526789
research-article2014
TDEXXX10.1177/0145721714526789Complete Foot Exams in Patients With DiabetesSzpunar et al
Complete Foot Exams in Patients With Diabetes 281
Improving Foot Examinations in Patients With Diabetes A Performance Improvement Continuing Medical Education (PI-CME) Project
Purpose
Susan M. Szpunar, MPH, DrPH Steven E. Minnick, MD, MBA
The purpose of this project was to determine if a Performance-Improvement Continuing Medical Education (PI-CME) project, using the American Medical Association’s methodology, would help improve the timeliness and comprehensiveness of foot examinations in patients with diabetes.
Methods A PI-CME project was conducted with the Internal Medicine faculty staff physicians (n = 8) and residents (n = 45). Following the 3 steps of PI-CME, participants received baseline reports about their performance defined by the American Diabetes Association’s guidelines for foot examinations (stage A). Each group received an educational intervention (stage B) and a reminder tool for use in the practice. Participants received individualized reports about their performance post intervention (stage C) for comparison with preintervention data and reflection on any changes in compliance.
Imhoitsemeh Dako, MD Louis D. Saravolatz II From St. John Hospital and Medical Center, Department of Medical Education, Grosse Pointe Woods, Michigan (Dr Szpunar, Dr Minnick, Dr Dako, Mr Saravolatz). Correspondence to Dr Susan M. Szpunar, MPH, DrPH, Department of Medical Education, St. John Hospital and Medical Center, Mack Office Building, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI, 48236, USA ([email protected]). Acknowledgments: This project was supported by an educational grant from Pfizer. Conflict of Interest: No potential conflicts of interest relevant to this article were reported. DOI: 10.1177/0145721714526789 © 2014 The Author(s)
Results In the faculty and resident clinics, the percentage of patients who received an annual foot examination when due increased significantly. Both clinics also showed improvements in the percentage of patients who received all 3 components of the exam, with the greatest improvement in the resident clinic. Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 282
Conclusions
For foot care, the ADA issued the following recommendations:
The PI-CME approach can be successfully used both with faculty staff physicians (who receive CME credits) and residents (who do not receive credits) to improve performance on diabetes quality measures.
Introduction Diabetes mellitus is a highly prevalent condition in the US,1 and the complications of diabetes result in considerable costs, diminished quality of life, and mortality. Among individuals with diabetes, the lifetime risk of developing a foot ulcer is estimated to be as high as 25%, with an annual incidence estimated at 2%.2 An episode of minor trauma that may lead to cutaneous injury is often the initiating event in the development of a foot ulcer. The principal risk factors for foot ulceration include: previous contralateral amputation, past foot ulcer history, peripheral neuropathy, foot deformity, peripheral vascular disease, visual impairment, diabetic nephropathy, elevated A1C, and cigarette smoking.2 Neuropathy is present in the majority of patients with foot ulcers. Neuropathy contributes to ulcer formation by decreasing pain and pressure sensation causing the muscle imbalance and gait disturbances that often lead to anatomic deformities. In addition, impaired microcirculation and skin integrity play a role in ulcer formation. Once ulcers form, healing may be delayed or difficult, particularly if infection penetrates the deep tissues and bone.3 Complications from foot ulcers can lead to severe infection, gangrene, and ultimately to amputation. Diabetes mellitus is the leading cause of nontraumatic lower limb amputations among adults in the US.1 Lower limb amputations are devastating events that result in permanent disability and often lead to loss of employment and a downward spiral into depression and worsening health problems. The total estimated cost of diagnosed diabetes was $245 billion in 2012. This figure includes $176 billion in direct medical costs and $69 billion in reduced productivity.4 From Medicare data, patients with a lower limb amputation visit their physician approximately 12 times per year and are hospitalized about 2 times per year. The total reimbursement for all Medicare services per year in this patient group is approximately $52 000.5 The American Diabetes Association (ADA) issues guidelines for the medical care of patients with diabetes.6
For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.
