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Evaluation of regional footcare programs: Uses of initial and repeat amputation rates as quality improvement indicators

Chin-Lin Tseng, DrPH1, Usha Sambamoorthi, PhD1, Mangala Rajan, MBA1, Drew Helmer, MD, MS1, Anjali Tiwari, MS1, Patricia Findley, DrPH, MSW1, James Wrobel, DPM, MS2, and Leonard Pogach, MD1. (1) Center for Healthcare Knowledge Management, Department of Veterans Affairs, NJ Health Care System, 385 Tremont avenue, VAMC#129, East Orange, NJ 07018, 973-676-1000 x2028, tseng@njneuromed.org, (2) Center of Lower Extremity Ambulatory Research (CLEAR), Dr. William M. Scholl College of Podiatric Medicine at Rosalind Franklin University of Medicine and Science, 3333 Green Bay Road, North Chicago, IL 60064

Background: Healthy People 2010 sets a goal of decreasing diabetes related lower extremity (LEA) amputation (LEA) rates by 55%. Within a defined system of care, distinguishing initial amputations from any amputation may better enable clinical administrators to evaluate the effectiveness of the different elements of foot care coordination programs. For example, the screening and surveillance elements of amputation prevention are often largely based in primary care clinics, whereas prevention of repeat amputations may best be the responsibility of multidisciplinary post-amputation care clinics.

Objective: Our objective was to compare the application of ILEA, and RLEA in evaluation of regional variation among Veteran Integrated Service Networks (VISNs) as quality improvement indicators.

Methods: Retrospective longitudinal cohort study of 363,538 veteran clinical users with diabetes who were either Veteran Health Administration (VHA) or dual VHA-Medicare-fee-for-service enrollees and alive as of the end of fiscal year (FY) 2000also. We ascertained baseline risks (age, sex, race, lower extremity risk factors, and medical comorbidities) in FY1999 and events of LEA occurring either in the VHA or private sector in FY 2000. ILEA was determined using evidence of prior amputation by procedure codes, post-amputation codes, and lower limb prosthetic codes within prior 24 months. Non-ILEA amputations were considered as repeat LEAs(RLEA). Multinomial logistic regression was used for risk-adjustment. We used the risk-adjusted Observed/Expected(O/E) amputation ratio to rank the 22 geographic areas defined by VISNs.

Results: Overall, 2,988 (8.2 per 1,000, 5.7~10.9 by VISNs) veterans experienced an amputation in fiscal year 2000. Of these, 2171 had ILEA (6.0/1000; 3.8~7.4), and 807 had RLEA (2.2/1000; 1.4~3.5). The Spearman statistic for correlation between risk adjusted VISN ranks for ILEA and LEA was 0.94 (p<0.001), and between RLEA and LEA was 0.82 (p<0.001). ILEA and RLEA ranks were moderately related (coefficient=0.59, p=0.004). Of the 10 VISNs ranked as high outliers (higher rate) by ILEA, five were also high outliers by RLEA, four were non-outliers, and one was low outlier (lower rate) by RLEA. Of the 8 non-outliers by ILEA, five were non-outliers and three were low outliers by RLEA. Two were lower outliers by both ILEA and RLEA.

Conclusion and Implication: Application of ILEA and RLEA results in different rankings and outlier status of VHA regional areas. These measures provide more granular information than LEA alone and may assist for quality improvement efforts for prevention services and comparisons of health system performance.

Learning Objectives:

Keywords: Outcome Measures, Quality of Care

Presenting author's disclosure statement:

Any relevant financial relationships? No

Health Services Research: Quality of Care and Patient Satisfaction

The 134th Annual Meeting & Exposition (November 4-8, 2006) of APHA