The VA has mandated the establishment of facility-level foot care programs with annual reporting to Congress. While the specific organizational framework can vary, there are specific processes of care that must be implemented. Specifically, risk for lower limb complications must be identified; provision of preventive care, footwear, social support, and education; and tracking of high risk foot care across the continuum of outpatient, inpatient and rehabilitative care. While the VA has been using administrative data to create a high risk foot registry since 2005, it is unclear how accurate this approach may be in the outpatient setting.
The objectives of this study were to create an exam-based stratified foot risk registry using class 3 Computerized Medical Record System (CPRS) software to populate foot risk using health factors; assess the accuracy of the coding before and after implementation; and assess the acceptability by clinicians.
A pre & post-test design assessed the accuracy of coding before and after implementation as well as acceptability by clinicians. A control hospital continued usual practice and offered similar scope of foot care service including a podiatric residency. The intervention hospital's reminder was replaced with the International Working Group Diabetic Foot Risk Classification System to populate foot risk using health factors. We abstracted 100 medical records at two VA hospitals. To limit potential site or historical effects, records were examined at both sites at baseline and three months after implementation. The analysis included use of the Fisher's Exact Test, one way ANOVA, and Kappa coefficients for each coded foot condition using chart notation as the gold standard.
Primary care performed the majority of foot screenings (45/49) at the control hospital while podiatrists exclusively performed these at the intervention hospital. Between hospitals, there were no changes in foot care or Hawthorne effect as use of podiatry consults didn't change at baseline or end of study (p=0.48; p=0.72 respectively) There were also no changes in service agreement adherence, no-show rates, scheduling errors, or clinic and patient cancellations. Foot condition coding was highly variable among provider types and centers (Table). The intervention seemed to improve coding as Kappa coefficients demonstrated substantial reliability and improved for diabetes, peripheral arterial disease, and foot deformity while nearly doubling for neuropathy. The control center demonstrated less than moderate reliability for coding foot conditions.
The potential impact of this approach includes better standardization of risk-based care. It permits measurement and insight into the function of service agreements and advanced clinical access. For example, grade 0 (no foot risk factors) should be retained in primary care and grade 1 (neuropathy) for a telemedicine opportunity for follow-up. It will also allow prosthetics to check the foot grade v. the shoe order. Grade 2&3 are recommended to have shoes based on the PACT mandate. From the case management perspective, it will make the new Proclarity cube registry more user friendly by limiting the focus to patients without a risk score (i.e., fall outs). Further testing of this tool is recommended at the VISN-level as coding improved at the intervention site. This has potential future implication for improving the accuracy of the current Proclarity cube registry that is based on ICD9 codes.
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