Journal of General Internal Medicine

, Volume 18, Issue 4, pp 258–265 | Cite as

Effect of a physician-directed educational campaign on performance of proper diabetic foot exams in an outpatient setting

  • Kevin E. O’Brien
  • Vineeth Chandramohan
  • Douglas A. Nelson
  • Joseph R. FischerJr.
  • Gary Stevens
  • John A. Poremba
Original Articles

Abstract

BACKGROUND: The established guidelines for a diabetes foot examination include assessing circulatory, skin, and neurological status to detect problems early and reduce the like-lihood of amputation. Physician adherence to the guidelines for proper examination is less than optimal.

OBJECTIVE: Our objective was to increase compliance with the performance of a proper foot examination through a predominantly physician-directed interventional campaign.

METHODS: The study consisted of 3 parts: a retrospective chart review to estimate background compliance, an educational intervention, and prospective chart review at 3 and 6 months. A properly documented foot examination was defined as assessing at least 2 of the 3 necessary components. The educational intervention consisted of 2 lectures directed at resident physicians and a quality assurance announcement at a general internal medicine staff meeting. Clinic support staff were instructed to remove the shoes and socks of all diabetic patients when they were placed in exam rooms, and signs remiding diabetics were placed in each exam room.

RESULTS: There was a significant increase in the performance of proper foot examination over the course of the study (baseline 14.0%, 3 months 58.0%, 6 months 62.1%; P<.001). Documentation of any component of a proper foot examination also increased substantially (32.6%, 67.3%, 72.5%; P<.001). Additionally, performance of each component of a proper exam increased dramatically during the study: neurological (13.5%, 35.8%, 38.5%; P<.001), skin (23.0%, 64.2%, 69.2%; P<.001), and vascular (14.0%, 51.2%, 50.5%; P<.001).

CONCLUSIONS: Patients with diabetes are unlikely to have foot examinations in their primary medical care. A simple, lowcost educational intervention significantly improved the adherence to foot examination guidelines for patients with diabetes.