It is essential that all 3 components of the foot examination be completed, as each component assists in identifying foot conditions that may lead to ulcers and in quantifying the risk for ulcer development in the future. Practice Gap
Patients with diabetes seen in the Internal Medicine Faculty and Resident clinics at St. John Hospital and Medical Center (Detroit, Michigan) frequently do not receive an annual foot examination, and when the foot examination is completed, 1 or more components of the examination is not done or not documented as done. We designed a Performance Improvement Continuing Medical Education (PI-CME) project to address this practice gap in the faculty clinic. The project also included the Internal Medicine resident staff, even though residents are not eligible to receive CME credits, in order to optimize the transfer of knowledge from Internal Medicine faculty staff physicians to residents. The overall goal of this project was to improve the percentage of patients with diabetes who receive an annual foot examination and to increase the percentage of patients who have all 3 components of the exam completed, in both the faculty and resident Internal Medicine clinics.
Methods Performance Improvement Continuing Medical Education
As defined by the American Medical Association (AMA) PI-CME is a certified CME activity in which an accredited CME provider structures a long-term 3-stage process by which a physician or group of physicians learn about specific performance measures, assess their practice using the selected performance measures (stage A), implement interventions to improve performance related to these measures over a useful interval of time (stage B), and then reassess their practice using the same performance measures (stage C).7 Physicians who participate in
Volume 40, Number 3, May/June 2014 Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
Complete Foot Exams in Patients With Diabetes 283
the project can earn 5 CME credits for each stage completed and an additional 5 credits for completing all 3 stages, for a total of 20 credits. To receive credit a physician must begin with stage A (baseline assessment). PI-CME Stage A
For this project, the first step was a baseline assessment of patients with diabetes seen in the faculty or resident clinic. We queried the outpatient billing records to identify all patients with diabetes who had a clinic visit to either the faculty or resident clinic during the period January 2011 to April 2011. For each patient, a research assistant (RA) reviewed the electronic medical record (EMR) to determine if the patient was due for an examination at that visit. A patient was considered to be “due” if no foot examination had been done in the past year. The RA reviewed the EMR to collect demographic and clinical variables (comorbidities, risk factors for foot ulcers, A1C values) and to determine whether a foot examination was done. The RA looked for evidence of inspection, results of monofilament testing, and assessment of pulses. If there was notation of either the monofilament test or pulse assessment but no notation of inspection, then credit for inspection was given (inspection done, not documented) because the patient would have had to take off his or her socks for the other assessments to be done. Following the chart review, a confidential report was prepared for each individual faculty staff physician and resident. The report listed the number of patients with diabetes that the physician had seen in the baseline period and the following metrics: •• number/percentage of patients who were due for an annual exam; •• number/percentage of patients who did not receive an exam when due; •• number/percentage of patients who had inspection done only; •• number/percentage of patients who had inspection and pulses done but no documentation of the monofilament test; •• number/percentage of patients who had inspection and the monofilament test done but no documentation of the assessment of pulses; and •• number/percentage of patients who had all 3 components done and documented in the EMR. PI-CME Stage B
For stage B, the faculty staff physicians participated in a lecture about the importance of foot examinations, the
components of a complete foot examination, and the PI-CME process. Aggregate baseline data for the faculty and resident clinics were presented along with the checklist (Figure 1). The checklist reminded the physician that a patient with diabetes should have an annual foot examination and listed the 3 components with a check box next to each component. Following the lecture, each physician received their confidential individual report of foot exam performance for the 4-month baseline period in a sealed envelopes. Similar to the faculty intervention, the residents participated in an educational session during their 1-hour morning report. A faculty staff physician demonstrated the proper method of doing the foot examination and answered any questions. The checklist was also introduced in the resident clinic. At the end of the educational session, each resident also received a confidential individual report about their performance on foot exams over the 4-month baseline period. PI-CME Stage C
For stage C, the outpatient billing records were again queried for all patients with diabetes who had a visit to the faculty or resident clinic during the period February 2012 to May 2012 for the faculty staff physicians and February 2012 to April 2012 for the residents. The resident postimplementation data collection period was 1 month shorter so that the chart review for the resident data could be completed in May and individual reports given to the residents in June. This would assure that graduating thirdyear residents would receive their follow-up information.
