Research ArticleResearch

Hyperbaric oxygen therapy and diabetic foot ulcers

Knowledge and attitudes of Canadian primary care physicians

A. Wayne Evans, Richard Gill, Aurelia O. Valiulis, Wendy Lou and Ted S. Sosiak
Canadian Family Physician May 2010; 56 (5) 444-452;

Article Figures & Data

Figures

  • Figure 1.
    Figure 1.

    Sources of referrals for HBOT: Percentages and thickness of dark blue arrows represent the proportion of direct referrals to the Hyperbaric Medicine Unit at Toronto General Hospital from different health care providers, between 2004 and 2007; light blue arrows represent indirect referrals.*

    HBOT—hyperbaric oxygen therapy.

    *A.W.E., unpublished data, 2007.

    †Can include extended primary care team: nurses, dieticians, etc.

    ‡Nephrologists, infectious disease specialists, endocrinologists, etc.

    §Including dermatologists.

  • Figure 2.
    Figure 2.

    Relative proportion of physicians in each Local Health Integration Network with a good knowledge of HBOT: Squares (▪) indicate the presence of a hyperbaric medicine unit; diamonds (♦) indicate the presence of a medical school and teaching hospitals.

    HBOT—hyperbaric oxygen therapy.

    *The city of Windsor does not have a hyperbaric medicine unit; physicians there often refer patients for treatment in nearby Detroit, MI.

  • Figure 3.
    Figure 3.

    Relative proportion of physicians in each Local Health Integration Network with a good attitude toward HBOT: Squares (▪) indicate the presence of a hyperbaric medicine unit; diamonds (♦) indicate the presence of a medical school and teaching hospitals.

    HBOT—hyperbaric oxygen therapy.

    *The city of Windsor does not have a hyperbaric medicine unit; physicians there often refer patients for treatment in nearby Detroit, MI.

Tables

  • Table 1.

    Respondents’ subjective knowledge of and attitudes toward HBOT in wound care: N=313, but not all categories add to 313 owing to missing data.

    PREDICTORRESPONDENTS, N (%)GOOD KNOWLEDGE, N (%)POOR KNOWLEDGE, N (%)P VALUEGOOD ATTITUDE, N (%)POOR ATTITUDE, N (%)P VALUE
    Sex
      • Male156 (49.8)20 (12.8)136 (87.2).033495 (60.9)61 (39.1).1903
      • Female157 (50.2)9 (5.8)146 (94.2)83 (53.5)72 (46.5)
    Age, y
      • < 4099 (31.6)5 (5.1)94 (94.9).080349 (49.5)50 (50.5).0613
      • ≥ 40214 (69.7)24 (11.2)190 (88.8)130 (60.7)84 (39.3)
    Years in medical practice
      • < 20148 (47.3)9 (5.7)147 (94.2).064689 (57.1)67 (42.9).8043
      • ≥ 20162 (51.8)18 (11.7)136 (88.3)90 (58.4)64 (41.6)
    No. of wound care patients per month
      • ≤ 5241 (77.0)22 (9.1)219 (90.9).8788134 (55.6)107 (44.4).2993
      • > 572 (23.0)7 (9.7)65 (90.3)45 (62.5)27 (37.5)
    Practice community
      • Urban260 (90.3)23 (8.8)237 (91.2)> .99142 (54.6)118 (45.4).0884
      • Rural28 (9.7)2 (7.1)26 (92.9)20 (71.4)8 (28.6)
    Patients requesting HBOT
      • No279 (89.4)22 (7.9)257 (92.1).0127156 (55.9)123 (44.1).1300
      • Yes33 (10.6)7 (21.2)26 (78.8)23 (69.7)10 (30.3)
    Previous physician HBOT referral
      • No268 (85.9)16 (6.0)252 (94.0)< .001144 (53.7)124 (46.3).0013
      • Yes44 (14.1)13 (29.5)31 (70.5)35 (79.5)9 (20.5)

    • HBOT—hyperbaric oxygen therapy.

