This article aims to describe the implementation and initial results of an audit–feedback quality improvement initiative in Belgian diabetic foot clinics.

Methods

Using self-developed software and questionnaires, diabetic foot clinics collected data in 2005, 2008 and 2011, covering characteristics, history and ulcer severity, management and outcome of the first 52 patients presenting with a Wagner grade ≥2 diabetic foot ulcer or acute neuropathic osteoarthropathy that year. Quality improvement was encouraged by meetings and by anonymous benchmarking of diabetic foot clinics.

Results

The first audit–feedback cycle was a pilot study. Subsequent audits, with a modified methodology, had increasing rates of participation and data completeness.

Over 85% of diabetic foot clinics participated and 3372 unique patients were sampled between 2005 and 2011 (3312 with a diabetic foot ulcer and 111 with acute neuropathic osteoarthropathy). Median age was 70 years, median diabetes duration was 14 years and 64% were men. Of all diabetic foot ulcers, 51% were plantar and 29% were both ischaemic and deeply infected. Ulcer healing rate at 6 months significantly increased from 49% to 54% between 2008 and 2011. Management of diabetic foot ulcers varied between diabetic foot clinics: 88% of plantar mid-foot ulcers were off-loaded (P10–P90: 64–100%), and 42% of ischaemic limbs were revascularized (P10–P90: 22–69%) in 2011.

Conclusions

A unique, nationwide quality improvement initiative was established among diabetic foot clinics, covering ulcer healing, lower limb amputation and many other aspects of diabetic foot care. Data completeness increased, thanks in part to questionnaire revision. Benchmarking remains challenging, given the many possible indicators and limited sample size. The optimized questionnaire allows future quality of care monitoring in diabetic foot clinics. Copyright © 2014 John Wiley & Sons, Ltd.