Data Collection and Analysis Data were collected by an experienced research assistant on paper data collection forms. The data were then entered into a Microsoft Access database. If a patient had more than 1 visit in a data collection period, only the first visit was used. Any patient who was included in the baseline data collection and had a visit during the post- education data collection period was removed from the post-education list. Statistical analysis was done using Student’s t-test and the chi square test. All data were analyzed using SPSS v. 21.0, and a P value of .05 or less was considered to indicate statistical significance. The project was deemed exempt by the St. John Hospital and Medical Center Institutional Review Board.
Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 284
Foot Examination Checklist for Patients with Diabetes
All patients with diabetes should have a comprehensive annual foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.
Date of patient’s last foot examination:______________________________ Is the patient due for a foot examination today? Yes No (stop here)
Comprehensive Foot Examination (all parts must be completed)
Inspection
Monofilament test for loss of protective sensation
Assessment of Foot Pulses
Does the patient need a referral to podiatry? Yes No
Figure 1. Foot examination checklist for patients with diabetes.
Results Participants
All of the faculty staff physicians in the Internal Medicine clinic participated in the project (n = 8), and there were no physicians who dropped out of the project. The mean number of charts reviewed per faculty staff physician was 56 (range, 29-114). All Internal Medicine residents (n = 52) attended the educational session. Because residents spend only a portion of their time in the outpatient clinic, the number of charts reviewed per resident would vary by the resident’s rotation schedule and program year. Thus, it was possible for some residents to see no patients with diabetes during one of the data collection periods. Residents received a report for any period in which they saw at least 1 patient with diabetes; thus, 45 residents received at least 1 performance
report. The mean number of charts reviewed per resident was 8 (range, 1-24). Medical assistants were asked to attach the paper reminder slip to the intake forms for each patient as part of their routine intake process. Comparison of Group Characteristics
Figure 2 shows the number of charts reviewed in the baseline and post-education periods by clinic. The percentage of patients who were due for an annual examination ranged from 60% in the baseline period for the resident clinic to 74% for the baseline period in the faculty clinic. For the overall study groups (data not shown), the only significant difference between the pre- and posteducation study groups was the distribution by race in the faculty clinic, with more patients in the post-education period being classified as “other.” Tables 1 and 2 show
Volume 40, Number 3, May/June 2014 Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
Complete Foot Exams in Patients With Diabetes 285
Total Faculty Clinic Charts Reviewed n=504
Total Resident Clinic Charts Reviewed n=521
Pre-intervention 1/2011-4/2011 n=252
Postintervention 2/2012-5/2012 n=252
Pre-intervention 1/2011-4/2011 n=300
Postintervention 2/2012-4/2012 n=221
Due for a Foot Exam n=188 (75%)
Due for a Foot Exam n=169 (67%)
Due for a Foot Exam n=180 (60%)
Due for a Foot Exam n=141 (64%)
Figure 2. Total number of charts reviewed, by clinic, time period and need for a foot examination.
