Assessing the feet of patients with diabetes.

Diabetic foot complications are common and often result in recurrent morbid events. Several studies have indicated that prevention practices are effective in preventing the development of foot ulcers and amputations. The first step in a lower-extremity ulcer prevention program is a systematic foot examination and risk stratification to select patients for more intensive prevention efforts. We provide current information on the components that should be indicated in a lower-extremity screening history and physical evaluation and a diabetic foot risk-classification scheme.

Predictors of physician nursing home practice: does what we do in residency training make a difference?

BACKGROUND AND OBJECTIVES: The number of physicians who care for nursing home patients is inadequate. This study determined predictors of current nursing home practice, including whether making nursing home rounds with an attending physician during residency is a predictor of subsequent nursing home practice. METHODS: We used a cross-sectional survey to study 170 family physicians in private or academic practice in a large, university-based Midwestern family practice residency program. RESULTS: The response rate was 86%. Fifty-five percent of respondents had an active nursing home practice. Rounding in a nursing home with an attending during residency had no relation to current nursing home practice. In comparison to physicians without an active nursing home practice, physicians with an active nursing home practice were more likely to reside in a smaller community, have a hospital practice (60.5% versus 39.5%), see more outpatients per week (105 versus 78), and work more hours per week (57 versus 49). In a logistic regression model, decreasing community size, number of hours worked per week, and having an active hospital practice were associated with active nursing home practice. CONCLUSIONS: Factors other than educational experience have an effect on physician nursing home practice.

Physician satisfaction with Medicaid managed care: the Missouri experience.

BACKGROUND: Medicaid managed care is important to health reform at the state level. However, little is known about physician satisfaction with these programs. We sought to measure this satisfaction in Missouri and determine its predictors. METHODS: We surveyed a random sample of primary care physicians participating in Medicaid managed care (n = 670) or traditional Medicaid (n = 670). Primary outcomes measured were physicians' satisfaction Medicaid managed care, traditional Medicaid and commercial managed care. Satisfaction was measured on a 5-point Likert-type scale. RESULTS: The response rate was 52%. Physicians participating in Medicaid managed care were less likely to be satisfied or very satisfied with Medicaid managed care (28.6%) than with commercial managed care (40%) or their previous experience with traditional Medicaid (39.7%). Among physicians participating in traditional Medicaid, 29.8% were satisfied or very satisfied with traditional Medicaid. Physicians participating in Medicaid managed care were less satisfied with clinical autonomy under that system in comparison with their previous experience with traditional Medicaid (relative difference = 10.8%, P =.001). In multiple linear regression analyses, clinical autonomy (R2 = 0.40) was a strong predictor of overall satisfaction with Medicaid managed care. CONCLUSIONS: Enhancing physicians' clinical autonomy may result in improved satisfaction with Medicaid managed care. State Medicaid agencies should include physician satisfaction as a measure of Medicaid managed care plans' quality.

Diagnosis and management of weight loss in the elderly.

Weight loss occurs commonly in elderly individuals, and is associated with functional decline and mortality. A 10% loss of body weight over 10 years is consistently associated with increased mortality and functional decline. A 4% body weight loss over 1 year should trigger a search for causes, which commonly include depression, cancers, benign gastrointestinal conditions, and medication toxicity. To evaluate weight loss, physicians should distinguish between four problems: anorexia, dysphagia, weight loss despite normal intake, or socioeconomic problems. In most cases, the cause of weight loss is identified by a thorough history, a targeted physical examination, and a simple laboratory evaluation. Assessment should include evaluation of functional and nutritional status. Management should include correction of potential causes and nutritional supplementation.