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2019 HSR&D/QUERI National Conference Abstract

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1103 — Secondary prevention in a high-risk population of Veterans with diabetes - findings from patient and provider interviews

Lead/Presenter: Alyson Littman,  COIN - Seattle/Denver
All Authors: Littman AJ (Seattle-Denver HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care and Seattle ERIC and University of Washington), Young JP (Seattle-Denver HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care), Moldestad M (Seattle-Denver HSR&D Center of Innovation for Veteran-Centered and Value-Driven Care) Landry GJ (Oregon Health & Science University) Czerniecki JM (VA Puget Sound, University of Washington, VA RR&D Center for Limb Loss and Mobility) Robbins JM (Louis Stokes Cleveland VA Medical Center) Tseng CL (VA NJ Health Care System) Boyko EJ (Seattle ERIC, VA Puget Sound, University of Washington)

Objectives:
Toe amputations are often performed because of limb-threatening infection yet may be naively viewed as an inconsequential procedure. Instead, a toe amputation is often the inciting event in a cascade of progressive loss of function and quality of life, involving subsequent amputation(s) and a high risk of death. This study aimed to understand patient and provider perspectives related to secondary prevention after a toe amputation and to identify potential opportunities to address patient, provider, and/or system-level shortcomings.

Methods:
We conducted semi-structured telephone interviews with a national sample of United States Veterans Health Administration (VHA) patients with diabetes who had undergone a toe amputation in the prior year (n = 61) and VHA clinicians who care for patients with toe amputations (n = 24). Interviews were conducted in 2018 and recorded, transcribed, and analyzed using inductive content analysis.

Results:
Patients reported delayed care-seeking for diabetes-related wounds that ultimately led to toe amputation. Patient-reported reasons for delayed care-seeking included not knowing what to look for, not understanding the seriousness of the wound, and having competing priorities (e.g., other health conditions and work demands). Barriers encountered by patients who sought foot care (e.g., with a primary care provider or urgent/emergency care) included: being told to ‘watch and wait' and not being referred to podiatrists or other specialists. To prevent amputation through early detection and treatment, providers described regular contact with patients as essential and reported system-level barriers such as a lack of: clinic capacity to see patients as frequently as needed, time in appointments to communicate about and address complex health needs, and interdisciplinary collaboration.

Implications:
Patients often lacked understanding of what to look for and when to seek care, suggesting a need for more explicit or frequent instructions and a way for patients to easily and directly contact a knowledgeable provider (in-person or remotely) to assess risk and make an appropriate treatment plan.

Impacts:
Addressing system-level and patient-specific barriers will be critical to reducing limb loss in this high-risk population.