Table 1
Clinical and Demographic Characteristics of Patients Due for a Foot Exam, Faculty Clinic, Pre- and Post-Intervention Characteristic Mean age Mean A1C Male gender Race Black White Other Diabetes type Type 1 Type 2 Undetermined Prior foot ulcer CAD CHF Hypertension Kidney disease Peripheral neuropathy PVD HIV or AIDs COPD CVA
Pre (n = 188) Mean or %
Post (n = 169) Mean or %
63.0 ± 12.9 7.5 ± 2.1 44.7
64.3 ± 12.4 7.5 ± 2.0 39.6
66.7 32.2 1.1
65.1 27.2 7.7
2.2 93.0 4.9 1.6 21.3 7.0 84.0 17.6 12.8 9.0 1.1 8.0 8.0
2.4 91.1 6.5 1.2 23.7 9.5 86.4 14.2 12.4 10.1 0.6 9.5 10.1
P-Valuea .33 .89 .34 .008
.79
.74 .59 .40 .52 .39 .92 .74 .63 .63 .49
a Student t-test was used to compare means; the χ2 test was used to compare proportions; a P-value of .05 or less was considered to indicate statistical significance. Abbreviations: CAD, coronary artery disease; CHF, congestive heart failure; PVD, peripheral vascular disease; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident
Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 286
Table 2
Clinical and Demographic Characteristics of Patients Due for a Foot Exam, Resident Clinic, Pre- and Post-Intervention Characteristic Mean age Mean A1C Male gender Race Black White Other Diabetes type Type 1 Type 2 Undetermined Prior foot ulcer CAD CHF Hypertension Kidney disease Peripheral neuropathy PVD HIV or AIDs COPD CVA
Post (n = 141) Mean or %
P-Valuea
55.4 ± 14.3 7.9 ± 2.1 33.9
54.7 ± 15.0 8.1 ± 2.4 34.8
85.0 10.6 4.4
85.8 9.2 5.0
.65 .51 .87 .91
6.1 90.5 3.4 1.7 14.4 10.8 85.4 21.7 11.7 6.1 1.1 14.4 10.1
5.7 90.1 4.3 1.4 19.1 20.6 87.9 21.3 9.9 7.1 0.0 18.4 7.8
Pre (n = 180) Mean or %
.73
.86 .26 .02 .51 .66 .62 .72 — .34 .49
a Student t-test was used to compare means; the χ2 test was used to compare proportions; a P-value of .05 or less was considered to indicate statistical significance. Abbreviations: CAD, coronary artery disease; CHF, congestive heart failure; PVD, peripheral vascular disease; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident.
the baseline and post-education demographic and clinical characteristics for all patients who were due for an examination at the queried visit in the faculty and resident clinics, respectively. As for the full study group, there were significantly more faculty clinic patients with race classified as “other” in the post-education period. In addition, there was a significantly higher percentage of patients with congestive heart failure (CHF) in the post-education period in the resident clinic. Thus, the pre- and posteducation study groups were largely similar in the baseline and post-education periods for both clinics. Comparison of Foot Examination Findings
Table 3 shows the percentage of patients in the faculty clinic who received their annual foot examination when due for an examination as well as the documented comprehensiveness of the examination for the pre- and postintervention time periods. As seen in the table, the
percentage of patients who received at least one component of the foot examination increased significantly from 49.5% to 66.3% (P = .001). The largest area of improvement was in patients receiving inspection (8.0% pre- to 22.5% post-intervention, P < .0001). The percentage of patients who received all 3 components of the foot examination increased from 28.7% to 36.7% (P = .11). The percentage of patients who had 2 components of the foot examination done but were missing the third component (either missing the monofilament test or the assessment of pulses) improved in the post-intervention period. This improvement is likely a result of the increase in the percentage of patients who received all 3 components. Table 4 shows the foot examination results for the resident clinic. For patients seen in the resident clinic, the percentage who received any portion of a foot examination when due increased significantly from 42.2% to 87.9% (P < .0001). With respect to the different components of the examination, the percentage who received
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Complete Foot Exams in Patients With Diabetes 287
Table 3
Comparison of Completeness of Foot Examinations by Time Period, Faculty Clinic Variable
Pre (n = 188) %
Any Component of Foot Exam Completed Inspection Only Inspection + Pulses (missing monofilament) Inspection + Monofilament (missing pulses) All three components
49.5 8.0 5.9 6.9 28.7
Post (n = 169) %
P-Value*
66.3 22.5 4.1 3.0 36.7
.001
research-article2014
TDEXXX10.1177/0145721714526789Complete Foot Exams in Patients With DiabetesSzpunar et al
Complete Foot Exams in Patients With Diabetes 281
Improving Foot Examinations in Patients With Diabetes A Performance Improvement Continuing Medical Education (PI-CME) Project
Purpose
Susan M. Szpunar, MPH, DrPH Steven E. Minnick, MD, MBA
The purpose of this project was to determine if a Performance-Improvement Continuing Medical Education (PI-CME) project, using the American Medical Association’s methodology, would help improve the timeliness and comprehensiveness of foot examinations in patients with diabetes.
