Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of TX

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

Diabetes

 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 Foot

 A person with Diabetes Mellitus has a 1-4% annual risk and has a 1525% 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
Economic Burden

 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.
San Antonio, TX Truths

 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
OBJECTIVES

What motivated me to create this study?

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.
OBJECTIVES OF THE 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.
STUDY DESCRIPTION

Type of Study / Patients

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
Questionnaire

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.
STUDY ANALYSIS

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.
PRELIMINARY RESULTS
and ANALYSES

WORKS-IN PROGRESS
RESULTS

Patients by Gender and Diabetes
Type
MALE
No response
7 71
TYPE 2
27
TYPE 1
23
FEMALE
No response
53
4
 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

KNOWLEDGE
GOOD
AVERAGE
22%
78%
POOR
RESULTS

COMPLIANCE
GOOD
POOR
AVERAGE
3%
55%
42%
RESULTS

ATTITUDES
FAVORABLE
UNFAVORABLE
1%
99%
Distribution

Joint
distributions of
good scores for
knowledge,
compliance and
attitudes on foot
care for 104
patients
Results show that…

 Many have GOOD KNOWLEDGE and
FAVORABLE ATTITUDES towards the care of
their feet.
 Patients, however, showed LESSER
COMPLIANCE towards foot care.
Several Interpretations…

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.
Less Compliance Interpretation

 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.
NEXT STEPS

THE FUTURE

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.
Additional Positive Outcomes

 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.
REFERENCES

 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
THANK YOU!!

ANY QUESTIONS?