1. 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.

2. Context l Academic Chronic Care Collaborative sponsored by the AAMC l Promoted health care innovations in academic health centers l 22 AHC participated in improving chronic illness care l Vanderbilt addressed diabetes care

3. Screening Diabetic Foot Exam l The American Diabetes Association recommends a yearly diabetic foot exam. l Early detection and intervention prevent morbidity and amputations. l Locally, our adherence to this guideline has been suboptimal.

4. What are you trying to accomplish?

5. Aims l Measure our local data on documented foot exams l 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 l Percentage of completed/documented DFEs would be improved by use of PDSA cycles to institute small tests of change in a year

6. How will you know a change is an improvement?

7. Process Measures l Percent of foot exams documented with each method Templated note Team DFE Both Other (free text writing in a note) Outcome Measure l Proportion of patients with diabetes who have 4 element DFE documented within the past 12 months

8. Design and Setting l Study Design: Observational Study with multiple Plan-Do-Study-Act cycles l Setting: Adult Primary Care Clinic Vanderbilt University Medical Center, Nashville, TN l IRB approval obtained

9. Study Timeline Registry created Intervention #1 - Provider Education Intervention #2 - Posters Intervention #3 - Note template Intervention #5- Team approach Study completed Intervention #4 - Provider Feedback (quarterly) July 2005 October 2005 June 2004 June 2006

10. Methods - Population l Inclusion Criteria Registry created, June 2004 Search problem lists for “diabetes” or “DM” ICD-9 CM = 250.x within the last 2 years l Patients < 18 y.o. were excluded l Study population 338 patients with diabetes (July 2005) Registry updated (April 2006) to 387 patients

11. What changes can you make?

12. Intervention #1 – Provider Education l July 2005 l Met with primary care providers l Encouraged cooperation by sharing data regarding foot exam rates l Discussed the goals of the Diabetic Foot Exam Project l Standardized DFE method for resident and faculty providers

13. Complete Diabetic Foot Exam l Based on ABIM’s PIM for diabetes l 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.

14. Intervention #2 – Poster Began July 2005

15. Intervention #3 – Note Template l Introduced July 2005 l Included ADA guidelines for: Glycemic control BP control LDL goals Annual DFE l Physical exam in template included 4 element DFE

16. Intervention #4 - Provider Feedback l Began July 2005 and continued quarterly l Practice report of patients with diabetes l Report included each patient’s most recent: A1c BP LDL DFE

17. 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

19. Analysis l Outcome extracted through manual and electronic chart review l Run Chart using a rolling 12 month period and updated monthly

20. Results- Patient characteristics CharacteristicPopulation=338 patients N (%) Age - years, mean ± SD 51.9 ± 14.3 Female sex218 (64.5) A1C <7%118 (35) LDL <100 (mg/dL)176 (52) BP <130/80111 (33) ACEi/ARB use270 (80)

21. Results- Provider characteristics CharacteristicN=38 providers (%) Age (mean ± SD)31 ± 5 Sex19 (50) Attending MD9 (23.7) Resident MD29 (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)

22. Results – Method to Complete/Document DFE

23. 17% 82% Absolute increase of 65% Results

24. Percent of Patients with Documented “Full” Diabetic Foot Exam Diabetic Foot Exam Run Chart Data From ACCC Cohort and Controls Baseline Goal 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

25. Limitations l One academic primary care clinic site l Small number of patients and providers l Multiple interventions employed simultaneously l Note templates may introduce some inaccuracy

26. 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”

27. Summary and Implications l Multi-factorial interventions resulted in an absolute increase of 65% in annual DFE rate l Increased teamwork among physicians, nurses, techs l Improved quality of care for patients with diabetes l Plan to expand these interventions to all primary care clinics at Vanderbilt

28. Acknowledgements l Susan Hata, MD l Christianne Roumie, MD MPH l William Gregg, MD, MPH l Julie Scott, RN l Kara Hall, RN l Robert Follett, BS l Phil Johnston, Pharm D l Charlotte Brown, BS

29. Excerpt of Note Template (Intervention #3)

30. “We are what we repeatedly do. Excellence, then, is not an act, but a habit.” - Aristotle