Evaluation and Management of Neuropathy: A Guide for Primary Care Providers

Patients with neuropathic symptoms often seek initial evaluation in primary care. Primary care providers face challenges in evaluating and managing neuropathic symptoms; subsequently, patients with neuropathic symptoms may be underdiagnosed or undermanaged. Current existing treatment guidelines lack unanimity of both evaluation and management efforts. The purpose of the project was to enhance the evaluation and management of patients with neuropathy symptoms by strengthening primary care provider use of evidence-based treatment approaches for neuropathy through the development and subsequent implementation of a treatment algorithm. The project participants included eighteen primary care providers from local primary care clinics. Aggregate pre and post survey data were evaluated after providers used the treatment algorithm in practice for one month. Mann Whitney U results showed no difference between the pre and post survey data to support usefulness of the treatment algorithm; however, Likert scale post-survey results revealed that the majority of providers agreed that guidelines would be useful in practice. Distributing the treatment algorithm to a larger population of primary care providers in expanded organizations, over more extended time periods might capture further data to support usefulness.

Running head: EVALUATION AND MANAGEMENT OF NEUROPATHY Evaluation and Management of Neuropathy: A Guide for Primary Care Providers Cassie J. Kuhn University of Utah 1 EVALUATION AND MANAGEMENT OF NEUROPATHY 2 Abstract Patients with neuropathic symptoms often seek initial evaluation in primary care. Primary care providers face challenges in evaluating and managing neuropathic symptoms; subsequently, patients with neuropathic symptoms may be underdiagnosed or undermanaged. Current existing treatment guidelines lack unanimity of both evaluation and management efforts. The purpose of the project was to enhance the evaluation and management of patients with neuropathy symptoms by strengthening primary care provider use of evidence-based treatment approaches for neuropathy through the development and subsequent implementation of a treatment algorithm. The project participants included eighteen primary care providers from local primary care clinics. Aggregate pre and post survey data were evaluated after providers used the treatment algorithm in practice for one month. Mann Whitney U results showed no difference between the pre and post survey data to support usefulness of the treatment algorithm; however, Likert scale post-survey results revealed that the majority of providers agreed that guidelines would be useful in practice. Distributing the treatment algorithm to a larger population of primary care providers in expanded organizations, over more extended time periods might capture further data to support usefulness. Keywords: neuropathy, primary care, treatment algorithm, neuropathic symptoms, peripheral neuropathy, diabetic neuropathy EVALUATION AND MANAGEMENT OF NEUROPATHY 3 Evaluation and Management of Neuropathy: A Guide for Primary Care Providers Introduction Problem Description Neuropathy is a common neurological condition affecting 26% to 47% of individuals in the United States and is treated by many specialties of healthcare providers (Kaku, Vinik, & Simpson, 2015; Watson & Dyck, 2015). Neuropathy is acknowledged as one of the most complicated pain-related neurological disorders to manage and is often underdiagnosed and undertreated (Adams, Callaghan, & Grant, 2017; Reed et al., 2013; Sobhy, 2016; van Hecke, Austin, Khan, Smith, & Torrance, 2014). Because the presentation of neuropathy varies, it may be difficult to identify and treat (Adams et al., 2017). Early identification and treatment of neuropathy are essential to prevent or delay irreversible nerve damage (England et al., 2014). Symptoms may include, but are not limited to, numbness, weakness, tingling, burning, prickling, or stabbing pain (Watson & Dyck, 2015). Autonomic symptoms may also be observed and include: orthostatic hypotension, abnormal sweating, or impotence (Watson & Dyck, 2015). Primary care providers are often the initial contact point for patients experiencing symptoms of neuropathy (Midik, Yalcin, Yalcin & Ozturk, 2017). A treatment algorithm would benefit patients in primary care, especially those in rural settings who may have reduced access to specialty care. Additionally, it would assist primary care providers