Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003

Univ of TX Health Science Center San Antonio Family and Community Medicine

Chief Resident 2015-2016 July 18, 2015

BACKGROUND

World Health Organization currently estimates that there are 347 Million

people who have diabetes According to CDC, Diabetes affects 9.3% of US population, which is

approximately 21 million people Population Estimates from 2005-2008 National Health and Nutrition

Examination Survey, CDC estimates that approximately 79 Million Americans have prediabetes.

Currently the 7th leading cause of death in the United States. With projected 2/3 increase between 2008 and 2030

Diabetes is the cause of death for about 3.4 Million people worldwide in 2004

Diabetes

A person with Diabetes Mellitus has a 1-4% annual risk and has a 15-

25% lifetime risk of developing a foot ulcer Based on recent evidence, prevention and delay of foot ulcers can be

done with better glucose control and proper foot care However, proper foot care is not practiced by the general population

leading to foot ulcers with recurrence rate of >50% in 3 years About 80% of lower extremity amputations is caused by foot ulcers

and the frequency these amputations can decrease by about 49-85% if preventive foot care measures are placed

Diabetes Foot

Diabetes itself costs an excess of $176 billion on health care

expenditures and $69 Billion in reduced workforce productivity Foot ulcers are also a huge economic burden – an article concluded that

Diabetic foot ulcers end up costing about $9-13 billion in addition to costs associated with diabetes itself (2012 US dollars)

Previous literature report that the burden of Diabetic foot ulcers have shown average per patient costs of approximately $4595 per episode and about $35000 annually for all services.

Economic Burden

Data assembled by our San Antonio Metropolitan Health

District have shown that San Antonio, TX is at the top of large metropolitan area in the incidence of foot amputation.

In 2012-2013, within a span of 15 months, a total of 2025 diabetic patients with HbA1c > 9 have been seen in our Family Health Clinic at the University Hospital Robert B. Green Campus in San Antonio, TX

San Antonio, TX Truths

OBJECTIVES

Diabetes affects everybody’s lives… even my family’s. Noticed a huge number of patients with diabetes foot ulcers

that were being admitted at the University Hospital, under our service

Wanted to understand what factors contribute to poor care of feet in diabetes patients.

I care for my patients.

What motivated me to create this study?

Determine Self-reported knowledge, attitudes and practices

among diabetic patients attending the Family Health Clinic at the University Hospital Robert B. Green Downtown Campus in San Antonio, TX

Identify patient practices that put them at increased risk of developing foot ulcers.

Through this study, we aim to understand what our patients know about proper foot care, how they practice caring for their feet in their everyday lives and how willing they are to learn more about the care of their feet.

OBJECTIVES OF THE STUDY

STUDY DESCRIPTION

A Cross Sectional study utilizing questionnaires completed by

diabetic patients seen at the Family Health Clinic. Study enrolled 104 patients, both English and Spanish literate

patients. Inclusion/Exclusion Criteria: adults ages 18 and above, with

a history of Type 1 and Type 2 Diabetes, and without history of amputation of any part of the lower extremity

Type of Study / Patients

Questions focused on the following: Knowledge: Medication Compliance, Foot Care, Foot

complications and Health advice Practices: Foot care practices (i.e., cleaning of feet, cutting

toenails, walking barefoot, etc.) Attitudes: Willingness to learn more, to practice at home

what they learned and to follow physician/health care providers' advice.

Questionnaire

Scoring method: Each favorable response to a question would be given 1 point. Unfavorable responses would be given a score of 0. KNOWLEDGE SCORE- to assess patient’s knowledge

Total score is 14. Score of 11-14: good knowledge, Score of 6-10: average knowledge and Score of 1-5: poor knowledge. COMPLIANCE SCORE – to assess patient’s practices

Total score is 9. Score of 7-9: good compliance, Score of of 4-6: average compliance and Score of 1-3: poor compliance. ATTITUDE SCORE – to assess patient’s attitude

Total score is 5. Score of 3-5: a favorable attitude and a score of 1-2 : unfavorable attitude.

STUDY ANALYSIS

PRELIMINARY RESULTS and ANALYSES

WORKS-IN PROGRESS

RESULTS

TYPE 1

TYPE 2

No response

2

27

7

3

53

7

4

1

Patients by Gender and Diabetes Type

MALE FEMALE No response

Majority of patients are Type 2 Diabetics Questionnaires were

patient-completed, “No response” – patients unaware of their Diabetes type Very few Type 1

diabetics since most are seen in Endocrinology clinic

RESULTS

78% 22%

KNOWLEDGE GOOD AVERAGE POOR

RESULTS

42% 55%

3%

COMPLIANCE GOOD AVERAGEPOOR

RESULTS

99%

1%

ATTITUDES FAVORABLE UNFAVORABLE

Distribution

Joint distributions of good scores for

knowledge, compliance and attitudes on foot

care for 104 patients

Many have GOOD KNOWLEDGE and

FAVORABLE ATTITUDES towards the care of their feet. Patients, however, showed LESSER

COMPLIANCE towards foot care.

Results show that…

First, our clinic’s emphasis on foot exams and foot care may

be having beneficial effects to our patient population, giving them adequate knowledge on how to care for their feet.

Patients who agree to participate in the study may be those with more favorable attitudes and behaviors.

Patients may be answering the survey in a more socially desirable manner that does not reflect their actual practices.

Several Interpretations…

It is an important finding that demonstrates patients’

inability to regularly apply what they know This could be due to competing demands in their

lives, or underestimation of their risk, or even a belief that foot ulcers are inevitable.

Less Compliance Interpretation

NEXT STEPS

We plan to evaluate all these questions in further

work. Help understand how we can create improved

protocols, measures, and patient-centered quality improvement projects in our clinic and in our future practice as primary care physicians. Understand how to help prevent diabetic foot ulcers

from affecting our patients’ lives.

THE FUTURE

As a result of being a patient-centered study, this works-in progress

study won the Patient’s Choice Award at the 2014 North American Primary Research Group (NAPCRG) Conference in New York, NY.

Additional Positive Outcomes

1 Pollock, et al. “Knowledge and practice of foot care in people with diabetes”.

Diabetes Research and Clinical Practice 2004. 64: 117-122. 2 Desalu, et al. “Diabetic Foot Care: Self Reported Knowledge and Practice among

Patients Attending Three Tertiary Hospital in Nigeria”. Ghana Medical Journal June 2011. 45 (2): 60-65

3 Khamseh, et al. “Knowledge and practice of foot care in Iranian people with Type 2 Diabetes”. International Wound Journal 2007; 4: 298-302

4 Chellan, et al. “Foot care practice – The key to prevent diabetic foot ulcers in India”. Elsevier. The Foot (22) 2012: 298-302

5 Fassil, et al. Diabetic Foot Infections. American Family Physician August 1, 2013; 88(3):177-184

6 Rice, et. Al. Burden of Diabetic Foot Ulcers for Medicare and Private Insurers. Diabetes Care 2014; 37: 651-658

REFERENCES

THANK YOU!!

ANY QUESTIONS?