{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,28]],"date-time":"2026-07-28T09:07:43Z","timestamp":1785229663379,"version":"3.55.0"},"reference-count":34,"publisher":"Public Library of Science (PLoS)","issue":"3","license":[{"start":{"date-parts":[[2021,3,10]],"date-time":"2021-03-10T00:00:00Z","timestamp":1615334400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/publicdomain\/zero\/1.0\/"}],"funder":[{"DOI":"10.13039\/100000738","name":"U.S. Department of Veterans Affairs","doi-asserted-by":"publisher","award":["IIR 15-372"],"award-info":[{"award-number":["IIR 15-372"]}],"id":[{"id":"10.13039\/100000738","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["www.plosone.org"],"crossmark-restriction":false},"short-container-title":["PLoS ONE"],"abstract":"<jats:sec id=\"sec001\"><jats:title>Aims<\/jats:title><jats:p>To describe how patients respond to early signs of foot problems and the factors that result in delays in care.<\/jats:p><\/jats:sec><jats:sec id=\"sec002\"><jats:title>Methods<\/jats:title><jats:p>Semi-structured interviews were conducted with a large sample of Veterans from across the United States with diabetes mellitus who had undergone a toe amputation. Data were analyzed using inductive content analysis.<\/jats:p><\/jats:sec><jats:sec id=\"sec003\"><jats:title>Results<\/jats:title><jats:p>We interviewed 61 male patients. Mean age was 66 years, 41% were married, and 37% had a high school education or less. The patient-level factors related to delayed care included: 1) not knowing something was wrong, 2) misinterpreting symptoms, 3) \u201csudden\u201d and \u201cunexpected\u201d illness progression, and 4) competing priorities getting in the way of care-seeking. The system-level factors included: 5) asking patients to watch it, 6) difficulty getting the right type of care when needed, and 7) distance to care and other transportation barriers.<\/jats:p><\/jats:sec><jats:sec id=\"sec004\"><jats:title>Conclusion<\/jats:title><jats:p>A confluence of patient factors (e.g., not examining their feet regularly or thoroughly and\/or not acting quickly when they noticed something was wrong) and system factors (e.g., absence of a mechanism to support patient\u2019s appraisal of symptoms, lack of access to timely and convenient-located appointments) delayed care. Identifying patient- and system-level interventions that can shorten or eliminate care delays could help reduce rates of limb loss.<\/jats:p><\/jats:sec>","DOI":"10.1371\/journal.pone.0248310","type":"journal-article","created":{"date-parts":[[2021,3,10]],"date-time":"2021-03-10T18:42:22Z","timestamp":1615401742000},"page":"e0248310","update-policy":"https:\/\/doi.org\/10.1371\/journal.pone.corrections_policy","source":"Crossref","is-referenced-by-count":13,"title":["How patients interpret early signs of foot problems and reasons for delays in care: Findings from interviews with patients who have undergone toe amputations"],"prefix":"10.1371","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-4247-8286","authenticated-orcid":true,"given":"Alyson J.","family":"Littman","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jessica","family":"Young","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Megan","family":"Moldestad","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chin-Lin","family":"Tseng","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph R.","family":"Czerniecki","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gregory J.","family":"Landry","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jeffrey","family":"Robbins","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3695-192X","authenticated-orcid":true,"given":"Edward J.","family":"Boyko","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael P.","family":"Dillon","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2021,3,10]]},"reference":[{"key":"pone.0248310.ref001","article-title":"Incidence of diabetic foot ulcer and lower extremity amputation among Medicare beneficiaries, 2006 to 2008: Data Points #2","author":"DJ Margolis","year":"2011","journal-title":"Data Points Publication Series"},{"key":"pone.0248310.ref002","doi-asserted-by":"crossref","first-page":"480","DOI":"10.1016\/j.apmr.2004.06.072","article-title":"Reamputation, mortality, and health care costs among persons with dysvascular lower-limb amputations","volume":"86","author":"TR Dillingham","year":"2005","journal-title":"Arch Phys Med Rehabil"},{"key":"pone.0248310.ref003","article-title":"Amputation rates of the lower limb by amputation level\u2014Observational study using German national hospital discharge data from 2005 to 2015","volume":"19","author":"M Spoden","year":"2019","journal-title":"BMC Health Serv Res."},{"key":"pone.0248310.ref004","doi-asserted-by":"crossref","first-page":"1033","DOI":"10.2337\/dc19-2337","article-title":"Risk of ipsilateral reamputation following an incident toe amputation among U.S. Military veterans with diabetes, 2005\u20132016","volume":"43","author":"AJ Littman","year":"2020","journal-title":"Diabetes Care"},{"key":"pone.0248310.ref005","first-page":"1676","volume-title":"Lancet.","author":"GE Reiber","year":"2005"},{"key":"pone.0248310.ref006","article-title":"Assessment of Simple Bedside Wound Characteristics for a Prediction Model for Diabetic Foot Ulcer Outcomes","author":"C Bender","year":"2020","journal-title":"J Diabetes Sci Technol"},{"key":"pone.0248310.ref007","doi-asserted-by":"crossref","first-page":"2158","DOI":"10.3109\/09638288.2012.677936","article-title":"How \u201cpreventable\u201d are lower extremity amputations? 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