Increasing Healthcare Provider Compliance in Performing Foot Examinations in Diabetic Patients


Williams, Y., Jones, S., & Johnson, K. (November, 2018). Increasing Healthcare Provider Compliance in Performing Foot Examinations in Diabetic Patients. Online Journal of Nursing Informatics (OJNI), 22(3), Available at


Diabetes mellitus is a chronic and potentially life-threatening disease with many types of complications.  Diabetic foot ulcers are a major source of morbidity and mortality and can impact quality of life.  Amputations and diabetic foot ulcers are costly complications of diabetes.  The cost of diabetic foot ulcers can lead to an additional ten thousand dollars more a year for a diabetic patient (Talrico, 2013).  The American Diabetes Association (ADA) (2016) recommended an annual foot examination for all people with diabetes and more often if they have a history of past foot ulcers or neuropathy.  A proper foot examination involves inspection of the foot and a neurological assessment to include 10-g monofilament testing.  The Centers for Disease Control and Prevention (CDC) (2014) reported that one-third of patients with diabetes do not receive a foot examination each year from their primary healthcare provider. 

The purpose of this project was to increase foot examinations performed among healthcare providers in primary care settings by implementing a reminder system in the electronic health record (EHR) in the charts of diabetic patients to alert the provider to perform and document the foot examination.  Prior to the implementation of the reminder system, 100 EHRs were reviewed and only four EHRS included documentation of a diabetic foot examination.  After the availability of the reminder system, another 100 EHRs were reviewed and 78 EHRs were found to have documentation of diabetic foot examinations.

Background of the Problem

Diabetic foot complications account for more hospital inpatient visits than all other diabetes related complications (Yarwood-Ross & Randall, 2013). The rate of mortality increases after a lower extremity amputation from 13-40% the first year, 35-65% in three years, and 39-80% at five years after an amputation (Woodbury, Sibbald, Ostrow, Paersaud, & Lowe, 2015). Diabetic foot problems can be prevented with early screening and treatment of vascular and peripheral neuropathy problems. 
Studies have shown 63% of people with diabetes rarely perform self-examinations of the foot (McInnes et al., 2016). Patients often attribute issues with their feet to a lack of blood supply rather than nerve damage. Many patients believe there should be a visible open sore on the foot before reporting foot problems to a healthcare provider. Healthcare professionals must provide education about basic foot care to all patients with diabetes. When the healthcare provider emphasizes the importance of proper foot care, patients will more likely make home foot examinations a priority and alert the healthcare provider of any changes or abnormalities.

Significance of the Problem to Healthcare

According to the ADA (2016), foot examinations should be completed by a healthcare provider annually, or more frequently, to identify patients at risk for ulcers and amputations. Providers may need to perform foot examinations more frequently with diabetic patients with circulatory problems or neuropathy. A proper foot care examination includes inspecting the skin of the foot.  In addition to a foot inspection, a neurological assessment of the foot includes a 10-g monofilament testing, pinprick, or vibration testing. The monofilament testing is performed on the first, third and fifth metatarsal heads of the toes and on the plantar surface of the distal hallux. A vascular assessment is included to check the pulses in the legs and feet (McInnes et al., 2016).


The purpose of this study is to increase the number of foot examinations in patients with diabetes in a primary care setting by adding a reminder in the patient’s electronic medical record. Since foot examinations and early detection of foot injuries can prevent lower extremity ulcers or amputations, the ADA (2016) recommended people with diabetes receive an annual foot exam from a healthcare provider or more frequently if the patient has a history of neuropathy or diabetic foot ulcers. The CDC (2015) reports that one-third of patients do not receive a foot examination each year from a healthcare provider. Research shows consistent foot examinations and preventative care reduces foot ulcers and amputations among patients with diabetes (Miller Salloum, Button, Giovinco, & Armstrong, 2014).