Methods A PI-CME project was conducted with the Internal Medicine faculty staff physicians (n = 8) and residents (n = 45). Following the 3 steps of PI-CME, participants received baseline reports about their performance defined by the American Diabetes Association’s guidelines for foot examinations (stage A). Each group received an educational intervention (stage B) and a reminder tool for use in the practice. Participants received individualized reports about their performance post intervention (stage C) for comparison with preintervention data and reflection on any changes in compliance.
Imhoitsemeh Dako, MD Louis D. Saravolatz II From St. John Hospital and Medical Center, Department of Medical Education, Grosse Pointe Woods, Michigan (Dr Szpunar, Dr Minnick, Dr Dako, Mr Saravolatz). Correspondence to Dr Susan M. Szpunar, MPH, DrPH, Department of Medical Education, St. John Hospital and Medical Center, Mack Office Building, 19251 Mack Avenue, Suite 340, Grosse Pointe Woods, MI, 48236, USA ([email protected]). Acknowledgments: This project was supported by an educational grant from Pfizer. Conflict of Interest: No potential conflicts of interest relevant to this article were reported. DOI: 10.1177/0145721714526789 © 2014 The Author(s)
Results In the faculty and resident clinics, the percentage of patients who received an annual foot examination when due increased significantly. Both clinics also showed improvements in the percentage of patients who received all 3 components of the exam, with the greatest improvement in the resident clinic. Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 282
Conclusions
For foot care, the ADA issued the following recommendations:
The PI-CME approach can be successfully used both with faculty staff physicians (who receive CME credits) and residents (who do not receive credits) to improve performance on diabetes quality measures.
Introduction Diabetes mellitus is a highly prevalent condition in the US,1 and the complications of diabetes result in considerable costs, diminished quality of life, and mortality. Among individuals with diabetes, the lifetime risk of developing a foot ulcer is estimated to be as high as 25%, with an annual incidence estimated at 2%.2 An episode of minor trauma that may lead to cutaneous injury is often the initiating event in the development of a foot ulcer. The principal risk factors for foot ulceration include: previous contralateral amputation, past foot ulcer history, peripheral neuropathy, foot deformity, peripheral vascular disease, visual impairment, diabetic nephropathy, elevated A1C, and cigarette smoking.2 Neuropathy is present in the majority of patients with foot ulcers. Neuropathy contributes to ulcer formation by decreasing pain and pressure sensation causing the muscle imbalance and gait disturbances that often lead to anatomic deformities. In addition, impaired microcirculation and skin integrity play a role in ulcer formation. Once ulcers form, healing may be delayed or difficult, particularly if infection penetrates the deep tissues and bone.3 Complications from foot ulcers can lead to severe infection, gangrene, and ultimately to amputation. Diabetes mellitus is the leading cause of nontraumatic lower limb amputations among adults in the US.1 Lower limb amputations are devastating events that result in permanent disability and often lead to loss of employment and a downward spiral into depression and worsening health problems. The total estimated cost of diagnosed diabetes was $245 billion in 2012. This figure includes $176 billion in direct medical costs and $69 billion in reduced productivity.4 From Medicare data, patients with a lower limb amputation visit their physician approximately 12 times per year and are hospitalized about 2 times per year. The total reimbursement for all Medicare services per year in this patient group is approximately $52 000.5 The American Diabetes Association (ADA) issues guidelines for the medical care of patients with diabetes.6
For all patients with diabetes, perform an annual comprehensive foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.
