Foot and Ankle Care by Podiatrists and Amputations in Patients With Diabetes and Kidney Failure.

Importance: Patients with kidney failure have an increased risk of diabetes-related foot complications. The benefit of regular foot and ankle care in this at-risk population is unknown. Objective: To investigate foot and ankle care by podiatrists and the outcomes of diabetic foot ulcers (DFUs) in patients with kidney failure. Design, Setting, and Participants: This retrospective cohort study included Medicare beneficiaries with type 2 diabetes receiving dialysis who had a new DFU diagnosis. The analysis of the calendar year 2016 to 2019 data from the United States Renal Data System was performed on June 15, 2023, with subsequent updates on December 11, 2023. Exposures: Foot and ankle care by podiatrists during 3 months prior to DFU diagnosis. Main Outcomes and Measures: The outcomes were a composite of death and/or major amputation, as well as major amputation alone. Kaplan-Meier analysis was used to estimate 2 to 3 years of amputation-free survival. Foot and ankle care by podiatrists and the composite outcome was examined using inverse probability-weighted Cox regression, while competing risk regression models were used for the analysis of amputation alone. Results: Among the 14 935 adult patients with kidney failure and a new DFU (mean [SD] age, 59.3 [12.7] years; 35.4% aged ≥65 years; 8284 men [55.4%]; Asian, 2.7%; Black/African American, 35.0%; Hispanic, 17.7%; White, 58.5%), 18.4% (n = 2736) received care by podiatrists in the 3 months before index DFU diagnosis. These patients were older, more likely to be male, and have more comorbidities than those without prior podiatrist visits. Over a mean (SD) 13.5 (12.0)-month follow-up, 70% of those with podiatric care experienced death and/or major amputation, compared with 74% in the nonpodiatric group. Survival probabilities at 36 months were 26.3% vs 22.8% (P < .001, unadjusted Kaplan-Meier survival analysis). In multivariate regression analysis, foot and ankle care was associated with an 11% lower likelihood of death and/or amputation (hazard ratio [HR], 0.89 95% CI, 0.84-0.93) and a 9% lower likelihood of major amputation (above or below knee) (HR, 0.91; 95% CI, 0.84-0.99) than those who did not. Conclusions and Relevance: The findings of this study suggest that patients with kidney failure at risk for DFUs who receive foot and ankle care from podiatrists may be associated with a reduced likelihood of diabetes-related amputations.

Medicaid Coverage for Routine Foot Care.

BACKGROUND: Despite national and international guidelines supporting podiatric services as a means of prevention for lower-extremity complications, especially in at-risk individuals, current coverage for these services under the US Medicaid program is not universal. The vast differences between state Medicaid programs regarding reimbursable foot care services is confusing and potentially serves as a barrier for the most vulnerable populations to receive preventative services. This article provides a brief discussion of "routine" podiatric services from a clinical perspective and provides a review of state Medicaid programs including optional services (eg, podiatric coverage). METHODS: Using data from a national survey of state Medicaid programs, we present and discuss common Medicaid coverage schemes for routine foot care provided by podiatric physicians. RESULTS: Analysis demonstrated that states vary dramatically in basic descriptions of preventive foot care, levels of coverage, eligibility, and methods of documenting coverage details. CONCLUSIONS: The authors recommend bringing Medicaid in line with other federal health programs and including podiatric physicians in the definition of "physician" for coverage purposes. States should move away from describing preventative services as "routine" and choose language that more accurately reflects the true nature and purpose of the care.

Medicaid Coverage for Podiatric Care: A National Survey.

OBJECTIVES: Medicaid provides health insurance for low-income people meeting specific eligibility requirements. It is funded and administered by both the federal and state governments; this decentralization leads to vastly different programs across the country. The objective of this legal surveillance project was to describe state-by-state differences in podiatric care coverage for nonelderly adults across Medicaid programs. METHODS: We used policy surveillance, a form of advanced legal mapping. It is the systematic collection and analysis of written policies across jurisdictions. Policy surveillance captures the important features of law through a rigorous scientific process to turn these policies into structured, quantitative legal data that are suitable for further evaluation or modeling. Data for the 51 jurisdictions were current as of September 1, 2020. RESULTS: The vast majority of jurisdictions (82%) covered podiatric services for all classes of Medicaid beneficiaries, but the rules, restrictions, and limitations around coverage differed. Twenty-five jurisdictions had no limits on the number of podiatric visits during a specified period; 26 jurisdictions indicated a cap. Ten jurisdictions had no explicit limitations on coverage of routine foot care, whereas 33 jurisdictions covered routine foot care only when medically necessary or with a triggering condition. Eight jurisdictions did not cover routine foot care at all, and 28 jurisdictions required prior authorizations. CONCLUSIONS: Podiatric care coverage, which is often preventive, varies greatly by state. This variability in coverage, which has not been previously tracked at the level of detail provided in our study, has implications for cost and health outcomes. The value of podiatric care is especially apparent in Medicaid populations. The compilation of these data can serve as a valuable resource for clinicians, researchers, and policy makers.

