identified as a 'gold standard' for assessing HRQOL in diabetes-related foot disease. Specific areas for further development include the most valid HRQOL PROM with disease-specific content; HRQOL outcomes in minor and major amputations and the role of HRQOL tools in routine clinical care.

Arch support use for improving balance and reducing pain in older adults

PURPOSE

The purpose of this study was to examine the effects of arch supports on balance, functional mobility, and pain in the back and lower extremity joints among older adults.

DESIGN

A single-factor within-subjects design was used.

METHOD

A convenience sample of older adults formed a single group for fitting with arch supports. Balance, functional mobility, and self-reported pain in the back and lower extremities were measured without the arch supports, immediately after the insertion of the supports in the subjects' shoes, and after 6 weeks of arch support use.

FINDINGS

Sixty-seven older adults completed the study. The measures used indicated statistically significant improvements in scores for the Berg Balance Scale [Berg, K., Williams-Dauphinee, S., & Williams, J. I., (1995). The Balance Scale: Reliability assessment for elderly residents and patients with an acute stroke. Scandinavian Journal of Rehabilitation Medicine, 27, 27-31] and functional mobility [Timed Up and Go test; Podsiadlo, D., & Richardson, S. (1991). The Timed "Up and Go": A test of basic functional mobility for frail elderly persons. Journal of the American Geriatrics Society, 39, 142-148] as well as reduced back, foot, knee, and hip pain (p < .05). There was no statistically significant change in ankle pain (p > .05).

IMPLICATIONS

Knowledge of interventions that enhance health and well-being is essential for nurses. Arch supports may provide improved balance and functional mobility while reducing back and lower extremity joint pains. Further research is needed to support evidence-based practice.

The effectiveness of footwear and offloading interventions to prevent and heal foot ulcers and reduce plantar pressure in diabetes: a systematic review

BACKGROUND

Footwear and offloading techniques are commonly used in clinical practice for the prevention and treatment of foot ulcers in diabetes, but the evidence base to support this use is not well known. The goal of this review was to systematically assess the literature and to determine the available evidence on the use of footwear and offloading interventions for ulcer prevention, ulcer treatment, and plantar pressure reduction in the diabetic foot.

METHODS

A search was made for reports on the effectiveness of footwear and offloading interventions in preventing or healing foot ulcers or reducing plantar foot pressure in diabetic patients published prior to May 2006. Both controlled and uncontrolled studies were included. Assessment of the methodological quality of studies and data extraction was independently performed by two reviewers. Interventions were assigned into four subcategories: casting, footwear, surgical offloading and other offloading techniques.

RESULTS

Of 1651 articles identified in the baseline search, 21 controlled studies were selected for grading following full text review. Another 108 uncontrolled and cross-sectional studies were examined. The evidence to support the use of footwear and surgical interventions for the prevention of ulceration is meagre. Evidence was found to support the use of total contact casts and other non-removable modalities for treatment of neuropathic plantar ulcers. More studies are needed to support the use of surgical offloading techniques for ulcer healing. Plantar pressure reduction can be achieved by several modalities including casts, walkers, and therapeutic footwear, but the diversity in methods and materials used limits the comparison of study results.

CONCLUSIONS

This systematic review provides support for the use of non-removable devices for healing plantar foot ulcers. Furthermore, more high-quality studies are urgently needed to confirm the promising effects found in both controlled and uncontrolled studies of footwear and offloading interventions designed to prevent ulcers, heal ulcers, or reduce plantar pressure.

The Effects of Interventions on Health-Related Quality of Life Among Persons With Diabetes

BACKGROUND

Health-related quality of life (HRQL) is increasingly used to measure the outcomes of interventions among people with chronic diseases.

OBJECTIVES

To assess the effect of interventions for adults with diabetes on HRQL, as measured by the Short Form (SF)-36 questionnaire.

RESEARCH DESIGN

The systematic review was conducted using the methods of the Cochrane Collaboration. Studies reporting SF-36 scores before and after an intervention focused on adults with diabetes were obtained from searches of multiple bibliographic databases. The mean changes and standardized mean differences between pre- and post-intervention were reported as outcome measures. Pooled estimates were obtained using random effects models.

RESULTS

: We identified 33 studies examining a wide range of interventions, including diabetes education and behavioral modifications (15 studies), pharmacotherapy (11 studies), and surgery (7 studies). Interventions generally demonstrated improvement in HRQL. When all available profile scores were examined together, the ranges of mean changes in scores were as follows: surgery for treating diabetes comorbidities, 15.0 to 42.0 point improvement; surgery for treating diabetes complications, -13.0 to 37.9; pharmacotherapy using insulin to optimize glycemic control, -4.6 to 27.6; pharmacotherapy for treating comorbidities, 3.8 to 33.2; pharmacotherapy for treating complications, -2.6 to 14.6. Pooled effects from 5 randomized controlled trials of educational interventions demonstrated significantly improved physical function [3.4 (95% CI, 0.1-6.6)] and mental health [4.2 (95% CI, 1.8-6.6)], and a decrease in bodily pain [3.6 (95% CI, 0.6-6.7)].

