Behaviors predicting foot lesions in patients with non-insulin-dependent diabetes mellitus.

Associations between specific foot-care behaviors and foot lesions in patients with non-insulin-dependent diabetes mellitus were prospectively investigated. Data from a randomized controlled trial for preventing diabetic foot lesions were analyzed as a prospective cohort using logistic regression. Independent variables included foot-care behaviors, patient self-foot examination, going barefoot, availability of foot-care assistance, and visits to health-care providers. The dependent variable was a foot wound on each foot at follow-up. In the final multivariate model, patients who rarely lubricated their feet had an increased risk of foot lesions. Increasing patient use of emollients may be key to preventing foot lesions.

Factorial validation of a widely disseminated educational framework for evaluating clinical teachers.

PURPOSE: To examine an instrument for evaluating clinical teaching using factor analysis and to refine the validated instrument to a practical length. METHOD: Factor analysis on a split sample of 1,581 student evaluations rating 178 teachers. The instrument was based on the seven-category Stanford Faculty Development Program's (SFDP's) clinical teaching framework and contained 58 Likert-scaled items, with at least seven items per category plus five items measuring "teacher's knowledge." Standard methodology for survey item reduction was used to remove items with low or complex factor loadings and iteratively remove items with low item-scale correlation. Results were replicated on the second sample. RESULTS: The seven original categories emerged and items originally categorized under "knowledge" statistically combined with "promoting self-directed learning." Over 73% of the variance was explained. Item reduction resulted in 25 items with overall internal consistency over .97 and internal consistency of constructs ranging from .82 to .95. CONCLUSIONS: Factor analysis of student ratings validated the seven-category SFDP framework. An abbreviated instrument to measure the seven categories is described. Results suggest that students may not systematically distinguish between their teachers' knowledge and their teachers' ability to promote self-directed learning, an important finding for both administrators and faculty development programs.

Beneficial and harmful effects of augmented feedback on physicians' clinical-teaching performances.

PURPOSE: To evaluate whether clinical-teaching skills could be improved by providing teachers with augmented student feedback. METHOD: A randomized, controlled trial in 1994 included 42 attending physicians and 39 residents from the Department of Medicine at the Indiana University School of Medicine who taught 110 students on medicine ward rotations for one-month periods. Before teaching rotations, intervention group teachers received norm-referenced, graphic summaries of their teaching performances as rated by students. At mid-month, intervention group teachers received students' ratings augmented by individualized teaching-effectiveness guidelines based on the Stanford Faculty Development Program framework. Linear models were used to analyze the students' mean ratings of teaching behaviors at mid-month and end-of-month. Independent variables included performance ratings, intervention status, teacher status, teaching experience, and interactions with baseline ratings. RESULTS: Complex interactions with baseline performance were found for most teaching categories at mid-month and end-of-month. The intervention-group teachers who had high baseline performance scores had higher student ratings than did the control group teachers with similar baseline scores; the intervention group teachers who had low baseline performance scores were rated lower than were the control group teachers with comparable baseline scores. The residents who had medium or high baseline scores were rated higher than were the attending physicians with comparable baseline scores; the performance of the residents who had low baseline scores was similar to that of the attending physicians with comparable baseline scores. CONCLUSION: Baseline performance is important for targeting those teachers most likely to benefit from augmented student feedback. Potential deterioration in teaching performance warrants a reconsideration of distributing students' ratings to teachers with low baseline performance scores.

Independent physiological predictors of foot lesions in patients with NIDDM.

OBJECTIVE: To identify and quantify independent physiological risk factors for foot lesions in diabetic patients. RESEARCH DESIGN AND METHODS: There were 352 patients enrolled in a 1-year randomized controlled trial aimed at reducing risks for lower-extremity pathology through patient education and system interventions. Inclusion criteria were as follows: being age 40 years or over, being at or above ideal body weight, and having been diagnosed with NIDDM. Participants were predominantly African-American (76%), elderly (mean 60 years of age), indigent (77% with annual income < +10,000), or women (81%) who had diabetes for 10 years. Prospective multivariate modeling used baseline clinical signs (e.g., blood pressure, dermatological characteristics, and neuropathic measures) and laboratory values (e.g., lipid profiles and measures of glycemic control) to predict foot lesions rated using the Seattle Wound Classification. RESULTS: When controlling for intervention effects, only measures of neuropathy (monofilament testing [odds ratio ¿OR¿ 2.75, 95% CI 1.55-4.88] and thermal sensitivity testing [2.18, 1.13-4.21]) predicted wounds classified 1.2 (minor injury), but investigation of wounds rated at least 1.3 (nonulcerated lesions) indicated baseline wounds (13.41), 3.19-56.26), monofilament abnormalities (5.23, 2.26-12.13), and low HDL (1.63, 1.11-2.39) as predictors. Although fungal dermatitis, dry cracked skin, edema, ingrown nails, microalbuminuria, fasting blood glucose, and hemoglobin A1c were candidates for one or both of the multivariable models (P < 0.3), they were not significant multivariate predictors. CONCLUSIONS: Lesions may be preventable with aggressive screening for peripheral neuropathy and abnormal lipids. Also, these results provide empirical support for the commonly held belief that foot lesions prospectively predict future wounds.

