Diabetes is a chronic and debilitating disease that has long-term consequences for those that become insulin-dependent. One of those long-term consequences is the formation of foot ulcers. Foot ulcers can lead to amputation of an insulin-dependent patient's legs and feet. Amputation is a serious and expensive economic burden on anyone that must endure it. To avoid amputation, foot exams performed by a physician may help provide the kind of preventative care that may lead to a reduced risk for amputation in diabetes mellitus patients. Foot ulceration develops as a result of trauma, neuropathy, and deformity (Scott, 2013). Foot exams have various components that allow for effective assessment of any potential problems the patient is facing in regards to foot ulceration and amputation. One such component is history of the patient. Another is assessment of peripheral/neuropathic vascular symptoms, possible renal replacement therapy, and impaired vision. Another part of foot examinations is determining if a patient's tobacco use as this is a major risk factor both neuropathy and vascular disease.

Aside from patient history, foot exams require a general inspection and dermatological assessment. The next step is musculoskeletal assessment that includes assessment of any gross deformity. This is followed by a neurological assessment. The last step is vascular assessment. These steps can be achieved in as little as three minutes (Dorresteijn & Valk, 2012).

While research shows single preventative methods have not provided reduction of occurrence of foot ulceration to a major degree, clinical practice in the form of foot examinations may offer some positive results. The objective of this essay is to determine whether frequent foot examinations versus annual foot examinations minimize the rate of amputations and foot ulcerations. Research from three different articles will offer a look into which way is most effective in minimizing amputation and foot ulceration. The research will also highlight the consequences of performing foot exams frequently versus infrequently in relation to medical expenses.

Integration and Synthesis of the Evidence

Patient education is a big part of prevention. Patients can perform their own foot exams daily without the need of physician intervention and is the main means of reducing potential amputation and foot ulceration complications. "Teaching diabetes patients the principles of self-examination of the feet and foot care has since long been advocated as an essential attribute of prevention strategies and is widely implicated...

101). This is an important part to understand when seeing the effectiveness of physician assisted foot exams frequently versus infrequently. Should the patient receive adequate education on performing their own daily foot exams, the need to employ physician-assisted foot exams would be considered unnecessary.
In a 2013 article, researchers discuss modifying a physical examination sequence model that can be employed to enable improved preventative efforts for patients at risk for amputation and foot ulceration. "The modified sequence should reduce physician time while improving efficiency and effectiveness, utilizing a physical examination sequence model with which the physicians are familiar and can easily adopt and apply in a consistent manner" (Scott, 2013, p. 73). Physicians perform regular physical examinations during an annual physical and modification of the sequence may help with delivering a higher quality of care for those experiencing complications from diabetes mellitus. The researchers also determined variation in regions in accordance with modified efforts. "We used regression models to determine whether previously described regional variation in LEA incidence was associated with responses to the Behavioral Risk Factor Surveillance System. Regions were created using Dartmouth Atlas Health Referral Regions" (Margolis, Hoffstad, & Weibe, 2014, p. 2296).

The researchers assessed other factors as well such as daily foot evaluations and whether these actions led to a decreased occurrence of amputation. "Statistically significant inverse associations were found between LEA and the rate of patients reporting colorectal screening (P < 0.0001) or the participation in diabetes management classes (P = 0.018). Most other factors, including daily foot evaluations, were not associated with a decreased risk of LEA" (Margolis, Hoffstad, & Weibe, 2014, p. 2296). The results demonstrated that daily foot evaluations did not present with a decrease risk of amputation. Meaning there was no major impact in decreasing said risk for amputation for diabetes patients. Patient education and modification of physical examination sequence model does have a positive effect in decreasing risk for amputation. This helps provide further support for patient education being an important preventative measure.

Another study examined insulin-dependent beneficiaries with a history of foot ulcers to assess medical spending as well as whether higher spending reduced mortality or not. "Insulin-dependent beneficiaries with foot ulcers and lower extremity amputations were enrolled in Medicare Parts A and B. during the calendar year 2007. We used ordinary least squares regression to explain geographic variation in per capita Medicare spending, one-year mortality rates" (Sargen, Hoffstad, & Margolis, 2013, p. 128). Medical spending or in the case of the article, Medicare spending, increases with inclusion of foot exams each time a patient attends a medical appointment with a physician. If foot examinations become part of standard clinical practice for insulin-dependent patients, this may increase overall medical spending for patients and insurance companies.

The results of the 2013 study suggest higher medical spending did not promote a major decrease in mortality rates. "However, higher spending was not associated with a statistically significant reduction in one-year patient mortality (P=.12 for DFU, P=.20 for LEA). Macrovascular complications for amputees were more common in parts of the country with higher mortality rates (P