Theoretical Model

The Chronic Care Model was first established in 1992 by the MacColl Center. Named after Dr. William Sandy MacColl, the center is a research organization within the Group Health Research Institute (Wagner, 1998). The purpose of the model was to develop processes and incentives for making changes in the care delivery system for the treatment of chronic illnesses. In addition, this model is intended to ensure self-management support, which gives priority to increasing patient confidence and skills so that the patient can self-manage a condition. The Chronic Care Model identifies community, the health system, self-management support, delivery system design, decision support, and clinical information systems as all being essential to high-quality chronic disease care (Wagner, 1998) and leads to more informed and involved patients.

Literature Review

Research findings show that healthcare providers place achieving glycemic control as a primary priority and foot care a secondary priority. The healthcare providers were aiming for patients to have HbA1C levels under 7.0%, with diet, exercise and foot care next in priority once the patients had glycemic control maintained (Guell & Unwin, 2015). The two clinics were Wyoming Valley Family Practice Residency Program (WVFPRP) and Exeter Township Health Center (ETHC).  ETHC audited the EHR of every diabetic patient in compliance with the federally qualified health centers. WVFPRP used the Measuring, Evaluating and Translating Research into Care (METRIC) tool developed by the American Academy of Family Physicians to increase the rate of compliance according to the diabetic guidelines (Duncan et al., 2014).

Foot checks increased in primary care. The annual foot exam rate at WVFPRP was 50% and at ETHC was 52%. The physicians’ responses were that foot examination were easy to forget and time consuming. The investigators provided the physicians with an intervention where the nurses were asked to have every diabetic patient take off shoes prior to the physician entering the room (Duncan et al., 2014). Physicians were then asked to examine and document the foot examination of every patient who has diabetes.

After the three-month study, WVFPRP had an increase from 50% to 80% in foot examinations and ETHC had an increase from 52% to 63%. The investigators discovered that with ETHC, the nursing staff reflected positivity about the intervention; however, the staff was not as engaged in ensuring that patients took off shoes prior to the physician entering the room (Duncan et al., 2014). The WVFPRP nurses were fully engaged during the entire process but some of the physicians did not perform a foot exam with every patient encounter. The physicians did confirm that having the patients remove shoes prior to the examination helped increase the number of foot examinations performed. In addition, the physicians felt the patients’ awareness concerning the importance of foot care and other diabetic teachings increased during the time of the study.

Educational level. Silva, Haddad, Rossaneis, and Marcon (2015) focused on the prevalence of diabetic foot ulcers in people living in rural areas. The researchers did not include patients who were undergoing dialysis, had active diabetic foot ulcers, or were living with dementia or other neurological disorders that affected reasoning and judgment ability. The descriptive exploratory cross-sectional study involved 293 patients with type II diabetes. The researchers’ instrument tool involved sociodemographic and clinical data, which included foot examination results, vital signs, and body mass index measurement. The diabetic foot examination included neurological and vascular assessments.

Of the participants, 37.2% were found to be at risk for diabetic foot ulceration. The researchers found that study participants who did not finish high school had a greater risk of developing a foot ulcer (Silva et al., 2015). Educational level was an important factor when planning teaching activities for patients with type II diabetes since a lack of understanding can affect adherence to the treatment plan.

An important objective in caring for all diabetic patients is the prevention of foot ulcers and amputations. In one study, a screening was conducted to identify factors that can predict patients at high risk for foot ulcers (Sriyani, Wasalathanthri, Hettiarachchi, & Prathapan, 2013). The researchers identified five predictors that could help them identify patients at greater risk of developing foot ulcers. One of the predictors was 6th grade education level and below; individuals with this level of education were less likely to seek treatment and make lifestyle adjustments. The second predictor was patients with lower income.  The researchers also found that patients with diabetes had less opportunity to access healthcare if they lived in a rural area. Patients who wore open-toed shoes or had skin discoloration were also at an increased risk of developing foot ulcers. In addition, presence of diabetic peripheral neuropathy indicated an individual had an increased chance of developing a foot ulcer.