in rural settings who must manage patients independently. Use of the treatment algorithm could facilitate improvement in primary care provider's ability to manage neuropathy patients and subsequently improve patient outcomes by alleviating long-term patient consequences such as weakness, sensory loss, falls and subsequent injury, depression, sleep EVALUATION AND MANAGEMENT OF NEUROPATHY 4 disturbances, inability to complete activities of daily living (Callaghan et al., 2015; England et al., 2014). Available Knowledge Primary care providers who encounter patients with neuropathic symptoms are confronted with obstacles including ensuring proper evaluation, testing, provision of appropriate treatment, and establishing the point at which specialty consultation is necessitated (Watson & Dyck, 2015). The lack of evaluation or under-management of neuropathy can lead to long-term patient health consequences. Long-term health consequences of neuropathy include sensory loss, weakness, altered gait, falls with subsequent injury, and irremediable nerve impairment, ulcer formation, amputation, and unremitting pain (Callaghan et al., 2015; England et al., 2014). Unremitting neuropathic pain is a complaint in patients with neuropathy and can have a significant negative impact on a patient's quality of life leading to depression and poor sleep (Finnerup et al., 2015; Possidente & Tandan, 2009). Sobhy (2016) discussed that less than 28% of patients with neuropathy received adequate treatment for neuropathic pain. Of the patients being treated for neuropathic pain, therapy is often initiated in an untimely manner (Sobhy, 2016). The research of van Hecke et al. (2014) revealed the absence of unanimity related to neuropathy guidelines, standardized screening and evaluation tools, and diagnostic criteria. As identified by Sobhy (2016), there is a necessity for more comprehensive tools to assist primary care providers in the management of neuropathy in the primary care setting. Rationale The Academic Center for Evidence-Based Practice (ACE) Star Model of Knowledge Transformation was used to guide the development a treatment algorithm to assist primary care EVALUATION AND MANAGEMENT OF NEUROPATHY 5 providers in the management of neuropathy in the primary care setting. The ACE Star Model of Knowledge Transformation is an action model used to guide strategies of research implementation in standards of practice in healthcare (Nilsen, 2015; Schaffer, Sandau, & Diedrick, 2013). The model has been used in various clinical practice settings. Practitioners have used the ACE Star Model of Knowledge Transformation to practice guidelines for ventilator-associated pneumonia, virtual reality simulation training, and for improving health practices of adolescents in educational settings (Farra, Miller, & Hodgson, 2015; Schaffer et al., 2013). The ACE Star Model of Knowledge Transformation consists of five stages: discovery, evidence summary, translation, integration, and evaluation (Stevens, 2013) (Figure 1). Together the stages of the ACE model guide development of healthcare standards by identifying gaps in existing practice and presenting a framework for implementation and evaluation. Specific Aims The purpose of the project was to improve the evaluation and management of patients with neuropathy symptoms by strengthening primary care provider use of evidence-based treatment approaches for neuropathy through the development and subsequent implementation of a treatment algorithm. The objectives of the project include: 1. Identify the need within the literature and among local primary care providers for a treatment algorithm for neuropathy in the primary care setting. 2. Develop an evidence-based management approach for neuropathy in the primary care setting. 3. Apply expert knowledge to refining the treatment algorithm for appropriate use in clinical practice. EVALUATION AND MANAGEMENT OF NEUROPATHY 6 4. Distribute the revised treatment algorithm to primary care providers and evaluate the acceptability of the use of the treatment algorithm in practice for four weeks. Methods Context This project took place at a large urban academic healthcare system located in the mountain west. The healthcare system has community clinics located in the urban and suburban regions. The community clinics provide primary care services to patients of all ages. Participants included primary care providers from the community clinics. These clinics serve primarily Caucasian and Hispanic patients who are commercially