The role of footwear in the prevention of foot lesions in patients with NIDDM. Conventional wisdom or evidence-based practice?

OBJECTIVE: To conduct a prospective evaluation of footwear characteristics as predictors of diabetic foot wounds. RESEARCH DESIGN AND METHODS: A total of 352 patients with NIDDM enrolled in a randomized controlled trial aimed at preventing diabetic foot lesions in an academic general medicine practice were studied. Foot wounds (n = 63) were modeled univariately and multivariably using generalized estimating equations. The dependent variable was a wound classified as a 1.2 or greater according to the Seattle Wound Classification System, indicating at least a superficial or healing minor lesion with no functional interruption of the protective cutaneous barrier. Independent variables included detailed measures of style and material of patients' indoor and outdoor shoes, appropriate length and width, sock fibers, whether the patient had bought new shoes in the past 6 months, and if the patient had been recommended for special shoes. Modeling controlled for intervention status and physiological measures (baseline wound, monofilament abnormalities, and serum HDL level). RESULTS: Initial screening (P < 0.20) suggested that a recommendation for special shoes, shoe length, and shoe width were indicative of wounds at follow-up (odds ratios [ORs] 2.19, 1.84, 1.86, respectively), while having bought shoes in the past 6 months was associated with no wound at follow-up (OR 0.60). The final multivariable model included only the recommendation for special shoes (OR 2.19; 95% CI 1.07-4.49). CONCLUSIONS: Many variables commonly cited as protective measures in footwear for diabetic patients were not prospectively predictive when controlling for physiological risk factors. Rigorous analyses are needed to examine the many assumptions regarding footwear recommendations for diabetic patients.

Physicians' reasons for failing to comply with computerized preventive care guidelines.

The objective of this study was to assess reasons for physicians' noncompliance with computer-generated preventive care reminders. In an academic general internal medicine practice, a survey of physicians' reasons for noncompliance found that 55% of reminders were not complied with. Reasons included "not applicable" in 22.6% (test done elsewhere, patient too ill, no uterus), "next visit" in 22.5% (physician too busy, patient too ill), and "patient refuses" in 9.9% (test not necessary or too costly, patient too busy or fears result). We conclude that although noncompliance with reminders is sometimes appropriate, making time for prevention and patient education may augment preventive care.

Is obesity a barrier to physician screening for cervical cancer?

OBJECTIVE: To determine if obese and morbidly obese women are as likely to receive Papanicolaou (Pap) smears as nonobese women. PATIENTS AND METHODS: A secondary analysis was conducted of data collected during a prospective, controlled trial of computer-generated reminders to improve preventive care. The site was a large, academic general medicine practice providing primary care to an urban population at a university-affiliated municipal teaching hospital. Data were analyzed from 15 faculty and 77 resident physicians who delivered care to 1,321 women who were eligible for Pap smears. Patient data were obtained from a computerized medical record system. RESULTS: Outcomes were physician reports of Pap smear performance and reasons for nonperformance of Pap smears in eligible women. Pap smear performance was 21% for nonobese women, 20% for obese women, and 20% for morbidly obese women (P = NS). After adjusting for age and race, odds ratios for omission of Pap smear were 1.20 for both obese (95% confidence interval [CI] 0.86 to 1.67; P = NS) and morbidly obese women (95% CI, 0.58 to 2.47; P = NS). A significant dose-response relationship was found between increasing patient weight and physician responses that the Pap smear was delayed due to patient's acute illness, vaginitis, or menstruation (odds ratios [OR] 1.73 for obese, OR 4.59 for morbidly obese women; P < 0.005). CONCLUSIONS: In our general medicine practice, obesity does not appear to be associated with less Pap smear performance. Physicians are more likely to report delaying obese patients' Pap smears due to acute illness, vaginitis, or menstruation.

Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus. A randomized, controlled trial.

