Improving
Diabetic Foot Screening
Rates in an Academic
Primary Care Clinic
S Hata, CL Roumie, WM Gregg, J Scott, K Hall,
R Follett, P Johnston, C Brown, and GW Garriss
Vanderbilt University Medical Center
The speaker has no conflicts of interest to disclose pertinent to this presentation.
Context




Academic Chronic Care Collaborative
sponsored by the AAMC
Promoted health care innovations in
academic health centers
22 AHC participated in improving
chronic illness care
Vanderbilt addressed diabetes care
Screening Diabetic Foot Exam



The American Diabetes Association
recommends a yearly diabetic foot exam.
Early detection and intervention prevent
morbidity and amputations.
Locally, our adherence to this guideline has
been suboptimal.
What are you trying to
accomplish?
Aims
Measure our local data on documented foot
exams
 Improve the proportion of documented 4
element diabetic foot exams (DFE) to
greater than 90%, through use of PDSA
cycles to implement evidence-based
guidelines

Hypothesis

Percentage of completed/documented
DFEs would be improved by use of PDSA
cycles to institute small tests of change in a
year
How will you know a change is
an improvement?
Process Measures
 Percent
of foot exams documented
with each method
Templated note
• Team DFE
• Both
• Other (free text writing in a note)
•
Outcome Measure
 Proportion
of patients with diabetes
who have 4 element DFE documented
within the past 12 months
Design and Setting
 Study
Design: Observational Study
with multiple Plan-Do-Study-Act
cycles
 Setting: Adult Primary Care Clinic
Vanderbilt University Medical
Center, Nashville, TN
 IRB approval obtained
Study Timeline
Intervention #1 - Provider Education
Intervention #2 - Posters
Intervention #3 - Note template
Intervention #5- Team approach
Registry
created
June
2004
Study
completed
July
2005
October
2005
June
2006
Intervention #4 - Provider Feedback (quarterly)
Methods - Population
 Inclusion
•
•
•
Criteria
Registry created, June 2004
Search problem lists for “diabetes” or
“DM”
ICD-9 CM = 250.x within the last 2 years
 Patients < 18 y.o.
 Study population
•
•
were excluded
338 patients with diabetes (July 2005)
Registry updated (April 2006) to 387
patients
What changes can you make?
Intervention #1 – Provider Education
 July 2005
 Met with primary care providers
 Encouraged cooperation by sharing
data regarding foot exam rates
 Discussed the goals of the Diabetic
Foot Exam Project
 Standardized DFE method for
resident and faculty providers
Complete Diabetic Foot Exam
 Based
on ABIM’s
PIM for diabetes
 Four elements:
•
•
•
•
Visual inspection
Pulses
Sensation
10 g monofilament
Singh N, Armstong DG, and Lipsky BA. Preventing Foot Ulcers in Patients with Diabetes.
JAMA. 2005; 293:217-28.
Intervention #2 – Poster
Began July 2005
Intervention #3 – Note Template
Introduced July 2005
 Included ADA guidelines for:

Glycemic control
• BP control
• LDL goals
• Annual DFE
•

Physical exam in template
included 4 element DFE
Intervention #4 - Provider Feedback
 Began
July 2005 and continued
quarterly
 Practice report of patients with
diabetes
 Report included each patient’s
most recent:
•
•
•
•
A1c
BP
LDL
DFE
Intervention #5- Team Approach
Patient presents
to
primary care
Nurse
performs
DFE
Tech asks
“Do you have
diabetes?”
DFE completed &
documented in
medical record
Prompts pt to
remove shoes
Alerts Nurse
pt with DM
Nurse notifies
doctor
pt is ready
for visit
Intervention began October 2005
Analysis
 Outcome
extracted through manual
and electronic chart review
 Run Chart using a rolling 12 month
period and updated monthly
Results- Patient characteristics
Characteristic
Population=338 patients
N (%)
Age - years, mean ± SD
51.9 ± 14.3
Female sex
218 (64.5)
A1C <7%
118 (35)
LDL <100 (mg/dL)
176 (52)
BP <130/80
111 (33)
ACEi/ARB use
270 (80)
Results- Provider characteristics
Characteristic
N=38 providers (%)
Age (mean ± SD)
31 ± 5
Sex
19 (50)
Attending MD
9 (23.7)
Resident MD
29 (76.3)
Clinics per month, attending mean
(range)
12.5 (4-16)
Clinics per month, resident
mean (range)
3 (2.6-3.6)
Pts per provider, mean (range)
9.9 (1 - 50)
60
40
30
20
10
+
pl
at
e
th
er
O
FE
D
Te
m
Te
am
Te
Te
am
0
ot
e
N
July/August 2005
December 2005
June 2006
50
m
pl
at
e
percent of total foot exams
Results – Method to
Complete/Document DFE
Absolute increase of 65%
100
82%
80
60
40
17%
20
0
with
E
percent of patients with
documented DFE
Results
0 1
100
2 3 4 5 6 7 8 9 10 11 12
n = 338
Diabetic Foot Exam Run Chart
Registry updated/ expanded
from n = 338 to 387
Goal
(April 2006)
Team DFE started
in other Suites
O
ct
De
c
Fe
b
Au
g
Ju
n
Ap
r
(Jan 2006)
O
ct
De
c
Fe
b
Baseline
100
90
80
70
60
50
40
30
20
10
0
Au
g
Documented “Full” Diabetic Foot Exam
Percent of Patients with
Data From ACCC Cohort and Controls
* Controls = 350 Randomly Selected Non-ACCC Cohort Patients
ACCC Cohort
*Controls
Limitations
 One
academic primary care clinic
site
 Small number of patients and
providers
 Multiple interventions employed
simultaneously
 Note templates may introduce some
inaccuracy
Lessons Learned
•
Weak links in our system
•
•
•
•
Lost monofilaments
Forgetful, busy providers
Resistance to change
A team approach can fix problems
•
•
•
Redundancy to prevent missed opportunities
Time saving for providers
“Doctor-proofed”
Summary and Implications
 Multi-factorial
interventions resulted
in an absolute increase of 65% in
annual DFE rate
 Increased teamwork among
physicians, nurses, techs
 Improved quality of care for
patients with diabetes
 Plan to expand these interventions
to all primary care clinics at
Vanderbilt
Acknowledgements
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Susan Hata, MD
Christianne Roumie, MD MPH
William Gregg, MD, MPH
Julie Scott, RN
Kara Hall, RN
Robert Follett, BS
Phil Johnston, Pharm D
Charlotte Brown, BS
Excerpt of Note Template
(Intervention #3)
“We are what we repeatedly do.
Excellence, then, is not an act,
but a habit.”
- Aristotle