It is essential that all 3 components of the foot examination be completed, as each component assists in identifying foot conditions that may lead to ulcers and in quantifying the risk for ulcer development in the future. Practice Gap
Patients with diabetes seen in the Internal Medicine Faculty and Resident clinics at St. John Hospital and Medical Center (Detroit, Michigan) frequently do not receive an annual foot examination, and when the foot examination is completed, 1 or more components of the examination is not done or not documented as done. We designed a Performance Improvement Continuing Medical Education (PI-CME) project to address this practice gap in the faculty clinic. The project also included the Internal Medicine resident staff, even though residents are not eligible to receive CME credits, in order to optimize the transfer of knowledge from Internal Medicine faculty staff physicians to residents. The overall goal of this project was to improve the percentage of patients with diabetes who receive an annual foot examination and to increase the percentage of patients who have all 3 components of the exam completed, in both the faculty and resident Internal Medicine clinics.
Methods Performance Improvement Continuing Medical Education
As defined by the American Medical Association (AMA) PI-CME is a certified CME activity in which an accredited CME provider structures a long-term 3-stage process by which a physician or group of physicians learn about specific performance measures, assess their practice using the selected performance measures (stage A), implement interventions to improve performance related to these measures over a useful interval of time (stage B), and then reassess their practice using the same performance measures (stage C).7 Physicians who participate in
Volume 40, Number 3, May/June 2014 Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
Complete Foot Exams in Patients With Diabetes 283
the project can earn 5 CME credits for each stage completed and an additional 5 credits for completing all 3 stages, for a total of 20 credits. To receive credit a physician must begin with stage A (baseline assessment). PI-CME Stage A
For this project, the first step was a baseline assessment of patients with diabetes seen in the faculty or resident clinic. We queried the outpatient billing records to identify all patients with diabetes who had a clinic visit to either the faculty or resident clinic during the period January 2011 to April 2011. For each patient, a research assistant (RA) reviewed the electronic medical record (EMR) to determine if the patient was due for an examination at that visit. A patient was considered to be “due” if no foot examination had been done in the past year. The RA reviewed the EMR to collect demographic and clinical variables (comorbidities, risk factors for foot ulcers, A1C values) and to determine whether a foot examination was done. The RA looked for evidence of inspection, results of monofilament testing, and assessment of pulses. If there was notation of either the monofilament test or pulse assessment but no notation of inspection, then credit for inspection was given (inspection done, not documented) because the patient would have had to take off his or her socks for the other assessments to be done. Following the chart review, a confidential report was prepared for each individual faculty staff physician and resident. The report listed the number of patients with diabetes that the physician had seen in the baseline period and the following metrics: •• number/percentage of patients who were due for an annual exam; •• number/percentage of patients who did not receive an exam when due; •• number/percentage of patients who had inspection done only; •• number/percentage of patients who had inspection and pulses done but no documentation of the monofilament test; •• number/percentage of patients who had inspection and the monofilament test done but no documentation of the assessment of pulses; and •• number/percentage of patients who had all 3 components done and documented in the EMR. PI-CME Stage B
For stage B, the faculty staff physicians participated in a lecture about the importance of foot examinations, the
components of a complete foot examination, and the PI-CME process. Aggregate baseline data for the faculty and resident clinics were presented along with the checklist (Figure 1). The checklist reminded the physician that a patient with diabetes should have an annual foot examination and listed the 3 components with a check box next to each component. Following the lecture, each physician received their confidential individual report of foot exam performance for the 4-month baseline period in a sealed envelopes. Similar to the faculty intervention, the residents participated in an educational session during their 1-hour morning report. A faculty staff physician demonstrated the proper method of doing the foot examination and answered any questions. The checklist was also introduced in the resident clinic. At the end of the educational session, each resident also received a confidential individual report about their performance on foot exams over the 4-month baseline period. PI-CME Stage C
For stage C, the outpatient billing records were again queried for all patients with diabetes who had a visit to the faculty or resident clinic during the period February 2012 to May 2012 for the faculty staff physicians and February 2012 to April 2012 for the residents. The resident postimplementation data collection period was 1 month shorter so that the chart review for the resident data could be completed in May and individual reports given to the residents in June. This would assure that graduating thirdyear residents would receive their follow-up information.
