Journal of Medical Sciences and Health

Introduction

Type 2 diabetes mellitus (T2DM) is a widespread chronic health condition in the United States. Individuals diagnosed with type-2 diabetes lead the country in lower limb complications, such as foot ulcers, infections, and lower limb amputation. 1 In this population at an Illinois primary care clinic, there was a substantial difference in how foot care was approached and performed. Foot exams are a vital part of diabetes care, as they prevent morbidity, loss of function, diabetic foot complications, and death. 2 Unfortunately, foot examinations were frequently not performed by healthcare providers, contributing to increased foot ulceration rates and other complications such as foot infections and lower limb amputation. 1 Proper diabetic management, including routine foot exam performance, proper foot care, and wearing the correct footwear, could help avoid complications. The purpose of this quantitative quasi-experimental project was to determine to what degree the implementation of an electronic medical record (EMR) alert using Inlow’s 60-Second Diabetic Foot Screen would impact the number of diabetic foot exams performed compared to the current practice among T2DM patients at a primary care clinic in urban Illinois.

In the study by Hickes, 3 providers are not performing a diabetic foot exam at every patient visit. A comprehensive foot evaluation should be completed to identify risk factors. The goal was to shift the providers’ attention from a traditional approach to a strength-based approach. 2, 4 Strength-based approaches are critical care points in preventing diabetic foot ulcers, infections, and lower limb amputation. 4

Frequently, guidelines are not established for the exams’ performance at the primary care provider (PCP) clinics; hence, very few are being completed, emphasizing the need for quality improvement initiatives related to foot care. The American Diabetes Association (ADA) guidelines for the management of diabetes include general recommendations for foot care. One of the ADA’s recommendations is to inspect the feet every visit. 5 This recommendation is extremely imperative for patients with evidence of sensory loss, prior ulceration, or amputation.

The clinic strived to meet the American Diabetes Association 5 and the International Diabetes Federation (IDF) 6 guidelines, which focused on the providers’ early intervention and sense of urgency to complete diabetic foot exams and patient education. The two national benchmarks, which are quality metrics outlined by the National Healthcare Quality and Disparities Report, included patients receiving diabetic foot care and patient education (98.6%), and adults diagnosed with diabetes check their feet for sores, irritations, and ulcerations daily (75.2%) 7, 8 . The standards of diabetic care for providers focus on the obvious such as monitoring glucose levels, glycated hemoglobin (Hemoglobin A1C), diet, and lifestyle. 9 These are considered significant factors in managing diabetes; unfortunately, one aspect frequently lost is foot care. Providers must shift their focal point to include diabetic foot care as a standard of care. There must be an increased emphasis on provider education and reinforced teaching to note a change in current clinical practices.

Background

Type 2 diabetes mellitus and the disease’s complications have a significant effect globally. It is the seventh leading cause of death in the United States. 10 Diabetes poses a public health issue, involving roughly 415 million individuals and will increase from 642 million to 700 million by 2040. 11 1.6 million people have experienced diabetes-related complications, including death. 12 In a study by the Centers for Disease Control and Prevention, 13 79,535 deaths occur annually because of diabetic complications. On average, individuals with diabetes may accumulate $16,752 per year in medical expenses.14

Promoting routine assessment of the diabetic patient’s feet could prevent or decrease the severity of limb complications associated with T2DM. In a study by Formosa, Gatt, and Chockalingam, 15 diabetic foot exams should be embedded in everyday clinical practice. This routine could substantially reduce amputation rates by almost 75%. The literature supports the health advantages of diabetic foot exams performed by the PCP and patient education regarding daily self-foot inspections. 16 Although the evidence supports the health advantages of annual diabetic foot exams for patients who are at low risk of developing ulcers, infections, and lower limb amputation, these foot exams should be performed by the PCP at each visit for patients who are at a higher risk. 17

A study by Williams, Jones, and Johnson, revealed that one-third of patients with diabetes do not receive a foot examination from their primary healthcare provider. 18 Failure to perform a thorough diabetic foot exam negatively impacts the patient and contributes to ulcers, foot infections, neuropathy, and lower-limb amputations. Raghav et al. suggested that the cost of diabetic foot ulcers devoid of lower limb amputations ranges in the U.S. from $993 to $17,519. 19 These fees are overwhelming to any patient, especially those who have experienced treatment of a foot ulcer, amputation of foot or limb, and the additional expenditures of the lifestyle modifications, such as frequent doctors’ visits and in-home care. These expenses can be avoided with proper foot exams and patient education regarding the daily inspection of the feet.

Electronic medical record alerts and prompts can help providers prioritize their clinical practice to perform foot exams. Electronic medical records are capable of alerts and prompts, including using an assessment tool like Inlow’s 60-second screening tool, which can significantly increase the number of foot exams performed at the primary care level. 20 Patient education related to daily inspections and foot care must be a part of the patient’s clinic visit. Consequently, there is an apparent need to address the current gap in evidence-based practice related to diabetic foot care at the primary care clinic.

