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

Data Analysis

Data on the total number of accurately completed foot examinations and ARAs, total number of podiatry referrals, and total number of administrative text orders placed by PCPs, and education completed by nurse care managers were assessed. Statistical significance was evaluated using χ² and Fisher exact test as appropriate. A Pearson correlation coefficient was used to determine whether there was a statistically significant increase in accurate foot examinations and ARAs as well as total number of podiatry referrals during the study period. Statistical analyses were performed using Stata 14.1 statistical software (College Station, TX).

Results

A total of 1,242 completed diabetic foot examinations were identified from August 1, 2017 to July 31, 2018 using the Diabetes Registry (Table). For the 3 months prior to the change, there were 191 appropriately completed foot examinations and ARAs. This number increased progressively over three 3-month periods (Figure 1). Within the 1-year study period, there was a statistically significant increase in the number of appropriate foot examinations (r = 0.495). PCPs placed 34 podiatry referrals during the prechange period. After the change, the number of appropriate referrals increased statistically significantly in the 3 following 3-month-periods (r = 0.222) (Figure 2).

To determine the accuracy of documentation and ratio of appropriate referrals, the 3-month prechange data was compared with the 9-month postchange period. There was a statistically significant increase from pre- to postchange accuracy of documentation for examinations and ARAs (53.1% vs. 97.7%). The percentage of appropriate podiatry referrals increased significantly from 41.5% to 76.8%. Overall, there was poor adherence to protocol for the text order and education that was implemented during the change. Only 4.6% of patients had an administrative text order entered into CPRS and 3.9% were provided with foot care coaching. There was no statistical difference in the use of text orders between the first 3-month period and the last 3-month period (5.2% vs. 2.1%). Similarly, there was no statistical difference in the rate of patient education between the first 3-month period and the final 3-month period (2.6% vs. 2.1%).

Notably, at the end of the first year of this evaluation, 119 veterans at the clinic did not show a recorded comprehensive foot examination since receiving a DM diagnosis and 299 veterans were due for an annual examination—a 25.2% gap of veterans without the recommended progression of foot care services. Of those that previously had a recorded foot examination, 51 (17.0%) veterans were found to be ≥ 2 years overdue.

Discussion

DM management requires a comprehensive team-based approach to help monitor for associated complications. At the VA, PACTs are veterans’ initial and primary point of contact for chronic condition management. PACTs have regular opportunities to engage veterans in initial and follow-up care and appropriate self-care. PCPs are critical in placing referrals for specialized care promptly to prevent and minimize complications such as foot ulcers, and ultimately, lower limb amputations.^9,10,12

When PCPs assume responsibility for the entire foot examination, they are able to identify problems early.¹ Left untreated, foot wounds and ulcers have the potential to grow into serious infections.⁹ Early risk identification and management can lead to increased patient satisfaction, improved life expectancy, quality of life, and ultimately, lower healthcare costs.¹²

Multiple studies have shown the clinical importance of foot examinations in preventative care. In one study, researchers found that completing foot examinations, among other early interventions, increased life expectancy and reduced foot complications.¹³ Diabetic foot management programs involving screening and categorizing patients into low- and high-risk groups had a 47.4% decrease in the incidence of amputations and 37.8% decrease in hospital admissions.¹⁴ Amputations were found to be inversely correlated with multidisciplinary foot care programs with reduction of lower limb amputations at 2 years.¹⁵ The Centers for Disease Control and Prevention found that comprehensive foot care programs that include a foot examination, ARA, appropriate referrals to specialists, and foot-care education and preventative services can reduce lower limb amputation rates by 45% to 85%.¹⁶

With one of the highest amputation rates in VA, VAPORHCS needed an integrated approach to ensure that appropriate foot care occurred regularly with veterans with DM. Prior to the process change, LPNs completed foot examinations and PCPs completed the ARA. Separating these clinical services resulted in few veterans receiving an amputation risk score. Of those with scores, the lack of a standardized program protocol resulted in discrepancies between ARAs from patient to patient as health care providers did not have clear or enough information to select the correct score and make the appropriate referrals. Thus, veterans previously identified as at moderate or high risk also lacked podiatric follow-up care.

The new quality-driven process change corrected the documentation process to nationally accepted standards. The goal was to create a consistent template in the electronic health record for all health care providers. The new template simplifies the documentation process and clarifies the amputation risk score assignment, which allows for proper foot care management. The PCP completes the process from assessment through referral, removing gaps in care and improving efficiency. Although this change was initially met with resistance from PCPs, it led to a significant increase in the number of patients with accurately documented examinations. Similarly, the number of appropriate referrals significantly rose during the study period. The standardized documentation process resulted in improved accurate examinations and ARAs over the past year. The new program also resulted in an increased number of appropriate podiatry referrals for those identified to be at moderate or high risk. This elevation of care is crucial for veterans to receive frequent follow-up visits for preventative care and/or treatment, including surgical modalities to promote limb salvage.