The Effects of the COVID-19 Economic Downturn on Medicaid Coverage for Podiatry Services.

As of 2016, Medicaid accounted for nearly 20% of state general fund budgets. Optional Medicaid services such as podiatry are often subject to cost-cutting measures in periods of economic downturn, as was the case in the wake of the 2007 financial crisis. Although the cuts were intended as a cost-saving measure, research indicates that they had the opposite effect. The restriction and limitation of these services during the Great Recession resulted in both poorer health outcomes for beneficiaries, and poorer financial outcomes for state Medicaid programs. With states citing record levels of unemployment as of April of 2020 and projecting significant declines in annual revenue in 2021, the economic conditions resulting from the coronavirus disease of 2019 pandemic are likely to rival those of the Great Recession. Given the historical precedent for restricting or eliminating optional Medicaid services as a cost-saving measure, it is likely that podiatric services will once again come under scrutiny. Previous efforts by state-level podiatric societies have proven successful in lobbying for the reinstatement of coverage under Medicaid by conveying evidence of the negative outcomes associated with elimination to stakeholders. The specialty must once again engage policymakers by drawing on evidence gleaned and lessons learned from past cuts of optional Medicaid services to avert counterproductive coverage restrictions intended to mitigate the financial impact of the coronavirus disease of 2019 pandemic.

Geriatric Case Managers' Perspectives on Suicide Among Community-Dwelling Older Adults.

It has been suggested that clinical screening for suicide, along with firearm assessment and safety counseling, are important in service provision to older adults. It is unclear, however, how geriatric case managers respond to these issues. This study surveyed geriatric case managers (n=161) from Area Agencies on Aging in Ohio on their knowledge, attitudes, and behaviors related to suicide, firearm assessment, and safety counseling. Results indicated that the majority of respondents (70%) agree their clients are at risk for suicide. However, few (30%) in this study reported that they assess for firearms and less than half (48%) discuss firearms with their clients/family members when specifically assessing for suicide. Analyses identified barriers that contribute to the decreased likelihood that routine firearm assessment and safety counseling would occur, such as lack of training and time. Implications include the need for training with geriatric case managers that addresses barriers to suicide, firearm assessment and safety counseling as a means to decrease these population risks.

Suicide and firearm means restriction: can training make a difference?

Along with physician education in depression recognition and treatment, restricting lethal methods is an effective suicide prevention strategy. The present study surveyed a random sample (N = 697) of Ohio licensed social workers regarding client firearm assessment and safety counseling. Analyses sought to determine what independent factors would predict the probability that a social worker would hold positive attitudes regarding firearm risk assessment and counseling. Findings indicated that prior training and reporting from an urban area significantly increased the odds (p < .05) of registering more positive attitudes toward firearm assessment and safety counseling by 91.1% and 44.7%, respectively. Training mental health professionals in firearm assessment and safety counseling is an important aspect in addressing the reduction of suicide by this means.

Client firearm assessment and safety counseling: the role of social workers.

Firearms constitute an environmental risk factor for suicide among all age groups. Although other professions have been urged to assess firearm availability and advocate for the removal of firearms of their clients, little is known about the practices and the techniques within the social work profession. The present study surveyed a random sample (N = 697) of Ohio licensed social workers (requiring a BSW) and Ohio licensed independent social workers (requiring an MSW and 3,000 hours of post-master's practice experience) on their attitudes, knowledge, and behaviors regarding client firearm assessment and safety counseling. Findings indicated that the majority of social workers in this study did not report assessing for firearms or counseling on firearm safety on a routine basis. Barriers included lack of training on risks, lack of risk awareness, discomfort with the topic, not social work responsibility, lack of time, and more important topics to discuss. The most influential variable positively related to firearm assessment and counseling behaviors among these social workers was reporting previous firearm safety training. Other variables included influential media, depressed client, and suicidal client.

Race and jurors' receptivity to mitigation in capital cases: the effect of jurors', defendants', and victims' race in combination.

This paper examines the variation in receptivity to mitigation evidence by capital jurors as it varies by the race of the juror, defendant, and victim individually and in combination. Attitudinal and racial characteristics from 865 respondents in the Capital Jury Project were used in the analysis. Using a generalized form of multiple regression, the respondent's receptivity to mitigation evidence was predicted and changes in receptivity were calculated as the race of the main trial participants (juror, defendant, and victim) were varied. Statistical controls were put in place for gender of respondent; respondent's perception of the dangerousness of the defendant, heinousness of the crime, and view of the defense attorney; respondent's formation of a premature sentencing decision; and whether the trial took place in a southern state jurisdiction. Results indicate that Black jurors in cases where a Black is charged with killing a White victim are chiefly responsible for the observed variance in receptivity to mitigation.