Academic detailing boosts diabetic foot exams

An innovative program in Michigan has shown that academic detailing of physicians by podiatrists can improve the quality of foot examinations that physicians do with diabetic patients and may ultimately lead to a higher number of examinations and less need for amputation of feet and legs.

Lloyd Smith, DPM, chair of the Bethesda, MD-based American Podiatric Medical Association’s health policy committee, tells State Health Watch that the pilot project grew out of a meeting between his association, the Centers for Medicare & Medicaid Services (CMS), the Michigan Peer Review Organization in Plymouth, and other groups in which discussion centered on the fact that studies had demonstrated that diabetic patients receive less than optimal foot examinations in primary care outpatient settings and that even if foot examinations are performed, they are done less frequently than recommended in the literature.

The program was described earlier this year by representatives of several participating groups at the sixth Congress on Medicaid and Medicare sponsored by the National Managed Health Care Congress.

Since foot examinations provide a basis for risk assessment and early detection of foot problems and also are a means to prevent complications from diabetes, the long-term outcome of good examination protocol is expected to be a reduction in amputations of lower extremities.

Three project goals

CMS officials present at the meeting asked the other groups for help with an academic detailing program through which podiatrists could present foot examination how-to information to primary care physicians.

The goals of the project, Mr. Smith says, were to:

  • improve the quality and frequency of foot examinations provided to patients with diabetes;
  • improve documentation of foot examinations;
  • identify high-risk patients who could be referred to specialists.

An additional outcome was to add diabetic peripheral neuropathy with loss of protective sensation as a covered diagnosis.

CMS task leader Barbara Fleming, MD, told the Congress attendees that CMS was interested in the program because 10% of the 40 million Medicare beneficiaries are diagnosed with diabetes and that disease has been designated as a focus for clinical improvement through 2004.

Implementation of the project was a cooperative effort involving the podiatric medical association, state associations, and the local peer review organization. The state podiatry association recruited and trained academic detailing volunteers and the peer review organization recruited primary care offices to participate in the detailing.

At the heart of the program was a "diabetic foot exam toolkit" used in the detailing meetings with physicians. The kit contained how-to guidelines on office detailing, a paper on the philosophy of detailing, an article from the American Diabetes Association on preventive foot care in people with diabetes, foot specialist consult request and report forms, a description of the office process for a diabetic foot examination, a training video on how to perform foot examinations in the office setting, a chronic disease documentation flow sheet, and a fact sheet on the pilot program.

Mr. Smith says that as the program unfolded, they found that some of the most important items were office supplies such as stickers for use in charts and a sign for examination rooms asking patients to remove their shoes and socks when asked to undress.

Representing the Michigan Peer Review Organization at the Congress session, Paola Valsania, MD, said they targeted hospital outpatient clinics and private and group practices, primarily those involved in general practice, family practice, and internal medicine.

So the effects of the program could be evaluated, all PCP offices that participated in the pilot were asked to copy 10 to 15 medical records and the frequency and type of foot examination (visual inspection, vascular exam, or sensory exam) were abstracted using criteria from the CMS Diabetic Quality Improvement Project. Physician offices were divided into intervention and reference offices, and there were baseline, intervention, and repeat measurements taken.

The state peer review organization and podiatric medical association trained volunteer podiatrists on the contents of a detailing visit, principles of communication and persuasion, and a role-playing exercise of a detailing visit. Actual visits to PCPs were scheduled by the peer review organization.

During the detailing, physicians and their staff were shown how to perform a thorough five-minute foot examination, how to identify low- and high-risk patients, and how to follow the two patient groups appropriately. They were given information on the need for foot exams and tools including monofilaments, chart stickers, chart reminders, posters, patient education materials, and resource lists.

Nancy Parsley, director of health policy and practice for the American Podiatric Medical Association, tells State Health Watch that the Michigan pilot results suggest that academic detailing by podiatrists improves the quality of foot exams in PCP offices. She says the frequency of foot exams did not seem to be affected by the intervention, although those who conducted the pilot have expressed hope that as it continues, there may be an impact on exam frequency.

Because of the Michigan program, Ms. Parsley tells SHW, 30 other states have expressed an interest in receiving more information or setting up their own program. In some areas, she says, it has been used as part of hospital grand rounds rather than in individual physician offices.

[Contact Mr. Smith and Ms. Parsley at (301) 571-9200.]