insured; about 25% are insured by Medicare or Medicaid. Intervention The ACE Star Model of Knowledge Transformation was used to guide the project by identifying gaps in the existing practice of neuropathy management and assisting in implementing a standardized process through a treatment algorithm. The purpose of this project was to determine if neuropathy treatment guidelines would be useful for primary care providers in a primary care setting. After the development and revision of the treatment algorithm based on feedback from a neurologist, primary care providers were introduced to the treatment algorithm through a presentation at a clinic division meeting. Providers were given a set of instructions and the treatment algorithm, then alerted to an online survey designed to collect deidentified demographic data that they would receive following the division meeting. Study of the Intervention After the presentation, the clinical administrative manager distributed an introductory email to all primary care providers within the community clinics. The email contained EVALUATION AND MANAGEMENT OF NEUROPATHY 7 instructions, the treatment algorithm, and a REDCap-based link to the survey (see Appendix A). Providers were asked to complete the survey and use the treatment algorithm in practice for one month. Providers received a second survey (see Appendix B) after one month of using the treatment algorithm in their practice designed to assess whether providers used the treatment algorithm and to collect feedback on potential revisions. Measures Pre and post surveys were piloted with the content expert and current providers not participating in the project to evaluate content face-validity and assess errors, completeness, ease, and completion time. Pilot data demonstrated that both surveys could be completed in under three minutes. Analysis Descriptive statistics were used to describe the study sample (see Table 1). Pre and post survey results were categorized in a frequency table (see Table 2). The Mann Whitney U test was used to evaluate the pre and post-test data. Content analysis of free text responses was conducted. Ethical Considerations The project was reviewed by the University of Utah Institutional Review Board and was deemed as a quality initiative; informed consent was not required. Results Statistical analyses were completed using SPSS version 25, with the guidance of a statistician. The project instructions and surveys were electronically sent to 54 providers consisting of physicians, resident physicians, physician assistants, and nurse practitioners. The project was introduced at a division meeting which 22 primary care providers attended. In total, EVALUATION AND MANAGEMENT OF NEUROPATHY 8 eleven pre-surveys (n=11) were completed. Following the presentation, post-surveys were sent and seven post surveys (n=7) were completed. Participants who completed the pre-surveys consisted of physicians (9, 81.8%) and physician assistants (2, 18.2%). Of those who participated, 63.6% were female, and 36.4% were male (see Table 1). Pre-survey results revealed that 64% of responding providers had not been using treatment guidelines in practice. Of the 36% of providers who had previously used treatment guidelines, 27% stated that they used an online clinical resource and another 27% reported that the guidelines used were those committed to memory; nevertheless, their healthcare organization did not have established guidelines. Since 36% of providers stated that they had previously used guidelines from an online source or memory, they may lack the motivation to adapt to newer guidelines (see Table 2). Using a Mann Whitney U test, there was no difference in the provider's assessment of usefulness to support the treatment algorithm in clinical practice (U=36.5, Npre=11, Npost=7, p=0.8, 2-tailed); although, Likert scale post-survey results revealed that 57.2% of providers agreed/strongly agreed that guidelines would be useful in practice (see Table 2). Post-survey questions asked for feedback regarding the usefulness of the treatment algorithm. Free text results addressing usefulness of the treatment algorithm included that it was "easy to follow flow charts," "simple overall," "very clear and specific - tying together history, physical exam, and lab workup." Five participants were lost to follow up at post-survey. Efforts were made to increase survey response rates by sending three electronic reminders to participants. EVALUATION AND MANAGEMENT OF NEUROPATHY 9 Discussion Summary