Key words

diabetes foot ulceration foot exam prevention physician education 

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References

  1. 1.
    Centers for Disease Control and Prevention. National Diabetes Fact Sheet: National Estimates and General Information on Diabetes in the United States. Atlanta, Ga: U.S. Department of Health and Human Services; 1997.Google Scholar
  2. 2.
    Centers for Disease Control and Prevention. The Prevention and Treatment of Complications of Diabetes. A Guide for Primary Care Practitioners. Atlanta, Ga: U.S. Department of Health and Human Services; 1991.Google Scholar
  3. 3.
    Grunfeld C. Diabetic foot ulcers: etiology, treatment, and prevention. Adv Intern Med. 1992;37:103–32.PubMedGoogle Scholar
  4. 4.
    Levin ME, O’Neal LW, Bowker JH, eds. The Diabetic Foot, 5th ed. St. Louis: Mosby Year Book; 1993: xxi-xxii.Google Scholar
  5. 5.
    Levin ME. Foot lesions in patients with diabetes mellitus. In: Endocrinology and Metabolism Clinics of North America, vol. 25. Philadelphia: W.B. Saunders; 1996:447–62.Google Scholar
  6. 6.
    Smith D, Weinberger M, Katz B. A controlled trial to increase office visits and reduce hospitalizations of diabetic patients. J Gen Intern Med. 1987;2:232–38.PubMedCrossRefGoogle Scholar
  7. 7.
    Macleod AF, Williams DRR, Sonksen PH, et al. Risk factors for foot ulceration in hospital clinic attendees. Diabetologia. 1991;34(suppl 2):A39.Google Scholar
  8. 8.
    Sathe SR. Managing the diabetic foot in developing countries. IDF Bull. 1993;38:16–8.Google Scholar
  9. 9.
    U.S. Deptartment of Health and Human Services. Diabetes Surveillance: Annual 1990 Report. Atlanta, Ga: Centers for Disease Control, Division of Diabetes Translation; 1990: 23–25, 93–95.Google Scholar
  10. 10.
    Reiber GE, Boyko EJ, Smith DG. Lower extremity foot ulcers and amputations in diabetes. In: Diabetes in America, 2nd ed. Bethesda, Md: National Institute of Health; 1995.Google Scholar
  11. 11.
    American Diabetes Association. Preventive foot care in people with diabetes. Diabetes Care. 1999;22(Suppl 1):554–55.Google Scholar
  12. 12.
    Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischili JG. Practical criteria for screening patients at high risk for foot ulceration. Arch Intern Med. 1998;158:157–62.PubMedCrossRefGoogle Scholar
  13. 13.
    McNeely MJ, Bayko EJ, Ahronhi JE, et al. The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration. Diabetes Care. 1995;18:216–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care. 1990;13:513–21.PubMedCrossRefGoogle Scholar
  15. 15.
    Edmonds ME. Experience in a multi-disciplinary diabetic foot clinic. In: The Foot in Diabetics. Conor H, Boulton AJM, Ward JD. eds. Chichester, U.K.: Wiley; 1987:121–33.Google Scholar
  16. 16.
    Laing P. The development and complications of diabetic foot ulcers. Am J Surg. 1998;176(Suppl 1):115–95.Google Scholar
  17. 17.
    Prevention and Early Intervention for Diabetes Foot Problems. A Research Review. Available at http://ndep.nih.gov/materials/pubs/feet/feet2001.pdf. Accessed February, 2003.Google Scholar
  18. 18.
    American Diabetes Association. Clinical practice recommendations 2002. Diabetes Care 2002;25(Suppl 1):1–147.Google Scholar
  19. 19.
    Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P, Showstock JA. Lower extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12:24–31.PubMedCrossRefGoogle Scholar
  20. 20.
    National Institute of Diabetes and Digestive and Kidney Diseases. Survey of Physician Practices Related to the Treatment of People with Diabetes Mellitus. Primary Care Physicians. Rockville Md: Prospect Associates; 1990.Google Scholar
  21. 21.
    Mazze R, Deeb L, Palumbo PJ. Altering physicians’ practice patterns: a nationwide educational experiment: evaluation of the Clinical Education Program of the American Diabetes Assocaition. Diabetes Care. 1986;9:420–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Mayfield JA, Rith-Najarian SJ, Acton KJ, et al. Assessment of diabetes care by medical record review: The Indian Health Service model. Diabetes Care. 1994;17:918–23.PubMedCrossRefGoogle Scholar
  23. 23.
    Bloomgarden ZT. Diabetes and managed care. Diabetes Care. 1994;17:1552–54.PubMedGoogle Scholar
  24. 24.
    Wylie-Rosett J, Walker EA, Shamoon H, Engel S, Basch C, Zybert P. Assessment of documented foot examinations for patients with diabetes in inner-city primary care clinics. Arch Fam Med. 1995;4:46–50.PubMedCrossRefGoogle Scholar
  25. 25.
    Deeb LC, Pettjohn FP, Shirah JK, Freeman G. Intervention among primary care practitioners to improve care for preventable complications of diabetes. Diabetes Care. 1988;11:275–80.PubMedCrossRefGoogle Scholar
  26. 26.
    Williams DRR, Munroe C, Hospedales CJ, Greenwood RH. A three-year evaluation of the quality of diabetes care in the Norwich community care scheme. Diabet Med. 1990;7:74–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction of lower extremity clinical abnormalities in patients with non-insulin-dependent diabetes mellitus: a randomized, controlled trial. Ann Intern Med. 1993;119:36–41.PubMedGoogle Scholar
  28. 28.
    Payne TH, Gabella BA, Michael SL, et al. Preventive care in diabetes mellitus: current practices in an urban health care system. Diabetes Care. 1989;12:745–47.PubMedCrossRefGoogle Scholar
  29. 29.
    Michigan Diabetes Research and Training Center. Diabetes in Communities. Hiss RG, ed. Ann Arbor: University of Michigan; 1992:1–136.Google Scholar
  30. 30.
    Cohen SJ. Potential barriers to diabetes care. Diabetes Care. 1983;6:499–500.PubMedCrossRefGoogle Scholar
  31. 31.
    Carter WB, Belcher DW, Inui TS. Implementing preventive care in clinical practice. II. Problems for managers, clinicians and patients. Med Care Rev. 1981;38:195–216.PubMedCrossRefGoogle Scholar
  32. 32.
    Green LW, Krenter MW. Health Promotion Planning: An Educational and Environmental Approach. 2nd ed. Mountain View, Calif: Mayfield Publishing Co; 1991.Google Scholar
  33. 33.
    Bailey TS, Yu HM, Rayfield EJ. Pattern of foot examination in a diabetes clinic. Am J Med. 1985;78:371–74.PubMedCrossRefGoogle Scholar
  34. 34.
    Davidson JK, Alogna M, Goldsmith M, Borden J. Assessment of program effectiveness of Grady-Memorial Hospital-Atlanta. In: Steiner G, Lawrence PA. eds. Educating Diabetic Patients. New York: Springer-Verlag; 1981:329–48.Google Scholar
  35. 35.
    Runyan JW Jr. The Memphis Chronic Disease Program. Comparisons in outcome and the nurse’s extended role. JAMA. 1975;231:264–7.PubMedCrossRefGoogle Scholar
  36. 36.
    Assal JP, Muhlhauser I, Pernat A, Gfeller R, Jorgens V, Berger M. Patient education as the basis for diabetes care in clinical practice. Diabetologia. 1985;28:602–13.PubMedCrossRefGoogle Scholar
  37. 37.
    Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in patients with diabetes mellitus: a case-control study. Ann Intern Med. 1992;117:97–105.PubMedGoogle Scholar
  38. 38.
    Jackson JL, Strong J, Cheng EY, Meyer G. Patients, diagnoses, and procedures in a military internal medicine clinic: comparison with civilian practices. Mil Med. 1999;164:194–7.PubMedGoogle Scholar
  39. 39.
    Jackson JL, Cheng EY, Jones DL, Meyer G. Comparison of discharge diagnoses and inpatient procedures between military and civilian health care systems. Mil Med. 1999;164:701–4.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2003

Authors and Affiliations

  • Kevin E. O’Brien
    • 1
    • 4
  • Vineeth Chandramohan
    • 1
    • 4
  • Douglas A. Nelson
    • 1
    • 4
  • Joseph R. FischerJr.
    • 3
  • Gary Stevens
    • 5
  • John A. Poremba
    • 2
    • 4
  1. 1.the Division of General Internal MedicineWilford Hall Medical CenterSan Antonio
  2. 2.the Division of EndocrinologyWilford Hall Medical CenterSan Antonio
  3. 3.Department of Clinical InvestigationsWilford Hall Medical CenterSan Antonio
  4. 4.Uniformed services University of Health SciencesBethesda
  5. 5.the Biostatistics Clinical LaboratoryUniversity of Florida College of MedicineGainesville

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