Preventative Foot Care Project May Reduce Amputations, Hospitalization and Length of Stay in ESRD

At the 2015 BC Kidney Days, Dr. Shaoyee Yao and Sarah Lacroix present the preliminary results from a quality improvement project designed to reduce preventable complications from lower extremity wounds in patients on dialysis.

It has been know for some time that foot wounds are very common in patients on hemodialysis and peritoneal dialysis, affecting up to 30-40% patients.

In addition, lower limb disease is associated with an increase risk of death, with 5 year survival decreasing from 46% in those without lower limb disease, to 23% in those with disease.

The Fraser Health Renal program designed a CQI project to establish a multidisciplinary approach to early detection and treatment of lower limb lesions in patients with ESRD.

This project was funded via our discretionary fund for just these type of projects, in addition to funding from Amgen Canada.

We elected to roll out the pilot at the Abbotsford Regional Hospital (ARH) and compare outcomes in 2 ways.  We performed an observational analysis of patients outcomes, comparing outcomes at the same site the year prior to the intervention vs the year during the intervention.  Given some concerns over a possible Hawthorne effect or that foot care might have just improved due to general medical progress, we also elected to compared outcomes at control sites that were only offering routine foot care (Surrey Memorial Hospital and Royal Columbian Hospital).

Have a look at the slide deck included on this page (below).

Fraser Health Foot Care Project Shows Reduced Amputation, Hospitalization and Length of Stay in Dialysis Patients from Daniel Schwartz

In addition, Sarah Lacroix presents an excellent overview of the program and more details on our outcomes.

BC Kidney Days 2015 – Foot Care Nursing Breakout Session from Daniel Schwartz

Results

In brief, our raw data comparing pre/post outcomes at ARH suggests that:

a) Amputations were reduced from 2.6% to 1.6% (RRR 38%)
b) Days in hospital were reduced from 9.0 to 5.6 per patient (RRR 38%)
c) Hospitalization for infection was reduced from 8.9% to 4.4% (RRR 51%), overall hospitalization rate was reduced from 18.9% to 17.5% (RRR 7.4%) and total length of stay was reduced

Raw data comparing outcomes at ARH (active intervention) vs SMH/RCH (control sites) suggest that:

a) Amputations were reduced from 3% to 1.6% (RRR 47%)
b) Days in hospital were reduced from 9.9 to 5.6 per patient (RRR 43%)
c) Hospitalization for infection was reduced from 8.5% to 4.4% (RRR 48%), overall hospitalization rate was reduced from 24.2% to 17.5% (RRR 28%) and total length of stay was reduced

It’s interesting to note that we saw an increase in hospitalization for peripheral vascular disease but less amputations and lower admissions for lower limb infections, suggesting that we were intervening earlier in the disease process.  This is also supported by a much lower length of stay in hospital overall.  This suggests that intervening earlier results in earlier revascularization and overall better outcomes.

In fact, this intervention resulted in approximately 3.4-4.2 less days of hospitalization for each patient in our program.

Impact

Extrapolating to our entire program (were we able to roll this out more widely across the health authority), with a ‘back of the napkin’ calculation:

a) Approximate number of patients with ESRD at FHA: ~1100
b) Approximate cost per hospitalization day (as per CIHI report) : ~$1000 per day
c) Approximate reduction in length of hospital stay per patient (mean of pre/post & active/control results): 3.8 days

1100 patients X 3.8 hospital day reductions/patient X $1000 per day

= $4, 180, 000

The financial investment to achieve these outcomes was relatively modest, with total expenditure of $80 888.76 during the period for which we report outcomes.

So that’s a potential $4,180,000 saved per year as a result of preventative foot care in ESRD.

Next step is to perform appropriate statistical testing and an economic analysis.  We are hopeful that we will confirm this intervention is highly cost saving, while at the same time showing an improvement in patient outcomes; essentially that it is cheaper to provide better care.

If we are able to demonstrate that the results are both statistically significant and economically advantageous, we will go back to funders to seek support for a widespread implementation of this preventative care program across the region, and hopefully the province.

What can we take away from this project?

a) Pending our statistical and economic analysis, it appears that investing in preventative care may result in better patient outcomes at markedly lower cost
b) Our discretionary project funds, in addition to industry sponsorship, can provide an amazing opportunity to explore new methods of improving outcomes (we are unique within FHA in that we have access to such funds)
c) Creating high quality project proposals is an important first step in identify projects that are set up for success.  While brief and simple, the foot care proposal we reviewed addressed the following:
a) the problem you’re trying to solve ie why does this matter?
b) what you’re going to do ie what’s the intervention?
c) how you’re going to define and measure success ie how will we know if we’ve succeeded?
d) what it’s going to cost
Have a look at the original proposal – it’s a great template for those considering future submissions.
View Foot Care Project Proposal

 
 

References

 
Ndip A1, Lavery LA, Lafontaine J, Rutter MK, Vardhan A, Vileikyte L, Boulton AJ. High levels of foot ulceration and amputation risk in a multiracial cohort of diabetic patients on dialysis therapy. Diabetes Care. 2010 Apr;33(4):878-80. PMID: 20067975.
 
Orimoto Y1, Ohta T, Ishibashi H, Sugimoto I, Iwata H, Yamada T, Tadakoshi M, Hida N. The prognosis of patients on hemodialysis with foot lesions. J Vasc Surg. 2013 Nov;58(5):1291-9. PMID: 23810259.