In summary, management of patients with neuropathic symptoms lacks standardization with the possibility of inadequate patient management. A treatment algorithm was successfully created and piloted in an attempt to bridge the gap in care of patients with neuropathy. Based on free text responses, providers in busy primary care clinics are willing to use a treatment algorithm. In general, the participating providers felt that the algorithm was useful in clinical practice. Interpretation of the Findings Findings from this project align with other projects which have found that there is an absence of standardization related to neuropathy guidelines, screening and evaluation tools, and diagnostic criteria as determined by survey results. As stated in the literature, the use of a comprehensive treatment algorithm would improve the management of patients with neuropathic symptoms, prevent long-term health consequences, and alleviate unnecessary referrals to specialty care. The project was not time-intensive, and the cost was minimal. The treatment algorithm could be distributed to a larger population of primary care providers in other healthcare organizations. Limitations of the Findings Despite sending the survey to 54 providers, response rates were minimal. Low response rates were not surprising for a busy practice and may have been impacted by the holiday schedule. Potential solutions include providing participant incentives, more extended data collection periods, and possible avoidance of holiday months. EVALUATION AND MANAGEMENT OF NEUROPATHY 10 Conclusion In conclusion, there is a significant need for a standardized treatment algorithm to optimize patient care, which is supported by survey data displaying varying laboratory testing and confidence in the ability to independently manage patients with neuropathy (see Table 2). The main focus of this project was to create a comprehensive treatment algorithm to assist in improving the evaluation and management of patients with neuropathy symptoms by strengthening primary care provider use of evidence-based treatment approaches (see Appendix C). With the guidance of the ACE Star Model of Knowledge Transformation, the creation of the comprehensive treatment algorithm was meant to be simplistic, sustainable by all healthcare providers, and assist in standardizing treatment approaches. Pilot results generally suggest that providers considered the algorithm useful; however, data should be interpreted with caution due to the low response rate. Future studies could look at disseminating the treatment algorithm to a larger population of primary care providers in other healthcare organizations, over more extended time periods to capture further data to support usefulness. The use of a standardized treatment algorithm in practice could assist providers in ensuring proper evaluation, testing, provision of treatment, and establishing the point at which specialty consultation is needed. Early identification and appropriate treatment of patients with neuropathy would prevent further health consequences. The treatment algorithm would support sustainability by increasing efforts to manage neuropathy in primary care, thus reducing referrals and associated costs. Suggested next steps include publishing the proposed neuropathy treatment algorithm and distributing the treatment algorithm to a larger population of primary care providers in other organizations to evaluate usefulness. Additional dissemination approaches include presenting EVALUATION AND MANAGEMENT OF NEUROPATHY 11 project in-services to primary care providers from additional organizations who provide care to multiple populations, including rural areas and underserved communities. Acknowledgments Assistance provided by faculty chair, Margaret F. Clayton, Ph.D., FNP-BC, FAAN, was greatly appreciated. It was an honor to work alongside neurologist and content expert, Mark Bromberg, MD, Ph.D., who was a driving force in the project. A special thanks to Jennifer Leiser, MD, University of Utah Chief of Family Medicine and Becky Reynolds, Clinical Administrative Manager of the University of Utah Department of Family and Preventive Medicine who aided in arranging the project presentation and communication to participating providers. Finally, a thank you to participating providers at the University of Utah Community Clinics who completed the pre and post surveys and used the treatment algorithm in practice. EVALUATION AND MANAGEMENT OF NEUROPATHY 12 References