  • Table 2.

    Respondents’ subjective knowledge of HBOT: N=313.

    TOPICFAMILIARITY
    LITTLE OR NOT AT ALL, N (%)SOMEWHAT, N (%)QUITE A BIT OR VERY MUCH, N (%)
    The therapeutic mechanisms of HBOT in wound healing165 (52.7)117 (37.4)31 (9.9)
    The potential risks (eg, barotrauma, seizure, hypoglycemia) associated with using HBOT217 (69.3)79 (25.2)17 (5.4)
    The pre-existing conditions (eg, pneumothorax, pharyngotympanic tube dysfunction, high fevers) that contraindicate HBOT188 (60.1)77 (24.6)48 (15.3)

    • HBOT—hyperbaric oxygen therapy.

  • Table 3.

    Respondents’ attitudes toward use of HBOT in wound care: N=313.

    STATEMENTSTRONGLY DISAGREE OR DISAGREE, N (%)NEITHER AGREE NOR DISAGREE, N (%)STRONGLY AGREE OR AGREE, N (%)
    It is effective6 (1.9)125 (39.9)182 (58.1)
    It is cost-saving13 (4.2)197 (62.9)103 (32.9)
    It is safe4 (1.3)131 (41.9)178 (56.9)
    It decreases the chance of major lower-extremity amputation5 (1.6)132 (42.2)176 (56.2)
    It reduces healing time5 (1.6)102 (32.6)206 (65.8)
    Overall, it is very beneficial3 (1.0)131 (41.9)179 (57.2)

    • HBOT—hyperbaric oxygen therapy.

  • Table 4.

    Correlation between respondents’ subjective knowledge of and their attitudes toward the use of HBOT in wound care: N=313; P = .0115.

    KNOWLEDGEATTITUDE
    GOODPOOR
    N% OF KNOWLEDGE CATEGORY% OF TOTALN% OF KNOWLEDGE CATEGORY% OF TOTAL
    Good (n = 29)2379.37.3620.71.9
    Poor (n = 284)15654.949.812845.140.9
  • Table 5.

    Multivariate analysis of respondents’ subjective knowledge of HBOT

    INDEPENDENT VARIABLEESTIMATESTANDARD ERRORADJUSTED OR95% CI*P VALUE
    Years in practice (≥ 20)0.44370.23522.4290.966–6.107.0593
    Referral request (yes)0.54070.26242.9491.054–8.249.0394

    • CI—confidence interval, HBOT—hyperbaric oxygen therapy, OR—odds ratio.

    • ↵* Calculated using the Wald statistical test.

  • Table 6.

    Variables associated with adoption of HBOT in primary care practice

    INDEPENDENT VARIABLEESTIMATESTANDARD ERRORADJUSTED OR95% CI*P VALUE
    Knowledge (good)0.70130.29104.0661.300–12.720.0158
    Attitude (good)0.46450.24022.5320.988–6.491.0531
    Sex (male)0.65970.25193.7411.394–10.043.0088
    Years in practice (≥ 20)0.15490.22441.3630.566–3.286.4901
    No. of wound care patients per week (> 5)0.09370.24341.2060.464–3.132.7004
    Community (LHIN)0.19100.33791.4650.390–5.510.5719
    Referral request by patients (yes)1.50980.254120.4847.565–55.466< .0001

    • CI—confidence interval, HBOT—hyperbaric oxygen therapy, LHIN—Local Health Integration Network, OR—odds ratio.

    • ↵* Calculated using the Wald statistical test.

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Hyperbaric oxygen therapy and diabetic foot ulcers
A. Wayne Evans, Richard Gill, Aurelia O. Valiulis, Wendy Lou, Ted S. Sosiak
Canadian Family Physician May 2010, 56 (5) 444-452;
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