Conference Coverage
Smart insoles reduce ‘high-risk’ diabetic foot ulcer recurrence
BERLIN – Novel plantar pressure–sensing insoles reduced the recurrence of diabetic foot ulcers by 71% in a randomized, single-blind controlled...
Barriers
This project identified several barriers to the Comprehensive Foot Care program. One major barrier was health care provider resistance to using the new process. For example, VAPORHCS podiatrists are not using the new template with established patients, which requires PCPs to complete the clinical reminder template for quality performance, an additional burden unrelated to clinical care. PCPs that do complete the foot examination/ARA templated note use the podiatrist’s visit note without personally assessing the patient.
PCPs also have been resistant to entering administrative text orders for preventative foot care in normal- or low-risk veterans (4.6% overall), which has resulted in decreased patient education (3.9% overall). Education for normal-risk and low-risk patients is designed to engage veterans in self-care and prevent risk progression, critical to prevention.
It was found that PCPs often did not ask nurses to coach normal- or low-risk veterans on preventative foot care, as suggested by the low rates at which patients were offered education. This is an area we will target with future quality improvement efforts. All patients with DM should have general education about risk factors and appropriate management of them to decrease their risk for complications.9 Preventative foot care education is a critical resource to share with patients during health coaching opportunities to clarify misunderstandings and support change talk when patients are ambivalent or resistant to change. Individual or group-based nurse visits can facilitate better coaching for patients.
At the VA, coaching begins with a conversation about what matters most to the veteran, facilitating the development of a personalized plan based on patients’ values, needs, preferences and goals.9,10,12,17 Coaching allows nurses to assess veterans’ knowledge and willingness to engage in healthy habits; and identify additional resources to help them achieve their goals.
Limitations
There are many limitations to this short quality improvement analysis. For example, only 1 of 2 clinics that piloted the program change was evaluated. In addition, there are 11 other clinics that need additional in-depth education on the program change. Although this analysis was overwhelmingly positive, it may not be as successful at other clinic sites and may be subject to the Hawthorne effect—since the 2 piloted locations knew they were being observed for the quality improvement program and may have made an extra effort to be compliant.18 Additionally, we were unable to track the records of veterans receiving care through the VA Choice Program for this analysis resulting in a lack of documentation of completed diabetic foot examinations and a lack of internal referrals to VA podiatry.
Another major limitation of this project involved calculating the number of referrals placed to podiatry. On January 1, 2018, about halfway through the program evaluation, a national VA decision enabled veterans to self-refer to podiatry, which may have limited the number of podiatry referrals placed by PCPs. Finally, patients could refuse podiatry referrals. In the 9-month postimplementation period, 57 (64.8%) veterans declined podiatry referrals, according to their CPRS records.
Although, there was an improvement in the accuracy of diabetic foot examinations, ARAs, and appropriate podiatry referrals, the ultimate goal of reducing diabetic foot ulcers and lower limb amputations was not tracked due to the limited timeframe of this analysis. Tracking these endpoints with continuous plan-do-study-act cycles are needed for this ongoing quality improvement project.