In this study, clinics in Sri Lanka, which faced high turnovers in staff, were evaluated. The goal of identifying predictors using a simple, less time-consuming tool allowed diabetic foot examinations to be performed by paramedics. Teaching the predictors to these healthcare personnel was beneficial to the overall diabetic population (Sriyani et al., 2013).

A total of 100 patients admitted to the hospital or tertiary centers from May 2013 to May 2014 participated in a study by Kishore, Upadhyay, and Jyotsna (2015). The mean time since each patient had been diagnosed with diabetes was seven years. The patients’ examination included dermatologic, musculoskeletal and neurological assessments. The neurological assessment was performed to determine the loss of protective sensation, which is the perception of pressure and identification of the correct site using the 10-g monofilament on the first, third and fifth metatarsal heads of the toes and on the plantar surface of the distal hallux. 

The neurological exams showed 43% of patients lost protective sensation and 19% were diagnosed with peripheral arterial disease. Of the patients in the study, 52% of the patients were at risk for diabetic foot ulcers. The researchers found that the participants who had a diagnosis of diabetes, lack of formal education, and lower socioeconomic status had a greater risk of developing a foot ulcer (Kishore et al., 2015).


Data Collection Tools
The data collection tool for this project was created by the author in a Microsoft Excel document. The data collection tool used the chart number to identify the patient instead of any personal information.  The data collected from the chart reviews consisted of age, gender, BMI, number of years with diabetes, type I or II diabetes, HbA1C, foot exam result, and any diagnoses of peripheral neuropathy, hypertension, coronary artery arterial disease, or hyperlipidemia. After an electronic alert was placed in the EMR for a two-month period, a post-intervention chart review was performed. The pre and post intervention data were evaluated with the Statistical Package for the Social Sciences (SPSS) version 25 software to measure the change in the rate of foot examinations performed on the diabetic study participants using chi-square analysis and simple linear regression tests.

A chart review was conducted of 100 patients with diabetes seen over a two-month period prior to implementing the reminder alert in the EMR. The charts were reviewed, and the Microsot Excel data collection tool was created by the author. The author also provided the healthcare providers at the facility with a handout demonstrating the correct technique to perform a diabetic foot examination.

The medical assistants employed at the practice site were educated about the project via email and instructed to ask each diabetic patient to remove their shoes and socks prior to examination. The medical assistants also gave each of these patients an educational handout detailing the basics of foot care. The patients were allowed to take the educational brochure home to review. The PI added an alert to all diabetic patient charts during the months of August and September 2017. After the two-month implementation was completed, there was a two-month post-chart review of 100 charts to gather the required data collection tool content.

Statistical Analyses
Description of the sample. Data were compiled into a dataset and analyzed using IBM SPSS version 25. Table 1 illustrates the gender frequencies of the the pre-intervention (N = 100) and post-intervention (N = 100) samples. There were 54 females in the pre-intervention data and 56 females in the post-intervention samples.

Table 1: Frequencies of Pre-and Post-Intervention Gender

Table 2 describes the frequencies of age for both pre- and post-intervention samples. The average age of the pre-intervention sample was 65 years old and 63.9 years old for the post-intervention sample.

Table 2: Mean, Standard Deviation and Range of Pre- and Post-Intervention Sample Age

Descriptive statistics. Table 3 describes the frequencies of nominal level variables. The pre-intervention sample had a higher frequency of neuropathy and hyperlipidemia than the post-intervention samples. Interestingly, despite the higher frequency of neuropathy in the pre-intervention sample, only 4% of EHRs documented the performance of a foot examination in diabetics. After the reminder system was implemented, 78% of the EHRs documented that a foot examination was performed.

Table 3: Frequencies of selected Pre- and Post-Intervention Nominal Variables

Table 4 shows the mean, standard deviation and range of years of diabetes, HgbA1C, and BMI of both the pre- and post-intervention samples. The pre-intervention sample had a higher mean of years with diabetes, but the HgbA1C and BMI were very similar between the two samples.