OBJECTIVE: To evaluate the effect of a patient, health care provider, and systems intervention on the prevalence of risk factors for lower extremity amputation in patients with non-insulin-dependent diabetes. DESIGN: Blinded, randomized, controlled trial. SETTING: Academic general medicine practice. PARTICIPANTS: Of the 395 patients with non-insulin-dependent diabetes who underwent the initial patient assessment, 352 completed the study. INTERVENTION: The 12-month intervention was multifaceted. Patients received foot-care education and entered into a behavioral contract for desired self-foot care, which was reinforced through telephone and postcard reminders. Health care providers were given practice guidelines and informational flow sheets on foot-related risk factors for amputation in diabetic patients. In addition, the folders for intervention patients had special identifiers that prompted health care providers to: 1) ask that patients remove their footwear, 2) perform foot examinations, and 3) provide foot-care education. RESULTS: Patients receiving the intervention were less likely than control patients to have serious foot lesions (baseline prevalence, 2.9%; odds ratio, 0.41 [95% CI, 0.16 to 1.00]; P = 0.05) and other dermatologic abnormalities. Also, they were more likely to report appropriate self-foot-care behaviors, to have foot examinations during office visits (68% compared with 28%; P < 0.001), and to receive foot-care education from health care providers (42% compared with 18%; P < 0.001). Physicians assigned to intervention patients were more likely than physicians assigned to control patients to examine patients' feet for ulcers, pulses, and abnormal dermatologic conditions and to refer patients to the podiatry clinic (10.6% compared with 5.0%; P = 0.04). CONCLUSIONS: An intervention designed to reduce risk factors for lower extremity amputations positively affected patient self-foot-care behavior as well as the foot care given by health care providers and reduced the prevalence of lower extremity clinical disease in patients with diabetes.

Requiring physicians to respond to computerized reminders improves their compliance with preventive care protocols.

OBJECTIVE: To improve compliance with computer-generated reminders to perform fecal occult blood testing (FOBT), mammography, and cervical Papanicolaou (Pap) testing. DESIGN: Six-month prospective, randomized, controlled trial. SETTING: Academic primary care general internal medicine practice. SUBJECTS: Thirty-one general internal medicine faculty, 145 residents, and 5,407 patients with scheduled visits who were eligible for any of the three cancer screening protocols. INTERVENTION: Primary care teams of internal medicine residents and faculty received either routine computer reminders (control) or the same remainders to which they were required to circle one of four responses: 1) "done/order today," 2) "not applicable to this patient," 3) "patient refused," or 4) "next visit." RESULTS: Intervention physicians complied more frequently than control physicians with all remainders combined (46% vs 38%, respectively, p = 0.002) and separately with remainders for FOBT (61% vs 49%, p = 0.0007) and mammography (54% vs 47%, p = 0.036) but not cervical Pap testing (21% vs 18%, p = 0.2). Intervention residents responded significantly more often than control residents to all reminders together and separately to reminders for FOBT and mammography but not Pap testing. There was no significant difference between intervention and control faculty, but the compliance rate for control faculty was significantly higher than the rate for control residents for all reminders together and separately for FOBT but not mammography or Pap testing. The intervention's effect was greatest for patients > or = 70 years old, with significant results for all tests, together and singly, for residents but not faculty. Intervention physicians felt that the reminders were not applicable 21% of the time (due to inadequate data in patient's electronic medical records) and stated that their patients refused 10% of the time. CONCLUSIONS: Requiring physicians to respond to computer-generated reminders improved their compliance with preventive care protocols, especially for elderly patients for whom control physicians' compliance was the lowest. However, 100% compliance with cancer screening remainders will be unattainable due to incomplete data and patient refusal.

Age and sex differences in the human auditory brainstem response.

Age and sex differences in the brainstem auditory evoked response (BAER) were investigated in older (60 to 79 yrs), middle-aged (40 to 59 years), and young (20 to 39 yrs) individuals. Within each age group the number of males (N = 10) and females (N = 10) were divided equally. Scalp potentials were recorded from the vertex to clicks presented at 60, 70, and 80 dB(SL) for stimulus rates of 5, 10, and 15 clicks/sec. Results indicated that older adults had longer latencies at Wave III than either middle-aged or young adults. Age effects were also found for Waves I, II, and IV but were restricted to the lowest intensity and were more evident in older males than females. Significant sex effects showed that the females in each group had shorter Wave IV and V latencies than males. The results suggest that age affects neural propagation at the level of the olivary complex (Wave III) and that BAER latencies are also influenced by the sex of the individual.