References

1 Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366: 1719–1724.
10.1016/S0140-6736(05)67698-2
PubMed Web of Science® Google Scholar
2 Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005; 293: 217–228.
10.1001/jama.293.2.217
CAS PubMed Web of Science® Google Scholar
3 Ribu L, Hanestad BR, Moum T, Birkeland K, Rustoen T. A comparison of the health-related quality of life in patients with diabetic foot ulcers, with a diabetes group and a nondiabetes group from the general population. Qual Life Res 2007; 16: 179–189.
10.1007/s11136-006-0031-y
PubMed Web of Science® Google Scholar
4 Matricali GA, Dereymaeker G, Muls E, Flour M, Mathieu C. Economic aspects of diabetic foot care in a multidisciplinary setting: a review. Diabetes Metab Res Rev 2007; 23: 339–347.
10.1002/dmrr.706
PubMed Web of Science® Google Scholar
5 Prompers L, Huijberts M, Schaper N, et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia 2008; 51: 1826–1834.
10.1007/s00125-008-1089-6
CAS PubMed Web of Science® Google Scholar
6 Bakker K, Apelqvist J, Schaper NC. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab Res Rev 2012; 28(Suppl 1): 225–231.
10.1002/dmrr.2253
PubMed Web of Science® Google Scholar
7 Prompers L, Huijberts M, Apelqvist J, et al. Delivery of care to diabetic patients with foot ulcers in daily practice: results of the Eurodiale Study, a prospective cohort study. Diabet Med 2008; 25: 700–707.
10.1111/j.1464-5491.2008.02445.x
CAS PubMed Web of Science® Google Scholar
8 Ivers N, Jamtvedt G, Flottorp S, et al. Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 2012; 6: CD000259.
10.1002/14651858.CD000259.pub3
PubMed Web of Science® Google Scholar
9 Debacker N, Nobels F, Vandenberghe H, Van Crombrugge P, Scheen A, Van Casteren V. Organization of a quality-assurance project in all Belgian multidisciplinary diabetes centres treating insulin-treated diabetes patients: 5 years' experience. Diabet Med 2008; 25: 179–185.
10.1111/j.1464-5491.2007.02378.x
CAS PubMed Web of Science® Google Scholar
10 Wagner FW Jr. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981; 2: 64–122.
10.1177/107110078100200202
PubMed Google Scholar
11 Schaper NC. Diabetic foot ulcer classification system for research purposes: a progress report on criteria for including patients in research studies. Diabetes Metab Res Rev 2004; 20(Suppl 1): S90–S95.
10.1002/dmrr.464
PubMed Web of Science® Google Scholar
12 Spiegelhalter DJ. Funnel plots for comparing institutional performance. Stat Med 2005; 24: 1185–1202.
10.1002/sim.1970
PubMed Web of Science® Google Scholar
13 Akhtar S, Schaper N, Apelqvist J, Jude E. A review of the Eurodiale studies: what lessons for diabetic foot care? Curr Diab Rep 2011; 11: 302–309.
10.1007/s11892-011-0195-x
PubMed Web of Science® Google Scholar
14 Lobmann R, Müller E, Kersken J, et al. The diabetic foot in Germany: analysis of quality in specialised diabetic footcare centres, 2008. Available at: http://www.woundsinternational.com/case-reports/the-diabetic-foot-in-germany-analysis-of-quality-in-specialised-diabetic-footcare-centres. Accessed October 3, 2013.
Google Scholar
15 Mant J. Process versus outcome indicators in the assessment of quality of health care. Int J Qual Health Care 2001; 13: 475–480.
10.1093/intqhc/13.6.475
CAS PubMed Web of Science® Google Scholar
16 Lilford RJ, Brown CA, Nicholl J. Use of process measures to monitor the quality of clinical practice. BMJ 2007; 335: 648–650.
10.1136/bmj.39317.641296.AD
PubMed Web of Science® Google Scholar
17 Taylor SM, Johnson BL, Samies NL, et al. Contemporary management of diabetic neuropathic foot ulceration: a study of 917 consecutively treated limbs. J Am Coll Surg 2011; 212: 532–545.
10.1016/j.jamcollsurg.2010.12.027
PubMed Web of Science® Google Scholar
18 Blumenthal D. Part 1: Quality of care – what is it? N Engl J Med 1996; 335: 891–894.
10.1056/NEJM199609193351213
CAS PubMed Web of Science® Google Scholar
19 Greenfield S, Kaplan SH, Kahn R, Ninomiya J, Griffith JL. Profiling care provided by different groups of physicians: effects of patient case-mix (bias) and physician-level clustering on quality assessment results. Ann Intern Med 2002; 136: 111–121.
10.7326/0003-4819-136-2-200201150-00008
PubMed Web of Science® Google Scholar
20 Hofer TP, Hayward RA, Greenfield S, Wagner EH, Kaplan SH, Manning WG. The unreliability of individual physician ‘report cards’ for assessing the costs and quality of care of a chronic disease. JAMA 1999; 281: 2098–2105.
10.1001/jama.281.22.2098
CAS PubMed Web of Science® Google Scholar
21 Scholle SH, Roski J, Adams JL, et al. Benchmarking physician performance: reliability of individual and composite measures. Am J Manag Care 2008; 14: 833–838.
PubMed Web of Science® Google Scholar
22 Kaplan SH, Griffith JL, Price LL, Pawlson LG, Greenfield S. Improving the reliability of physician performance assessment: identifying the ‘physician effect’ on quality and creating composite measures. Med Care 2009; 47: 378–387.
10.1097/MLR.0b013e31818dce07
PubMed Web of Science® Google Scholar
23 Mohammed MA, Worthington P, Woodall WH. Plotting basic control charts: tutorial notes for healthcare practitioners. Qual Saf Health Care 2008; 17: 137–145.
10.1136/qshc.2004.012047
CAS PubMed Web of Science® Google Scholar
24 Jeffcoate WJ, van Houtum WH. Amputation as a marker of the quality of foot care in diabetes. Diabetologia 2004; 47: 2051–2058.
10.1007/s00125-004-1584-3
CAS PubMed Web of Science® Google Scholar
25 Prompers L, Schaper N, Apelqvist J, et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008; 51: 747–755.
10.1007/s00125-008-0940-0
CAS PubMed Web of Science® Google Scholar
26 Jeffcoate WJ, Chipchase SY, Ince P, Game FL. Assessing the outcome of the management of diabetic foot ulcers using ulcer-related and person-related measures. Diabetes Care 2006; 29: 1784–1787.
10.2337/dc06-0306
PubMed Web of Science® Google Scholar

Citing Literature

Volume30, Issue5

July 2014

Pages 435-443

Implementation of a quality improvement initiative in Belgian diabetic foot clinics: feasibility and initial results

Abstract

Background

Methods

Results

Conclusions

References

Citing Literature

References

Information

About Wiley Online Library

Help & Support

Opportunities

Connect with Wiley

Implementation of a quality improvement initiative in Belgian diabetic foot clinics: feasibility and initial results

Abstract

Background

Methods

Results

Conclusions

References

Citing Literature

References

Related

Information