Mayfield and coworkers provide important additional evidence supporting the inclusion of foot examinations as a routine part of the evaluation of patients with diabetes. The article by itself does not prove that these examinations are useful. Even with the whole weight of evidence in the literature, this is still a contentious issue. However, the study by Mayfield and colleagues lends additional support to this practice.
There are several limitations to their study, however. The study used a highly select population. As the authors note, the Gila River Indian community has one of the world’s highest reported rates of diabetes and amputations. It may be that diabetes in this population is a fundamentally different disease, and that amputations are more likely and foot examinations are less effective than in the general population. If this were the case, the findings of this study grossly underestimate the true impact of foot examinations. Or it may be that in this population foot examinations are more likely to be beneficial than in another population. If that were the case, the study grossly overestimates the impact of foot examinations for reducing amputation risk.
Each year our government spends billions of dollars on research, but some basic clinical questions remain unanswered. Should we adopt foot screening as a standard in diabetes care? If not, is there a subset of patients that would benefit from screening? If we do screen, how often should it be done? Each visit? Annually? Even simple questions like "What constitutes a quality foot examination?" go unanswered.
The answers may not be determined soon, but family physicians can play a key role in finding them. Our practice-based research networks contain a large number of patients with diabetes, and carefully designed studies can assess either retrospective or even prospective evaluations of diabetes care. Diabetes care is a major challenge, and family physicians provide the bulk of this care to patients. Perhaps we will also provide the answers to some of the key questions about quality care for this disease.
Acknowledgments
Dr Ganiats is a recipient of the American Academy of Family Physicians Advanced Research Training Grant.