Table 4: Mean, Standard Deviation and Range of Continuous Level Variables

Inferential statistics. Pearson correlation statistics were conducted to examine relationships between interval and ratio level variables in the pre-EHR review. These results are displayed in Table 5.  There was an indirect relationship between BMI and the number of years with diabetes, indicating the higher the number of years with diabetes, the lower the BMI. There was also a direct relationship between HgbA1C and BMI, meaning that the higher the HgbA1C, the higher the BMI.

Table 5: Pearson Correlation Analysis of Selected Variables

A simple linear regression was conducted to examine whether HgbA1C predicted BMI in the EHR sample. There was a significant prediction of BMI by HgA1C (R2 =.060, F(1, 98) = 6.208, p < .05) in the pre-intervention sample.  
Pearson correlations were also conducted to examine relationships between interval and ratio level variables in the post-EHR review. Table 6 displays these results. There were no significant relationships found with HgbA1C in the post-EHR review. 

Table 6: Pearson Correlation Analysis of Final Selected Variables

A chi-square test was conducted to determine if there were any differences in history of coronary artery disease and whether a foot examination was performed in the post-intervention sample. This chi-square was not significant (χ2(1)  = 2.465, p = .116), but it did show that 86.5% of persons with CAD in the post-intervention sample did have foot examinations.

Finally, independent samples t-tests were conducted in the post-intervention sample to determine any differences in age, number of years with diabetes, HgbA1C, BMI, and whether a foot examination was conducted. None of these t-tests were significant, which may indicate that none of the variables impacted the provider’s decision to conduct a foot examination.


Due to time constraints, there were only 100 charts reviewed during the pre-intervention and an additional 100 charts reviewed during post-intervention phases. A total of 200 different patient charts were reviewed during the study. Due to patients’ appointment schedules, the author was not able to review the exact same charts before and after the intervention. The patients in the facility have follow up appointments scheduled every three to four months. If the author had reviewed the same charts for the pre-intervention and post-intervention chart reviews, data trends could have been evaluated to determine the effects of the intervention on the same group of 100 patients. This study was only conducted at one primary care site in the southeastern U.S. In addition, there were nine healthcare providers in the facility and the author did not gather data regarding which providers were most complaint in completing the diabetic foot examinations after the EHR alert was implemented. It would have been helpful to gather these data and to establish the reasons why some healthcare providers did not perform the foot examinations on patients with diabetes.


The project has the potential to impact nursing practice due to the growing number of diabetic patients. Foot-related complications are common among people with diabetes. According to the literature, about 50% of diabetic foot complications can be prevented with proper education.  Primary care is the main gateway to the health system and is the foundation for the basis of health promotion and prevention. Patients with diabetes often enter the primary care setting and properly educating them on diabetic foot care and the complications that can occur related to diabetes is vital.


Preventative care is important to diabetes. Early identification and treatment of complications of diabetes can potentially reduce the severity of complications. This project involved implementing an alert in the EHR so that primary care providers would remember to perform foot examinations in the diabetic patient population. Although foot examinations are a crucial part of the examination of a diabetic patient, these examinations are often overlooked.  Previously, alerts have been placed in patients’ EHR to warn practitioners of potential safety hazards of medications (Ojeleye, Avery, Gupta, & Boyd, 2013). The alert in the EHR to remind healthcare providers to perform diabetic foot examinations will ultimately be beneficial for primary care patients with diabetes.