Adams, A. S., Callaghan, B., & Grant, R. W. (2017). Overcoming barriers to diabetic polyneuropathy management in primary care. Healthcare, 5(4), 171-173. https://doi.org/10.1016/j.hjdsi.2016.10.003 Callaghan, B. C., Price, R. S., & Feldman, E. L. (2015). Diagnostic and Therapeutic Advances: Distal Symmetric Polyneuropathy. JAMA, 314(20), 2172-2181. doi:10.1001/jama.2015.13611 England, J. D., Franklin, G., Gjorvad, G., Swain-Eng, R., Brannagan, T. H., David, W. S., … Smith, B. E. (2014). Quality improvement in neurology. Neurology, 82(19), 1745-1748. doi:10.1212/WNL.0000000000000397 Finnerup, N. B., Attal, N., Haroutounian, S., McNicol, E., Baron, R., Dworkin, R. H., … Wallace, M. (2015). Pharmacotherapy for neuropathic pain in adults: systematic review, meta-analysis and updated NeuPSIG recommendations. The Lancet Neurology, 14(2), 162-173. doi:10.1016/S1474-4422(14)70251-0 Kaku, M., Vinik, A., & Simpson, D. M. (2015). Pathways in the diagnosis and management of diabetic polyneuropathy. Current Diabetes Reports, 15(6), 35. doi:10.1007/s11892-0150609-2 Midik, O., Yalcin, B. M., Yalcin, E., & Ozturk, O. (2017). Neurophobia: A myth or an unpleasant fact for primary care physicians. BioMed Research International, 28(10), 8. Possidente, C. J., & Tandan, R. (2009). A survey of treatment practices in diabetic peripheral neuropathy. Primary Care Diabetes, 3(4), 253-257. https://doi.org/10.1016/j.pcd.2009.08.008 EVALUATION AND MANAGEMENT OF NEUROPATHY 13 Reed, C., Hong, J., Novick, D., Lenox-Smith, A., & Happich, M. (2013). Incidence of diabetic peripheral neuropathic pain in primary care - a retrospective cohort study using the United Kingdom General Practice Research Database. Pragmatic and Observational Research, 4, 27-37. doi:10.2147/POR.S49746 Sobhy, T. (2016). The need for improved management of painful diabetic neuropathy in primary care. Pain Research and Management, 1-4. doi:10.1155/2016/1974863 van Hecke, O., Austin, S. K., Khan, R. A., Smith, B. H., & Torrance, N. (2014). Neuropathic pain in the general population: a systematic review of epidemiological studies. Pain, 155(4), 654-662. doi:10.1016/j.pain.2013.11.013 Watson, J. C., & Dyck, P. J. B. (2015). Peripheral neuropathy: A practical approach to diagnosis and symptom management. Mayo Clinic Proceedings, 90(7), 940-951. doi:10.1016/j.mayocp.2015.05.004 EVALUATION AND MANAGEMENT OF NEUROPATHY 14 Figure 1 ACE Star Model of Knowledge Transformation Note. From "The Impact of Evidence-Based Practice in Nursing and The Next Big Ideas," by K. R. Stevens, 2013, Online Journal of Issues in Nursing, 18(2). Copyright 2013 by Stevens. Reproduced with permission. EVALUATION AND MANAGEMENT OF NEUROPATHY 15 Table 1 Demographic Frequency Table Characteristic Total N=11 Age in Years, No. (%) 35-44 4 (36.4%) 45-54 5 (45.5%) 55-64 2 (18.2%) Female 7 (63.6%) Male 4 (36.4%) Physician 9 (81.8%) Physician Assistant 2 (18.2%) 6-10 3 (27.3%) 11-15 2 (18.2%) 16-20 2 (18.2%) 21-25 2 (18.2%) Gender, No. (%) Healthcare Role, No. (%) Years in Practice, No. (%) EVALUATION AND MANAGEMENT OF NEUROPATHY 16 31 or greater 2 (18.2%) Family Medicine 9 (81.8%) Primary Care 1 (9.1%) Internal Medicine 1 (9.1%) White 9 (81.8%) Other 2 (18.2%) Not Hispanic or Latino 10 (100%) Specialty, No. (%) Race, No. (%) Ethnicity, No. (%) EVALUATION AND MANAGEMENT OF NEUROPATHY 17 Table 2 Result Frequency Table Characteristic Pre-Survey Post-Survey n=11 n=7 In the last six months, have you seen patients with neuropathic symptoms, No. (%) Yes 11 (100%) In the last six months, how many patients with neuropathic symptoms were seen, No. (%) 1-5 1 (9.1%) 6-10 5 (45.5%) 11-15 2 (18.2%) 16-20 1 (9.1%) 21-25 2 (18.2%) In the last month, have you seen patients with neuropathic symptoms, No. (%) No 1 (14.3%) Yes 6 (85.7%) In the last month, how many patients with neuropathic symptoms were seen, No. (%) 1-5 3 (50%) 6-10 2 (33.3%) 16-20 1 (16.7%) EVALUATION AND MANAGEMENT OF NEUROPATHY In the last six months, which of the following neuropathic symptoms were seen, No. (%) Numbness 11 (100%) Tingling 11 (100%) Burning Pain 11 (100%) Pins/Needles 8 (72.7%) Gait Imbalance 6 (54.5%) Itching 1 (5.6%) Weakness 1 (5.6%) In the last six months, have you used any treatment guidelines in practice, No. (%) No 7 (63.6%) Yes 4 (36.4%) What type of treatment guidelines were used in practice, No. (%) Online Clinical Resource/ 3 (27.3%) Smartphone Guidelines Committed to 3 (27.3%) Memory How satisfied are you with your current treatment guidelines, No. (%) Neutral 2 (50%) 18 EVALUATION AND MANAGEMENT OF NEUROPATHY