Data Collection and Analysis Data were collected by an experienced research assistant on paper data collection forms. The data were then entered into a Microsoft Access database. If a patient had more than 1 visit in a data collection period, only the first visit was used. Any patient who was included in the baseline data collection and had a visit during the post- education data collection period was removed from the post-education list. Statistical analysis was done using Student’s t-test and the chi square test. All data were analyzed using SPSS v. 21.0, and a P value of .05 or less was considered to indicate statistical significance. The project was deemed exempt by the St. John Hospital and Medical Center Institutional Review Board.
Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 284
Foot Examination Checklist for Patients with Diabetes
All patients with diabetes should have a comprehensive annual foot examination to identify risk factors predictive of ulcers and amputations. The foot examination should include inspection, assessment of foot pulses, and testing for loss of protective sensation.
Date of patient’s last foot examination:______________________________ Is the patient due for a foot examination today? Yes No (stop here)
Comprehensive Foot Examination (all parts must be completed)
Inspection
Monofilament test for loss of protective sensation
Assessment of Foot Pulses
Does the patient need a referral to podiatry? Yes No
Figure 1. Foot examination checklist for patients with diabetes.
Results Participants
All of the faculty staff physicians in the Internal Medicine clinic participated in the project (n = 8), and there were no physicians who dropped out of the project. The mean number of charts reviewed per faculty staff physician was 56 (range, 29-114). All Internal Medicine residents (n = 52) attended the educational session. Because residents spend only a portion of their time in the outpatient clinic, the number of charts reviewed per resident would vary by the resident’s rotation schedule and program year. Thus, it was possible for some residents to see no patients with diabetes during one of the data collection periods. Residents received a report for any period in which they saw at least 1 patient with diabetes; thus, 45 residents received at least 1 performance
report. The mean number of charts reviewed per resident was 8 (range, 1-24). Medical assistants were asked to attach the paper reminder slip to the intake forms for each patient as part of their routine intake process. Comparison of Group Characteristics
Figure 2 shows the number of charts reviewed in the baseline and post-education periods by clinic. The percentage of patients who were due for an annual examination ranged from 60% in the baseline period for the resident clinic to 74% for the baseline period in the faculty clinic. For the overall study groups (data not shown), the only significant difference between the pre- and posteducation study groups was the distribution by race in the faculty clinic, with more patients in the post-education period being classified as “other.” Tables 1 and 2 show
Volume 40, Number 3, May/June 2014 Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
Complete Foot Exams in Patients With Diabetes 285
Total Faculty Clinic Charts Reviewed n=504
Total Resident Clinic Charts Reviewed n=521
Pre-intervention 1/2011-4/2011 n=252
Postintervention 2/2012-5/2012 n=252
Pre-intervention 1/2011-4/2011 n=300
Postintervention 2/2012-4/2012 n=221
Due for a Foot Exam n=188 (75%)
Due for a Foot Exam n=169 (67%)
Due for a Foot Exam n=180 (60%)
Due for a Foot Exam n=141 (64%)
Figure 2. Total number of charts reviewed, by clinic, time period and need for a foot examination.
