Improving Diabetic Foot Screening Rates in an Academic Primary Care Clinic S Hata, CL Roumie, WM...
-
Upload
natalie-hamilton -
Category
Documents
-
view
215 -
download
2
Transcript of Improving Diabetic Foot Screening Rates in an Academic Primary Care Clinic S Hata, CL Roumie, WM...
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 CenterThe 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.
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
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
Registry created
Intervention #1 - Provider EducationIntervention #2 - PostersIntervention #3 - Note template
Intervention #5- Team approach
Study completed
Intervention #4 - Provider Feedback (quarterly)
July 2005
October2005
June 2004
June 2006
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. were excluded Study population
• 338 patients with diabetes (July 2005)
• Registry updated (April 2006) to 387 patients
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 #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
Patient presents to
primary care
Intervention #5- Team Approach
Intervention began October 2005
Tech asks “Do you have
diabetes?”
Prompts pt to remove shoes
Alerts Nurse pt with DM
Nurse notifies doctor
pt is ready for visit
DFE completed & documented in medical record
Nurse performs
DFE
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)
Results – Method to Complete/Document DFE
0
10
20
30
40
50
60 July/August 2005
December 2005
June 2006
pe
rce
nt o
f to
tal f
oo
t e
xa
ms
0 1 2 3 4 5 6 7 8 9 10 11 120
20
40
60
80
100
Month of intervention
n = 338
n = 387
pe
rce
nt o
f pa
tien
ts w
ithd
ocu
me
nte
d D
FE
0
20
40
60
80
100
Month of intervention
n = 338n = 387
pe
rce
nt o
f pa
tien
ts w
ithd
ocu
me
nte
d D
FE
17%
82%
Absolute increase of 65%
Results
Per
cen
t o
f P
atie
nts
wit
h
Do
cum
ente
d “
Fu
ll” D
iab
etic
Fo
ot
Exa
m
Diabetic Foot Exam Run Chart
Data From ACCC Cohort and Controls
01020
3040506070
8090
100
AugOct
DecFeb Apr
Jun
AugOct
DecFeb
ACCC Cohort
*Controls
Bas
elin
e
Go
al
Registry updated/ expanded from n = 338 to 387
(April 2006)
Team DFE started in other Suites
(Jan 2006)
* Controls = 350 Randomly Selected Non-ACCC Cohort Patients
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
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