![Page 1: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/1.jpg)
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
![Page 2: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/2.jpg)
BACKGROUND
![Page 3: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/3.jpg)
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
![Page 4: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/4.jpg)
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
![Page 5: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/5.jpg)
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
![Page 6: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/6.jpg)
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
![Page 7: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/7.jpg)
OBJECTIVES
![Page 8: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/8.jpg)
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?
![Page 9: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/9.jpg)
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
![Page 10: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/10.jpg)
STUDY DESCRIPTION
![Page 11: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/11.jpg)
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
![Page 12: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/12.jpg)
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
![Page 13: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/13.jpg)
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
![Page 14: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/14.jpg)
PRELIMINARY RESULTS and ANALYSES
WORKS-IN PROGRESS
![Page 15: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/15.jpg)
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
![Page 16: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/16.jpg)
RESULTS
78% 22%
KNOWLEDGE GOOD AVERAGE POOR
![Page 17: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/17.jpg)
RESULTS
42% 55%
3%
COMPLIANCE GOOD AVERAGEPOOR
![Page 18: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/18.jpg)
RESULTS
99%
1%
ATTITUDES FAVORABLE UNFAVORABLE
![Page 19: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/19.jpg)
Distribution
Joint distributions of good scores for
knowledge, compliance and attitudes on foot
care for 104 patients
![Page 20: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/20.jpg)
Many have GOOD KNOWLEDGE and
FAVORABLE ATTITUDES towards the care of their feet. Patients, however, showed LESSER
COMPLIANCE towards foot care.
Results show that…
![Page 21: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/21.jpg)
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…
![Page 22: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/22.jpg)
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
![Page 23: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/23.jpg)
NEXT STEPS
![Page 24: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/24.jpg)
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
![Page 25: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/25.jpg)
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
![Page 26: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/26.jpg)
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
![Page 27: Anna Cecilia Sandejas-Tenorio, MD UERM Batch 2003 Univ of](https://reader031.vdocuments.mx/reader031/viewer/2022012512/618bda84bb543619175c342d/html5/thumbnails/27.jpg)
THANK YOU!!
ANY QUESTIONS?