Table 1
Clinical and Demographic Characteristics of Patients Due for a Foot Exam, Faculty Clinic, Pre- and Post-Intervention Characteristic Mean age Mean A1C Male gender Race Black White Other Diabetes type Type 1 Type 2 Undetermined Prior foot ulcer CAD CHF Hypertension Kidney disease Peripheral neuropathy PVD HIV or AIDs COPD CVA
Pre (n = 188) Mean or %
Post (n = 169) Mean or %
63.0 ± 12.9 7.5 ± 2.1 44.7
64.3 ± 12.4 7.5 ± 2.0 39.6
66.7 32.2 1.1
65.1 27.2 7.7
2.2 93.0 4.9 1.6 21.3 7.0 84.0 17.6 12.8 9.0 1.1 8.0 8.0
2.4 91.1 6.5 1.2 23.7 9.5 86.4 14.2 12.4 10.1 0.6 9.5 10.1
P-Valuea .33 .89 .34 .008
.79
.74 .59 .40 .52 .39 .92 .74 .63 .63 .49
a Student t-test was used to compare means; the χ2 test was used to compare proportions; a P-value of .05 or less was considered to indicate statistical significance. Abbreviations: CAD, coronary artery disease; CHF, congestive heart failure; PVD, peripheral vascular disease; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident
Szpunar et al Downloaded from tde.sagepub.com at GEORGIAN COURT UNIV on March 9, 2015
The Diabetes EDUCATOR 286
Table 2
Clinical and Demographic Characteristics of Patients Due for a Foot Exam, Resident Clinic, Pre- and Post-Intervention Characteristic Mean age Mean A1C Male gender Race Black White Other Diabetes type Type 1 Type 2 Undetermined Prior foot ulcer CAD CHF Hypertension Kidney disease Peripheral neuropathy PVD HIV or AIDs COPD CVA
Post (n = 141) Mean or %
P-Valuea
55.4 ± 14.3 7.9 ± 2.1 33.9
54.7 ± 15.0 8.1 ± 2.4 34.8
85.0 10.6 4.4
85.8 9.2 5.0
.65 .51 .87 .91
6.1 90.5 3.4 1.7 14.4 10.8 85.4 21.7 11.7 6.1 1.1 14.4 10.1
5.7 90.1 4.3 1.4 19.1 20.6 87.9 21.3 9.9 7.1 0.0 18.4 7.8
Pre (n = 180) Mean or %
.73
.86 .26 .02 .51 .66 .62 .72 — .34 .49
a Student t-test was used to compare means; the χ2 test was used to compare proportions; a P-value of .05 or less was considered to indicate statistical significance. Abbreviations: CAD, coronary artery disease; CHF, congestive heart failure; PVD, peripheral vascular disease; COPD, chronic obstructive pulmonary disease; CVA, cerebrovascular accident.
the baseline and post-education demographic and clinical characteristics for all patients who were due for an examination at the queried visit in the faculty and resident clinics, respectively. As for the full study group, there were significantly more faculty clinic patients with race classified as “other” in the post-education period. In addition, there was a significantly higher percentage of patients with congestive heart failure (CHF) in the post-education period in the resident clinic. Thus, the pre- and posteducation study groups were largely similar in the baseline and post-education periods for both clinics. Comparison of Foot Examination Findings
Table 3 shows the percentage of patients in the faculty clinic who received their annual foot examination when due for an examination as well as the documented comprehensiveness of the examination for the pre- and postintervention time periods. As seen in the table, the
percentage of patients who received at least one component of the foot examination increased significantly from 49.5% to 66.3% (P = .001). The largest area of improvement was in patients receiving inspection (8.0% pre- to 22.5% post-intervention, P < .0001). The percentage of patients who received all 3 components of the foot examination increased from 28.7% to 36.7% (P = .11). The percentage of patients who had 2 components of the foot examination done but were missing the third component (either missing the monofilament test or the assessment of pulses) improved in the post-intervention period. This improvement is likely a result of the increase in the percentage of patients who received all 3 components. Table 4 shows the foot examination results for the resident clinic. For patients seen in the resident clinic, the percentage who received any portion of a foot examination when due increased significantly from 42.2% to 87.9% (P < .0001). With respect to the different components of the examination, the percentage who received
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Complete Foot Exams in Patients With Diabetes 287
Table 3
Comparison of Completeness of Foot Examinations by Time Period, Faculty Clinic Variable
Pre (n = 188) %
Any Component of Foot Exam Completed Inspection Only Inspection + Pulses (missing monofilament) Inspection + Monofilament (missing pulses) All three components
49.5 8.0 5.9 6.9 28.7
Post (n = 169) %
P-Value*
66.3 22.5 4.1 3.0 36.7
.001