Satisfied 19 2 (50%) In the last month, have you used the provided treatment guidelines in practice, No. (%) No 3 (42.9%) Yes 4 (57.1%) How difficult was it to use the provided treatment guidelines, No. (%) Moderately Difficult 1 (25%) Slightly Difficult 1 (25%) Not Difficult 2 (50%) How satisfied are you with the provided treatment guidelines, No. (%) Neutral 2 (50%) Satisfied 1 (25%) Very Satisfied 1 (25%) Treatment guidelines would be useful, No. (%) Strongly Disagree 1 (9.1%) Disagree 1 (9.1%) Neutral 2 (18.2%) 3 (42.9%) Agree 4 (36.4%) 3 (42.9%) Strongly Agree 3 (27.3%) 1 (14.3%) EVALUATION AND MANAGEMENT OF NEUROPATHY Laboratory tests ordered at initial consult, No. (%) Hemoglobin A1C 10 (90.9%) Random Blood Glucose 2 (18.2%) Vitamin B12 10 (90.9%) TSH 11 (100%) Folate 5 (45.5%) SPIEP 2 (18.2%) ESR 4 (36.4%) Other 3 (27.3%) Physical examination techniques used, No. (%) Evaluation of Strength 9 (81.8%) Monofilament 9 (81.8%) Vibratory Sensation 5 (45.5%) Proprioception 5 (45.5%) Superficial Pain 3 (27.3%) Temperature Perception 3 (27.3%) BLE DTRs 9 (81.8%) Gait 9 (81.8%) 20 EVALUATION AND MANAGEMENT OF NEUROPATHY 21 Classes of Medications used to treat, No. (%) Antidepressants 10 (90.9%) Anticonvulsants 11 (100%) Opioids/Opioid-Like 1 (9.1%) Medications NSAIDs 4 (36.4%) Topical Analgesics 8 (72.7%) Naturopathic 1 (91.%) Confidence in the ability to independently manage patients with neuropathy, No. (%) Slightly Confident 2 (18.2%) Moderately Confident 5 (45.5%) 3 (50%) Very Confident 2 (18.2%) 3 (50%) Extremely Confident 2 (18.2%) What percentage of patients have been referred to a specialist, No. (%) 0% 2 (18.2%) 3 (42.9%) 1-25% 8 (72.7%) 2 (42.9%) 26-50% 1 (9.1%) 1 (14.3%) To what specialty are patients referred, No. (%) EVALUATION AND MANAGEMENT OF NEUROPATHY Radiology/Imaging 1 (9.1%) Neurology 8 (72.7%) PM&R/PT 4 (36.4%) Pain Specialist 3 (27.3%) Podiatry 1 (9.1%) Other 1 (9.1%) 22 EVALUATION AND MANAGEMENT OF NEUROPATHY Appendix A Neuropathy Pre-Survey The following questions are related to you: 1. Age o 18-24 years o 25-34 years o 35-44 years o 45-54 years o 55-64 years o 65-74 years o 75 years or older 2. Gender o Male o Female o Transgender o Prefer not to say o Other  If other, please specify: 3. Profession o Physician o Resident Physician o Physician Assistant o Nurse Practitioner/Doctor of Nursing Practice (DNP) 23 EVALUATION AND MANAGEMENT OF NEUROPATHY 4. Years in Practice o 0-5 years o 6-10 years o 11-15 years o 16-20 years o 21-25 years o 26-30 years o 31 years or more 5. Specialty Text box 6. Board Certification (Sub-specialty certification for MDs) - Do you hold more than one board certification? If so, then please specify: Text box 7. Race o American Indian/Alaska native o Asian o Native Hawaiian or other Pacific Islander o Black or African-American o White o Prefer not to answer o Other  8. Ethnicity If other, please specify 24 EVALUATION AND MANAGEMENT OF NEUROPATHY 25 o Hispanic or Latino o Not Hispanic or Latino o Prefer not to answer o Other  If other, please specify: The following questions are related to your clinical practice: 1. In the last six months, have you seen patients with neuropathic symptoms (e.g., numbness, burning pain, etc.)? o Yes o No (If yes, then branching from question 1) a) In the last six months, how many patients with neuropathic symptoms have you seen? Estimate: 1-5 patients 6-10 patients 11-15 patients 16-20 patients 21-25 patients 26-30 patients 31-35 patients 36-40 patients 41-50 patients 50 patients or more EVALUATION AND MANAGEMENT OF NEUROPATHY (If yes, then branching from question 1) b) In the last six months, which of the following neuropathic symptoms have you seen in clinical practice? Select all that apply: o Numbness o Tingling o Burning pain o Pins/needles o Gait imbalance o Other:  If other, please specify 2. In the last six months, have you used any treatment guidelines for neuropathic symptoms in practice? o Yes o No (If yes, then branching from question 3) a) What type of treatment guidelines do you utilize in your clinical practice to evaluate and treat neuropathic symptoms? Select all that apply: o Guidelines provided by your organization o Online clinical resource/ Smartphone application (e.g., UpToDate, Epocrates, etc.) o Specialty consult by phone or e-mail o Guidelines committed to memory o Other 26 EVALUATION AND MANAGEMENT OF NEUROPATHY  27 If other, please specify: (If yes, then branching from question 3) b) How satisfied are you with your current treatment guidelines? o Very dissatisfied