American Diabetes Association.  (2016). National Diabetes Education Initiative.   Retrieved from
Centers for Disease Control and Prevention. (2015). Living with Diabetes: Keep Your    Feet Healthy. Retrieved from
Duncan, A., Sugarman, R., Klein, A., Parmar, M., DeJoseph, D., White, M…
English, R. (2014). No shoes, no socks, more service: An introduction to improve   diabetic foot care. Journal of Quality Improvement in Healthcare, 3, 26-30. Retrieved from
Guell, C., & Unwin, N. (2015). Barriers to diabetic foot care in a developing country with a high incidence of diabetes related to amputations: An exploratory qualitative interior study. BMC Health Services Research, 15(1), 1-7. doi: 10.1186/s12913-015-1043-5
Kishore, S., Upadhyay, A., & Jyotsna, V. (2015).  Categories of foot at risk in patients of diabetes at a tertiary care center: insights into need for foot care. Indian Journal of Endocrinology and Metabolism, 19(3), 405-410. doi: 10.4103/2230-8210.152789
McInnes, A., Jeffcoate, W., Vileikyte, L., Game, F., Lucas, K., & Higson, N.,…Anders, J.  (2011). Foot care education in patients with diabetes at low risk of complications: A consensus statement. Diabetic Medicine, 28, 162-167. doi: 10.1111/j.1464-5491.2010.03206.x.
Miller, J. D., Salloum, M., Button, A., Giovinco, N. A., & Armstrong, D. G. (2014). How can I maintain my patient with diabetes and history of foot ulcer in remission? The International Journal Of Lower Extremity Wounds13(4), 371–377.
Ojeleye, O, Avery, A., Gupta, V., & Boyd, M. (2013). The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: A systematic review. Biomed Central Medical Informatics and Decision Making, 13(69), 1-10. doi: 6947/13/69
Silva, J., Haddad, M., Rossaneis, M., & Marcon, S. (2015). Ulceration risk in diabetic   feet: a cross-sectional study.  Brazilian Journal of Nursing, 14(3), 229-237. doi: 10.17665/1676-4285.20155241
Sriyani, K., Wasalathanthri, S., Hettiarachchi, P., & Prathapan, S. (2013). Predictors of   diabetic foot and leg ulcers in a developing country with a rapid increase in the  prevalence of diabetes mellitus. Plos One, 8(11), 1-6. doi:  1371/journal.pone.0080856          
Talarico, R. (2013). Preventing diabetic foot amputations: Podiatry, protocols, and perfusion. Podiatry Management, 32(9), 127-134. Retrieved from
Wagner, E. H. (1998). Chronic disease management: What will it take to improve care     for chronic illness. Effective Clinical Practice 1, 2-4. Retrieved from
Woodbury, M., Sibbald, R.G., Ostrow, B., Persaud, R., & Lowe, J. (2015). Tool for rapid
and easy identification of high risk diabetic foot: Validation and clinical pilot of the simplified 60 second diabetic foot screening tool. Plos One, 10(6), 1-5 doi: 10.1371/journal.pone.0125578
Yarwood-Ross, L., & Randall, S. (2013). Managing a patient’s diabetic foot ulcer. Primary Health Care, 23(1), 16-20 doi:10.77481/phc2013.

Author Bios:

Dr. Kelly Johnson, DNP, RN Assistant Professor Troy University
DNP, MSN, and BSN from Troy University. A published author since 2008 and grants and projects author. Honors and awards from National League of Nursing and Sigma Theta Tau. Clinical focus is critical care nursing.

Dr. Stacey Jones DNP, FNP-BC
Assistant Professor Troy University
DNP, University of Alabama at Birmingham 2011
MSN, Troy University, 2001
BSN, Troy University, 1995
A published author since 2012 and presenter since 2008. Honors and awards include recipient of the Nurse Educator Scholarship from the Alabama Board of Nursing for 2009-2010 and 2010-2011. Recipient of the Nurse Faculty Loan Aware through University of Alabama at Birmingham sponsored by HRSA for 2009-2010 and 2010-2011. Clinical focus is family

Yauna Williams, DNP, FNP-BC (Primary Author)
Family Nurse Practitioner
DNP and BSN from Troy University
Currently working as a family nurse practitioner in a primary care office in South Florida.