Foot morbidity and exposure to chiropody: population based study

Introduction

Although one third of pensioners receive chiropody care, the NHS gives low priority to foot problems. Health economic assessment suggests that the cost effectiveness of chiropody surpasses other interventions.1 While rationing of chiropody is well documented,2 it is unknown whether delivery of service is targeted to those in greatest need. We investigated whether the extent of foot morbidity is a predictor of receipt of chiropody and whether chiropody is needs led or distributed according to less appropriate determinants.

Subjects, methods, and results

A random sample of 792 subjects aged 60 years and over from South Glamorgan Health Authority's register were contacted in 1988-91.3 Information about chiropody in the preceding 12 months was obtained, and their feet were examined for toe deformities (hallux valgus and lesser toe deformities), corns and callosities, ingrowing toenails, and toenail thickening. A foot morbidity index (index 1, range 0-5) was constructed with one point scored for each problem present (on either foot).

The analysis entailed modelling the impact of this index and of possible confounding variables on a binary outcome variable denoting receipt of chiropody care in the past year. Because a negative finding might be due to the effectiveness of care in remedying treatable conditions, a second index (index 2, range 0-2) including only bony disorders which chiropody care cannot correct was also modelled. Logistic regression was performed with spss for Windows.

In total 71% (560/792) of subjects responded (mean age 71.2), with no difference in age or sex composition between responders and the original population. The mean foot index scores were 2.5 (index 1)and 1.1 (index 2). Three or more foot problems were found in 53% (291/553), though only 33% (182/559) had received chiropody within the previous year.

Before adjustment the probability of receiving chiropody was higher among women, older subjects, those living alone, and those with more foot problems (1). There was no significant difference across social classes. Adjustment produced two important changes: both indices of foot problems ceased to be significantly associated, due mainly to adjustment for age; and subjects who lived alone become significantly less likely to receive chiropody, owing mainly to adjustment for age and sex.

Comment

Two fifths of those assessed as needing chiropody care do not receive it.1 The gap in care is filled by spouses or children. The informal criteria that are used to determine how this service is rationed are unknown. This study indicates that foot morbidity—unlike demographic (age, sex) and social factors (whether subjects live alone)—is not an independent determinant of receipt of care. Differential non-response is unlikely to account for these findings. Patient function was not assessed in this study for reasons of time and because of the multifactorial origins of reduced function.

The critical importance of controlling for confounding is underlined by the reversal, after adjustment, of the direction of the association with living alone. Previous unadjusted studies reporting that living alone is associated with an increased chance of receiving chiropody4 are probably biased by uncontrolled confounding. Though use of many other health services is greater among those who live alone, this might not apply to a low status service like chiropody. Poor access to transport by car in this group provides a possible mechanism. Proposals that domiciliary chiropody be reduced with increased centralised provision carry a risk of further exacerbating this problem.5 This mismatch between the capacity to benefit from care and the pattern of provision of that care affects a number of common but low status health problems. Careful consideration should be given in the purchasing process to ways of identifying those with severe foot morbidity and of providing accessible services.