CONCLUSIONS

A variety of interventions can improve HRQL among adults with diabetes, but the magnitude of effects varied with the interventions. The mechanism of these changes needs to be further examined in the future research.

Patient and professional perspectives on prescribed therapeutic footwear for people with diabetes: a vignette study

OBJECTIVE

This article draws on a qualitative study to identify and discuss patient and health professional views of the use of therapeutic footwear for people with diabetes-related foot complications.

METHODS

Semi-structured interviews were conducted with 15 patients and 15 health professionals using a 'vignette' technique. The interviews were audio-taped, and framework analysis was used to identify main themes and categories.

RESULTS

The prescription of therapeutic footwear was an important issue for patients, and health professionals were aware of this. The main issues were the differing perspectives between patients and professionals in terms of the expectations and reality of preventive behaviour, and difficulties in fitting shoes when feet are constantly changing shape.

CONCLUSIONS

Patients often have difficulty changing their shoe-wearing behaviour in line with guidelines, particularly within the limits of available therapeutic shoes. The choice of available shoes may not meet the varied and specific needs of patients. Patient perspectives therefore need to be taken into account in shoe provision.

PRACTICE IMPLICATIONS

The concept of concordance would appear to be useful in allowing patient needs to be identified before designing and prescribing therapeutic shoes. More choice in styles, and involving patients in footwear design and selection, might encourage the use of appropriate footwear.

Effective orthotic therapy for the painful cavus foot: a randomized controlled trial

Patients with a cavus or high-arched foot frequently experience foot pain, which can lead to significant limitation in function. Custom foot orthoses are widely prescribed to treat cavus foot pain. However, no clear guidelines for their construction exist, and there is limited evidence of their efficacy. In a randomized, single-blind, sham-controlled trial, the effect of custom foot orthoses on foot pain, function, quality of life, and plantar pressure loading in people with a cavus foot type was investigated. One hundred fifty-four participants with chronic musculoskeletal foot pain and bilateral cavus feet were randomly assigned to a treatment group receiving custom foot orthoses (n = 75) or to a control group receiving simple sham insoles (n = 79). At 3 months, 99% of the participants provided follow-up data using the Foot Health Status Questionnaire. Foot pain scores improved more with custom foot orthoses than with the control (difference, 8.3 points; 95% confidence interval [CI], 1.2 to 15.3 points; P = .022). Function scores also improved more with custom foot orthoses than with the control (difference, 9.5 points; 95% CI, 2.9 to 16.1 points; P = .005). Quality-of-life data favored custom foot orthoses, although differences reached statistical significance only for physical functioning (difference, 7.0 points; 95% CI, 1.9 to 12.1 points; P = .008). Plantar pressure improved considerably more with custom foot orthoses than with the control for all regions of the foot (difference, -3.0 N . s/cm(2); 95% CI, -3.7 to -2.4 N . s/cm(2); P < .001). In conclusion, custom foot orthoses are more effective than a control for the treatment of cavus foot pain and its associated limitation in function.

'Loss of self': a psychosocial study of the quality of life of adults with diabetic foot ulceration

At present, recognition of the importance of psychosocial factors in the care of individuals with diabetes is still in its infancy. Understanding of the specific psychosocial factors relating to diabetic foot ulceration is embryonic. The study reported in this paper begins to raise awareness of psychosocial quality of life issues for patients living with diabetic foot ulceration, as narrated by the patients themselves. Findings revealed a range of restrictions on daily life that profoundly affected the individual's sense of self. These findings have implications for patients' adherence to treatment. Implications of these findings for health promotion are also reported.

Emotional and quality-of-life aspects of diabetes management

Patients with diabetes commonly feel overwhelmed, frustrated, or "burned out" by the daily hassles of disease management and by the unending, often burdensome self-care demands. Many report feeling angry, guilty, or frightened about the disease, and often are unmotivated to complete diabetes self-care tasks. The toll of short- and long-term complications can make the disease even more burdensome. Not surprisingly, it is a consistent finding across studies that diabetes is associated with impaired health-related quality of life (HRQOL), measured in a variety of different ways. Importantly, the relationship between HRQOL and diabetes appears to be bidirectional. Both medical and psychosocial aspects of diabetes may negatively affect HRQOL; in turn, impaired HRQOL may negatively influence diabetes self-management. Unfortunately, the concept of HRQOL in diabetes remains unclear, making precise evaluation and intervention difficult. There is growing agreement that the focus of HRQOL assessment should be on the subjective burden of symptoms, not merely on the presence of objectively identifiable problems. Proper evaluation should include both generic and diabetes-specific elements of HRQOL. In this article, a comprehensive multidimensional model of HRQOL in diabetes involving six major components is introduced and described. Representative self-report questionnaires that may be valuable in assessing these components are also presented. Once the patient's most important HRQOL issues have been identified and prioritized, appropriate intervention becomes possible. The good news is that there are now a growing number of research-based interventions available for addressing almost all of the HRQOL impairments that may occur.