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© 2003 by the American Diabetes Association, Inc.
Epidemiology/Health Services/Psychosocial Research |
The Relationship Between Provider Coordination and Diabetes-Related Foot Outcomes
1 VA Medical and Regional Office Center, Department of Veterans Affairs, White River Junction, Vermont
2 Department of Community and Family Medicine, Dartmouth Medical School, Hanover, New Hampshire
3 VA Management Decision & Research Center, Boston University School of Public Health, Boston, Massachusetts
4 Program on Health Policy and Management, Boston University School of Public Health, Boston, Massachusetts
5 Department of Biostatistics, University of Washington, Seattle, Washington
6 Cleveland VA Medical Center, Department of Veterans Affairs, Cleveland, Ohio
7 Department of Health Services, University of Washington, Seattle, Washington
8 Department of Epidemiology, University of Washington, Seattle, Washington
9 Health Services and Research and Development, VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington
10 Primary and Specialty Medical Care Services, VA Puget Sound Health Care System, Department of Veterans Affairs, Seattle, Washington
11 VA New Jersey Health Care System, Department of Veterans Affairs, East Orange, New Jersey
Address correspondence and reprint requests to James Wrobel, DPM, VA White River Junction, Surgical Service #112E, White River Junction, VT 05009. E-mail: james.s.wrobel{at}dartmouth.edu
OBJECTIVE—To investigate the relationship between provider coordination and amputations in patients with diabetes.
RESEARCH DESIGN AND METHODS—The study design was a cross-sectional, descriptive study of process and outcomes for diabetes-related foot care at 10 Department of Veterans Affairs (VA) medical centers representing different geographic regions, population densities, patient populations, and amputation rates. The subjects included all providers of diabetes foot care and a random sample of primary care providers at each medical center. The main outcome measures were the Foot Systems Assessment Tool (FootSAT), nontraumatic lower extremity amputation rates, and investigators’ ordinal ranking of site effectiveness based on site visits.
RESULTS—The survey response rate was 48%. Scale reliability, as measured by Cronbach’s 
, ranged from 0.73 to 0.93. The scale scores for programming coordination (i.e., electronic medical record, policies, reminders, protocols, and educational seminars) and feedback coordination (i.e., discharge planning, quality of care meetings, and curbside consultations) were negatively associated with amputation rates, suggesting centers with higher levels of coordination had lower amputation rates. Statistically significant associations were found for programming coordination with minor amputations (P = 0.02) and total amputations (P = 0.04).
CONCLUSIONS—The FootSAT demonstrated a stronger association with amputation rates than site visit rankings. Among these 10 VA facilities, those with higher levels of programming and feedback coordination had significantly lower amputation rates.
Abbreviations: FootSAT, Foot Systems Assessment Tool • VA, Department of Veterans Affairs
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