September 2020

Improving Diabetes Care Management Processes and Referrals To Podiatry in Primary Care #1213756553

By Lynn Soban, PhD, MPH, RN

Diabetes mellitus (DM) can lead to long-term complications including limb amputations. Annually in the US about 73,000 nontraumatic lower limb amputations are performed and > 60% occur among persons with DM.

Veterans have a high number of risk factors and are especially vulnerable. One in 4 veterans has DM, compared to 1 in 6 in the general population.

A recent paper published in the Federal Practitioner describes a promising quality improvement project conducted at the VA Portland Healthcare System (VAPORHCS) that aimed to improve processes of care among primary care providers to prevent and treat lower limb complications.

VAPORHCS, which had one of the highest national amputation rates in the VA a few years earlier, examined their care processes and found:

  • not all at-risk veterans had both a comprehensive foot exam and an amputation risk assessment (ARA) completed and;
  • veterans with moderate to high risk for lower limb amputations were inconsistently referred to podiatry.

The team designed a quality improvement intervention (Table) with the goals of increasing:

  • the number diabetic foot exams and ARAs completed among veterans with DM;
  • the number and timeliness of appropriate referrals to podiatry for veterans found to be at moderate-high risk for lower limb amputations;
  • the number of administrative text orders entered by PCPs for RN care managers to offer foot care education to veterans who were at normal-to-low risk for lower limb amputations; and the completion of patient education for veterans at normal-to-low risk.

Data were collected from patients’ electronic health records.

Pre-implementation data were collected for the 3 months prior to implementation of the process change. Post-implementation data were collected at 3, 6 and 9 months after implementation. Statistical significance was evaluated using c2 and Fisher exact test.


  • 1,242 completed diabetic foot examinations were identified August 1, 2017 – July 31, 2018.
  • Clinically and statistically significant increases from pre- to post-implementation were found for:
    • Number of completed foot examinations and ARAs (r=0.495) (Figure)
    • Number of appropriate podiatry referrals (r=0.222)
    • Accuracy of documentation for examinations and ARAs (53.1% vs. 97.7%)
    • Percentage of appropriate podiatry referrals (41.5% vs.76.8%)
  • Provider use of administrative text orders to RN care managers requesting patient education for normal- to low-risk individuals was very low (4.6% overall) which resulted in decreased patient education for this group (3.9% overall).

Figure. Pre- and post-intervention rates of completion of foot exams and amputation risk assessments.

Implementation of a comprehensive program emphasizing improved documentation systems and streamlined care processes increased the number of annual foot exams, ARAs, and podiatry referrals in a primary care practice.

Source: Quach TV, Goldschmidt MH. Evaluating a Program Process Change to Improve Completion of Foot Exams and Amputation Risk Assessments for Veterans with Diabetes. Fed Pract. 2019;36(Suppl 7):S10-S15.

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