In 2006, a group of pediatric cardiologists in Boston set out to improve patient outcomes while decreasing unnecessary costs.1 The doctors based their initiative on the following five principles.
• Variation from sound medical principles decreases the likelihood of best outcomes and lowers efficiency. Standardization is a good thing.
• Standardization is based on consensual agreements developed across medical disciplines and is not based on complex rules and micromanagement.
• Standardization allows for measurements that can lead to improvements.
• There are no static “best practices” but rather a continuous search for improvements and innovations.
• Data gathering should focus on the most important clinical measures of the disease in question.
The doctors in Boston succeeded in improving patient outcomes and reducing resource utilization at their hospital through standardization.1 They named the process “Standardized Clinical Assessment and Management Plans,” or “SCAMPS” for short. The SCAMPS initiative offers a quality management tool that seeks to improve care and lower costs over time using data-backed pathways that measure the important and challenging facets of the specific disease. This is a winning formula that one can apply to podiatry and the care of patients with diabetes.
The following podiatric SCAMP initiative focuses on diabetic foot care, which is potentially the most impactful place in health care for podiatrists in the United States. This “Diabetic Foot Care” SCAMP is based on Appendix 11 of The Diabetic Foot Book.2
Identifying The Best Pathway For Monitoring And Care Of Patients With Diabetes
As we all know, patients with diabetes should have an initial and annual detailed foot examination by a podiatrist. One can determine the need for additional monitoring, testing or treatment of the feet based on the findings of this exam. After performing the diabetic foot exam, podiatrists can consider five clinical presentation categories that may be applicable for the individual patient and associated checklists they can follow to ensure optimal care.
In some cases, more than one category may be applicable. For example, a patient may have impaired circulation and impaired sensation in the feet. In these cases, the podiatrist would utilize both corresponding category checklists.
1) Foot examination with no significant findings. If the detailed foot examination reveals no problems with blood flow, nerve function or the structure of the foot, the podiatrist would use the following checklist.2
• Review the foot exam findings with the patient.
• Review diabetic foot care fundamentals.
• Review and apply a Diabetic Foot Wellness Program, which is detailed later in this article.
• Schedule a follow-up foot examination in one year, particularly if the person has risk factors for diabetic foot complications such as a hemoglobin A1c (HbA1c) of greater than 7.0 percent, a body mass index (BMI) over 28 kg/m2, a smoking habit, hypertension, or is over the age of 50.
When Patients Have PAD Or Nerve Issues
2) Foot examination reveals signs and symptoms of peripheral arterial disease (PAD). This patient is one where the foot examination reveals decreased blood flow to the feet via symptoms such as calf pain with walking or signs such as diminished foot pulses, cool toes, etc. The same checklist applies as for those with no significant findings with the addition of the following: 2
• Review or obtain the results of ankle- and toe-brachial indices, and/or microcirculation testing. Consider referral to a vascular specialist.
• Start a prescribed diabetic foot exercise program.
• Schedule periodic prophylactic foot care visits as necessary (usually every two to three months) in addition to the planned yearly detailed exam.
• Check and possibly modify or replace the patient’s footwear to prevent excessive pressure or friction.
3) Foot examination reveals problems with the nerves of the feet. If the provider finds evidence of diminished sensation to the feet, especially with the loss of protective sensation, the patient would benefit from the same checklist as the one for the patient with PAD but there would be two additional proactive steps to consider.2
• Review or initiate a protective footwear program focused on the patient’s needs (pain relief, pressure prevention, etc.).
• Schedule periodic prophylactic foot care visits as necessary (typically every two to six months for this population) in addition to the planned yearly detailed exam.
Addressing Structural Deformities
4) The foot examination reveals structural problems with the feet. If the patient has foot deformities such as hammertoes or bunions, podiatrists need to take the following measures.2
• Review or initiate a protective footwear program focused on the patient’s needs (pain relief, mechanical control, pressure prevention, etc.).
• If the pedal circulation is adequate, consider surgical correction of the deformity to prevent future problems.
• Schedule an annual follow-up foot examination in one year.
When The Patient Has A Non-Traumatic Amputation Or Chronic Wound
5) Foot examination reveals prior non-traumatic amputation or chronic foot wound. If the patient has had a partial or complete foot amputation due to impaired circulation or a foot infection, the case requires more vigilant foot monitoring to prevent additional problems. Those with a past history of a chronic wound on their foot also require additional monitoring and preventive care. The baseline checklist applies with the following additions and modifications in these two circumstances.2
• Review or initiate a protective footwear or prosthetic program focused on the patient’s needs (offloading, fillers, pressure prevention, etc.).
• Schedule periodic prophylactic foot care visits (usually every one to three months).
• Schedule a semi-annual foot examination.
Developing A Diabetic Foot Wellness Program
A diabetic foot wellness program includes information and instructions for patients, delivered via educational handouts and video, on how to optimize the health of their feet.2 Topics covered under this program could include: exercise, nutrition, weight loss, smoking cessation, stress management and quality sleep. Referring patients to a certified diabetes educator is another valuable component of this wellness program.
The aforementioned SCAMP pathway is standard for patients with diabetes in our practice. We also give them an electronic copy of The Diabetic Foot Book, which espouses principles of sound diabetic foot care. We then collect targeted data from these patients focusing on the development of foot ulcerations and the need for pedal amputations as these are the events we are aiming to prevent.
Over time, data analysis will allow for continuous improvement in outcomes and resource utilization. This pathway provides education, evaluation and care for the feet of everyone with diabetes but focuses most intensely on those with a prior foot ulcer or amputation. These are the folks who are at highest risk and need podiatry the most to maintain their quality of life. Additionally, these are the folks most likely to generate preventable increased costs to the health-care system.
Providers who want to be part of solutions to the health care challenges in our country should focus on finding ways to concurrently improve outcomes and lower costs. The aforementioned SCAMP protocol is a tool, which promotes standardization, measurement and ongoing improvement.
If podiatrists want to fit into a value-based health care environment, they need to work on their value propositions. They need to standardize, measure and improve. Do you have a SCAMP?
Dr. McDonald is in private practice with InStride Foot and Ankle Specialists in Concord, N.C. He is a Fellow of the American Academy of Podiatric Practice Management, and the American Professional Wound Care Association. He is a Diplomate of the American Board of Foot and Ankle Surgery, and the American Board of Podiatric Medicine.
Dr. McDonald discloses that he is lead author of the Diabetic Foot Book and a member of the Medical Advisory Board for Modulim. Dr. McDonald notes that all net proceeds of the Diabetic Foot Book will be donated to podiatric student scholarship funds.
1. Farias M, Jenkins K, Lock J, et al. Standardized clinical assessments and management plans. Health Aff. 2013;32(5):911-920.
2. InStride Foot and Ankle Specialists. The Diabetic Foot Book. Concord NC; InStride Foot Publishing; 2019.