o Dissatisfied o Neutral o Satisfied o Very Satisfied 3. Treatment guidelines would be useful in your practice: o Strongly disagree o Disagree o Neutral o Agree o Strongly agree 4. What laboratory tests do you order at initial consult to evaluate for the presence of neuropathic symptoms? Select all that apply: o Hemoglobin A1C o Fasting blood glucose o Random blood glucose o Vitamin B12 o Thyroid function tests o Folate o Heavy metals EVALUATION AND MANAGEMENT OF NEUROPATHY 28 o Serum protein immunofixation electrophoresis (SPIEP) o Serum antinuclear antibodies o Erythrocyte sedimentation rate o Other i. If other, please specify 5. What physical examination techniques do you use to evaluate a patient with the presence of neuropathic symptoms? Select all that apply: o Evaluation of strength o Evaluation of sensation via 10-g Semmes-Weinstein monofilament o Evaluation of vibratory sensation with a 128-Hz tuning fork o Evaluation of proprioception o Evaluation of superficial pain o Evaluation of temperature perception o Examination of bilateral lower extremity deep tendon reflexes o Evaluation of gait o Other  If other, please specify 6. What classes of medications do you prescribe to treat neuropathic symptoms? Select all that apply: o Antidepressants (e.g., amitriptyline, nortriptyline, desipramine, duloxetine, venlafaxine, etc.) o Anticonvulsants (e.g., pregabalin, gabapentin, sodium valproate, etc.) o Opioid or opioid-like medications (e.g., oxycodone, tramadol, etc.) EVALUATION AND MANAGEMENT OF NEUROPATHY 29 o Nonsteroidal anti-inflammatories (e.g., ibuprofen, etc.) o Topical analgesic (e.g., capsaicin cream, lidocaine ointment/patch, etc.) o Naturopathic (e.g., acetyl-L-carnitine, etc.) o Other i. If other, please specify: 7. In the last six months, how confident have you felt in your ability to manage patients with neuropathic symptoms independently? o Not confident o Slightly confident o Moderately confident o Very confident o Extremely confident 8. In the last six months, what percentage of patients with neuropathic symptoms have you referred to a specialist? o 0% o 1-25% o 26-50% o 51-75% o 76-100% 9. To what specialty do you refer patients with neuropathic symptoms? Select all that apply: o Endocrine o Radiology/Imaging EVALUATION AND MANAGEMENT OF NEUROPATHY o Neurology o Orthopedics o Physical Medicine and Rehab/Physical Therapy o Pain Specialist o Podiatry o Other i. If other, please specify 30 EVALUATION AND MANAGEMENT OF NEUROPATHY 31 Appendix B Neuropathy Post-Survey The following questions are related to the treatment guidelines which you have used in clinical practice for the last month: 1) In the last month, have you seen patients with neuropathic symptoms (e.g., numbness, burning pain, etc.)? o Yes o No (If yes, then branching from question 1) c) In the last month, how many patients with neuropathic symptoms have you seen? Estimate: 1-5 patients 6-10 patients 11-15 patients 16-20 patients 21 patients of more 2) In the last month, have you used the provided treatment guidelines for neuropathic symptoms in practice? o Yes o No (If yes, then branching from question 1) a) How difficult was it to use the provided treatment guidelines? o Extremely difficult EVALUATION AND MANAGEMENT OF NEUROPATHY o Very difficult o Moderately difficult o Slightly difficult o Not difficult (If yes, then branching from question 1) b) How satisfied are you with the provided treatment guidelines? o Very Dissatisfied o Dissatisfied o Neutral o Satisfied o Very Satisfied 3) The provided treatment guidelines are useful in your practice (if not used in the previous month, will be useful in the future): o Strongly disagree o Disagree o Neutral o Agree o Strongly agree a) If the provided treatment guidelines are useful, please specify what is useful about them: Text box 32 EVALUATION AND MANAGEMENT OF NEUROPATHY 33 b) How would you revise the provided treatment guidelines to meet the needs of your patients with neuropathic symptoms? Text box 4) In the last month, based on applying and using the provided treatment guidelines, how confident have you felt in your ability to manage patients with neuropathic symptoms? o Not confident o Slightly confident o Moderately confident o Very confident o Extremely confident 5) In the last month, what percentage of patients with neuropathic symptoms did you refer to a specialist? o 0% o 1-25% o 26-50% o 51-75% o 76-100% EVALUATION AND MANAGEMENT OF NEUROPATHY Appendix C Neuropathy Algorithm 34 EVALUATION AND MANAGEMENT OF NEUROPATHY 35