Evaluating a Program Process Change to Improve Completion of Foot Exams and Amputation Risk Assessments for Veterans with Diabetes

Methods

Established by the American Diabetes Association and endorsed by the American Association of Clinical Endocrinologists, the comprehensive foot exam includes a visual exam, pedal pulse checks, and a sensory exam.^9,10 The templated Computerized Patient Record System (CPRS) electronic health record note specifies normal and abnormal parameters of each section. On the same template, the provider assigns an ARA score based on the results of the completed foot exam. Risk scores range from 0 to 3 (0, normal or no risk; 1, low risk, 2; moderate risk; 3, high risk) If the veteran has normal or low risk, the PCP can encourage the veteran to remain at low risk by entering an administrative CPRS text order for the nurse care manager to offer education about daily foot care at the same visit or at a scheduled follow-up visit. This process facilitates nurse care managers to include routine foot care as integral to their usual duties coaching veterans to engage in self-care to manage chronic conditions. If the risk is assessed as moderate or high risk, PCPs are prompted to send a referral to podiatry to repeat the foot exam, verify the ARA score, and provide appropriate foot care treatment and follow-up.

On October 31, 2017, following training on the updated foot exam and ARA template with staff at the 13 VAPORHCS outpatient clinic sites, 2 sites piloted all components of the Comprehensive Foot Care program. An in-person training was completed with PCPs to review the changes of the foot care template in CPRS and to answer their questions about it. PCPs were required to complete both the 3-part foot exam and ARA at least once annually with veterans with DM.

An electronic clinical reminder was built to alert PCPs and PACTs that a veteran was either due or overdue for an exam and risk assessment. VA podiatrists agreed to complete the reminder with veterans under their care. One of the 2 sites was randomly selected for this study. Data were collected from August 1, 2017 to July 31, 2018. Patients were identified from the Diabetes Registry, a database established at VAPORHCS in 2008 to track veterans with DM to ensure quality care.¹¹ Veterans’ personal health identifiers from the registry were used to access their health records to complete chart reviews and assess the completion, accuracy and timeliness of all foot care components.

The Diabetes Registry lists a veterans’ upcoming appointments and tracks their most recent clinic visits; laboratory tests; physical exams; and screening exams for foot, eye, and renal care. Newly diagnosed veterans are uploaded automatically into this registry by tracking all DM-related International Classification of Diseases (ICD-10) codes, hemoglobin A_1c (HbA_1c) levels ≥ 6.5%, or outpatient prescriptions for insulin or oral hypoglycemic agents.¹¹

Study Design

This quality improvement project evaluated PCPs’ actions in a program process change intended to improve foot care provided with veterans at-risk for nontraumatic lower limb amputations. Audits of CPRS records and the Diabetes Registry determined the results of the practice change. Data on the total number of foot exams, amputation risk scores, appropriate podiatry referrals, administrative orders for nurse coaching, and completed foot care education were collected during the study period. Data collected for the 3-month period preceding the process change established preimplementation comparison vs the postimplementation data. Data were collected at 3, 6, and 9 months after implementation. The foot exams and ARAs were reviewed to determine whether exams and assessments were completed accurately during the pre- and post-implementation timeframes. Incomplete or clearly incorrectly completed documentation were considered inaccurate. For example, it was considered inaccurate if only the foot exam portion was completed in the assessment and the ARA was not.