Purpose

The aim of this quality improvement project was to determine to what degree an EMR alert with Inlow’s 60-Second Diabetic Foot Screen instrument would impact the frequency of routine foot inspection among T2DM patients at a primary care clinic in urban Illinois. 20 Evidence-based strategies such as EMR alerts have helped remind providers to perform diabetic foot exams. 21 A quantitative quasi-experiment design was used to implement an electronic medical record (EMR) alert using Inlow’s 60-Second Diabetic Foot Screen to impact the number of diabetic foot exams compared to the current practice. In a study by Johnson, Jones, and Williams et al. 2018, advocated that foot care was crucial in preventing incidences related to foot ulcer development, foot infections, and amputation of a limb. 22 

Foot exams are a vital part of diabetes care as they prevent morbidity, loss of function, diabetic foot complications, and death. 2 Although diabetic foot exams are believed to decrease diabetic foot ulcers by 60% and non-traumatic lower-limb amputations by 95% annually, these exams are not routinely completed by PCPs. 1, 23 Additionally, no patient education is provided to patients regarding foot care and daily foot inspections. 24

Design and Methods

A quantitative quasi-experiment design was applied to make inferential statements about the data producing quantifiable, objective, and easy-to-interpret results. This quasi-experimental design was considered reliable for determining a difference in the pre-and post-intervention foot exams using a quantitative method. The instrument used was Inlow’s 60-Second Diabetic Foot Screen coupled with an electronic medical alert (EMR). Inlow’s tool was used to help the providers complete a structured foot exam on their patients to identify any foot abnormalities early. The EMR was used as an alert for the physicians. Physicians were alerted of their patients appointment type and diagnosis visible via the EMR health condition list and prompted to complete the diabetic foot exams. The population included male and female patients ages 18-years old and older, diagnosed with T2DM within the last two years, had no diabetic foot exam or received foot care education, did not perform or complete self-reported foot inspections, and able to read and write English.

Results

Frequencies on diabetic foot exam performance were collected from two non-equivalent groups utilizing convenience sampling to obtain a sample of the targeted population. This population consisted of male and female patients ages 18 years and older, diagnosed with T2DM within the last two years and were able to read, write, and speak English.

The overall sample consisted of N = 65 diabetic patients, 18 years old and older, with n =34 (52%) receiving a diabetic foot exam. The groups sampled were n=35 in the pre-intervention group and n= 30 in the post intervention group. This overall proportion of patients from both groups getting a foot exam shows the continuing need to increase the performance of routine foot exams. The EMR alert was implemented to make the practitioner aware of the need for an exam and provide Inlow’s 60-Second Diabetic Foot Screening for use. The EMR was used to identify patients who received a foot exam from both groups. The demographic information for patients receiving a foot exam from both groups was displayed in Table 1. Thirty-two percent of patients had foot exams performed before implementation of the EMR alert compared to 77% of patients having foot exams performed after the intervention was implemented. This finding represents a 45% mean difference in the performance of foot exams. It appeared that using the EMR alert and an evidence-based tool for foot screening helped providers conduct more diabetic foot exams. Thirty-four patients out of 65 (52% in both groups), were recipients of a foot exam, with 11 (32%) in the baseline group and 23 (76%) in the post-implementation group. The EMR alert implementation (0-pre and 1-postintervention) and foot exam frequencies (0-no exam or 1-foot exam performed) were variables compared in the analysis. Both variables were measured using counts or frequencies and subsequently compared using a Pearson chi-square test (ꭓ²). Table 2 displays the Pearson’s Chi-square results showing the difference between pre/post intervention frequencies of foot exams was statistically significant [ꭓ² (1, N=65) = 5.286, p= 0.02].

Conclusion

Healthcare providers are the first line of defense against diabetes complications. Completing foot exams on their patient at each office visit could be one strategy for monitoring the disease and its complications.27 Clinicians must develop strategies to identify and prevent foot complications early to avoid invasive treatment modalities, including amputation. The results showed a 45% increase in the performance of foot exams after the intervention of coupling an EMR with an evidenced-based tool for foot screenings.

A sample size of N = 65 patients were compared using a chi-square analysis with a significance level set at p<.05. Two sample groups were compared: current practice or pre-implementation group of 35 patients and a post-implementation group of 30. The number of foot exams completed was reviewed pre-implementation and then again post-implementation. The current practice group only had 11-foot exams performed on 35 patients compared to 23-foot exams performed on the 30 post intervention patients. Providers who were prompted to complete the foot exams from the EMR alert showed an increase in exams.

Recommendations suggest that providers should choose to incorporate foot exams into their clinical practice as a standard of diabetic care. These practices are expected to improve the clinic’s workflow, increase healthcare providers’ knowledge levels, and contribute to a higher quality of patient-centered care. These recommendations provided an opportunity for growth and improvement related to patient outcomes.

Acknowledgments

Disclosure Statement : I, Angela Allen, the only authors have no conflicts of interest, including financial interests relationships, and affiliations relevant to the subject of their manuscript.