Diabetes-related foot care at 10 Veterans Affairs medical centers: must do's associated with successful microsystems.

BACKGROUND: Well-coordinated interdisciplinary preventive foot care has been reported to significantly reduce diabetes-related foot ulcers, amputations, and hospitalization. However, the contribution of the specific components leading to these "successes" is not fully characterized. The microsystem conceptual framework was adapted to foot care to determine which of the microsystem success characteristics were associated with decreased major lower-limb amputation rates at 10 Veterans Affairs (VA) medical centers. METHODS: Two-day site visits were conducted using standardized interviews at the 10 VA medical centers. RESULTS: Six "must do's" for foot care in microsystems were correlated at > or = (-.30) with amputation rates: (1) addressing all foot care needs, (2) appropriate referrals, (3) ease in recruiting staff, (4) confidence in staff, (5) available stand alone specialized diabetic foot care services, and (6) providers attending diabetic foot care education in the past three years. Using multiple linear regression, the sum of these items described 59% of the variance (p = 0.006). DISCUSSION: Clinicians and managers may want to include the must-do's in system modifications to improve foot care for people with diabetes. Many of the sites displayed exemplary features in foot care, such as providing a formal orientation to the foot care clinics.

The relationship between provider coordination and diabetes-related foot outcomes.

OBJECTIVE: To investigate the relationship between provider coordination and amputations in patients with diabetes. RESEARCH DESIGN AND METHODS: The study design was a cross-sectional, descriptive study of process and outcomes for diabetes-related foot care at 10 Department of Veterans Affairs (VA) medical centers representing different geographic regions, population densities, patient populations, and amputation rates. The subjects included all providers of diabetes foot care and a random sample of primary care providers at each medical center. The main outcome measures were the Foot Systems Assessment Tool (FootSAT), nontraumatic lower extremity amputation rates, and investigators' ordinal ranking of site effectiveness based on site visits. RESULTS: The survey response rate was 48%. Scale reliability, as measured by Cronbach's alpha, ranged from 0.73 to 0.93. The scale scores for programming coordination (i.e., electronic medical record, policies, reminders, protocols, and educational seminars) and feedback coordination (i.e., discharge planning, quality of care meetings, and curbside consultations) were negatively associated with amputation rates, suggesting centers with higher levels of coordination had lower amputation rates. Statistically significant associations were found for programming coordination with minor amputations (P = 0.02) and total amputations (P = 0.04). CONCLUSIONS: The FootSAT demonstrated a stronger association with amputation rates than site visit rankings. Among these 10 VA facilities, those with higher levels of programming and feedback coordination had significantly lower amputation rates.

Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery.

OBJECTIVE: To examine the impact of policy directives and performance feedback on the organization (specifically the coordination) of foot care programs for veterans, as mandated by public law within the Department of Veterans Affairs Health Care System (VA). STUDY DESIGN: Case study of 10 VA medical centers performing diabetes-related amputations. PATIENTS AND METHODS: Based on expert consensus, we identified 16 recommended foot care delivery coordination strategies. Structured interview protocols developed for primary care, foot care, and surgical providers, as well as administrators, were adapted from a prior study of surgical departments. RESULTS: Although performance measurement results for foot risk screening and referral were high at all study sites over 2 calendar years (average 85%, range 69% to 92%), the number of coordination strategies implemented by any site was relatively low, averaging only 5.4 or 34% (range 1-12 strategies). No facility had systematically collected data to evaluate whether preventive foot care was provided to patients with high-risk foot conditions, or whether these patients had unmet foot care needs. CONCLUSIONS: Although foot care policies and data feedback resulted in extremely high rates of adherence to foot-related performance measurement, there remained opportunities for improvement in the development of coordinated, technology-supported, data-driven, patient-centered foot care programs.

Personal and treatment factors associated with foot self-care among veterans with diabetes.

We developed and validated a survey of foot self-care education and behaviors in 772 diabetic patients with high-risk feet at eight Department of Veterans Affairs medical centers. Principal components analysis identified six subscales with satisfactory internal consistency: basic foot-care education, extended foot-care education, basic professional foot care, extended professional foot care, basic foot self-care, and extended foot self-care (alpha = 0.77-0.91). Despite high illness burden, adherence to foot self-care recommendations was less than optimal; only 32.2% of participants reported looking at the bottom of their feet daily. Independent predictors of greater adherence to basic foot self-care practices included African-American or Hispanic background, perceived neuropathy, foot ulcers in the last year, prior amputation (beta = 0.08- 0.12, p < 0.04-0.001), and provision of greater basic and extended education (beta = 0.16, p < 0.004, and beta = 0.15, p < 0.007). The survey subscales can now be used for evaluating foot care and education needs for persons with high-risk feet.