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QOF foot pulse doubts

A new study has thrown doubt on the evidence base for a key diabetes indicator in the quality and outcomes framework.

Primary care researchers found checking palpation of foot pulses failed to predict the risk of diabetic foot ulcers – challenging the test's inclusion in the contract.

NICE and the Scottish Intercollegiate Guidelines Network also advise checking foot pulses, but the authors called for the guidance to be revisited.

Their systematic review, published in February's QJM, found that tests to detect peripheral neuropathy, such as using monofilaments, were useful in predicting foot ulcers, and should be used instead.

Study leader Dr Fay Crawford, postdoctoral fellow in general practice at the University of Edinburgh, said: 'For palpation of foot pulses, the evidence is just not there – it's absent. When the guidelines are updated we hope the review will be incorporated.'

She added: 'All the evidence is that monofilaments work, and GPs should be confident using them in clinical practice.'

Dr Martin Hadley-Brown, chair of the Primary Care Diabetes Society and a GP in Thetford, Norfolk, said: 'I agree with them and it's been shown before. If you want to predict foot ulcers you should be using neuropathy.'

But he added that GPs should not stop testing for pulses because it could show up other problems, such as large blood vessel disease. 'The QOF is made up of payment trigger markers, not clinical guidelines. They're not designed to be a medical textbook – we like people to be thinking beyond that.'

Dr Hadley-Brown added: 'Yes, pulse measuring should be in the QOF, but people need to be more clear about why it's there and what they're testing.'

Dr Azhar Farooqi, a GP in Leicester and a member of the professional advisory board of Diabetes UK, said: 'I still think it's useful testing for pulses. If they're absent, the feet are still at risk.

'My feeling is you should carry on with both.'

The systematic review included five case-control and 11 cohort studies.

Dr Crawford is currently running a large cohort study in Dundee, to be completed in 2008, with the aim of developing a clinical risk tool incorporating three or four risk factors for foot ulcer.

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