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DIS 99-037 – HSR&D Study

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DIS 99-037
Impact of a Quality Management Intervention Upon Foot Care Outcomes
Leonard M Pogach MD MBA
East Orange Campus of the VA New Jersey Health Care System, East Orange, NJ
East Orange, NJ
Funding Period: February 2000 - July 2001

BACKGROUND/RATIONALE:
Diabetes mellitus is associated with 3,781 of 5,324 amputations within the VA in FY98 (71%), and 3,729 of 5,281 amputations in FY 1999 (71%). A number of interventions, including case management, patient education, and appropriate footwear have been identified to prevent foot ulceration and amputation in persons with diabetes within the context of a multidisciplinary program. While the VA evaluates screening veterans for high risk conditions, it has not evaluated the surveillance of high-risk veterans.

OBJECTIVE(S):
1) To describe facility-level variations in structural features, amputation rate, ulcer rate, quality of clinician-provided diabetes foot care through chart audit, and patient-reported foot care practices using patient surveys at 10 VA facilities; 2) to evaluate variations in case severity across facilities using person-level analysis: a) to develop a risk adjustment method to predict a patient's risk of ulceration, amputation and cost for high risk foot care; b) to develop an index of quality diabetic foot care based on chart audit and explore correlation with risk-adjusted foot ulcers and amputation outcomes; c) to develop an index of patient-reported self-care practices and explore the correlation with ulcerations and amputations; and 3) to modify and validate a Foot Systems Assessment Tool (Foot SAT) to describe coordination of a high-risk foot care system.

METHODS:
The protocol will characterize the facility level structure of the foot care program and provision of care through on site interventions, chart abstraction, and patient and provider surveys. Ten VAMCs were selected to reflect a range of lower extremity amputation rates, geographic distribution, and facility level characteristics. Veterans with diabetes at high risk for lower extremity complications will be identified using administrative codes for foot deformities, neuropathy, vascular conditions, and prior amputations and hospitalizations. The case studies of the facilities will emphasize qualitative techniques, while survey and chart abstractions will be analyzed using descriptive statistics, factor analysis and multiple linear and logistic regression techniques.

FINDINGS/RESULTS:
Structured interviews and provider surveys (FSAT) were completed at 10 sites. The patient level survey and chart abstraction tools are in the field.

IMPACT:
Our project will provide insight into the administrative structure of foot care programs at 10 representative VAMCs. In addition, variation in the care provided to high risk patients will be evaluated among these sites. These results are anticipated to result in recommendations to clinical policymakers regarding the use of patient surveys and chart audits to access the surveillance of high risk patients, as well as recommendations on management structure of the programs.

PUBLICATIONS:

Journal Articles

  1. Johnston MV, Pogach L, Rajan M, Mitchinson A, Krein SL, Bonacker K, Reiber G. Personal and treatment factors associated with foot self-care among veterans with diabetes. Journal of rehabilitation research and development. 2006 Mar 1; 43(2):227-38.
  2. Pogach L, Charns MP, Wrobel JS, Robbins JM, Bonacker KM, Haas L, Reiber GE. Impact of policies and performance measurement on development of organizational coordinating strategies for chronic care delivery. The American journal of managed care. 2004 Feb 1; 10(2 Pt 2):171-80.
  3. Wrobel JS, Charns MP, Diehr P, Robbins JM, Reiber GE, Bonacker KM, Haas LB, Pogach L. The relationship between provider coordination and diabetes-related foot outcomes. Diabetes Care. 2003 Nov 1; 26(11):3042-7.
  4. Reiber GE, Smith DG, Heagerty PJ, LeMaster J, Wallace C, Hayes SG, Sullivan K, Maciejewski M, Yu O. Therapeutic footwear in patients with diabetes. JAMA : the journal of the American Medical Association. 2002 Sep 11; 288(10):1231-1233.
Journal Other

  1. Rith-Najarian SJ, Reiber GE. Prevention of foot problems in persons with diabetes. [Review]. [Editorial]. Family Practice. 2000 Nov 1; 49(11 Suppl):S30-S39.
HSR&D or QUERI Articles

  1. Pogach LM, Charns M, Wrobel J, Diehr P, Robbins J, Reiber G. Coordination improves foot care for patients with diabetes. Transition Watch. 2002 Apr 1; 5 4-6.


DRA: Health Systems
DRE: Epidemiology
Keywords: Diabetes, Education (provider), Patient outcomes
MeSH Terms: none

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