Identification of valid and multidimensional quality indicators in diabetic foot care, useful to study quality of care in diabetic foot clinics

Diabetic foot ulceration (DFU) is a common late-stage complication, experienced by up to 25% of diabetics in their lifetime.1,2 Its impact, both on quality of life3 and on resource utilization4, drives diabetic foot clinics (DFCs) and national healthcare systems to improve foot care organization. Monitoring of performance and providing feedback to care providers (audit-feedback), which includes benchmarking, is one strategy to improve quality of care.5 The Initiative for Quality Improvement and Epidemiology in Multidisciplinary Diabetic Foot Clinics (IQED-Foot), implemented in Belgium since 2005, is one application of this principle.6 The specific aim of this project is to identify valid and multidimensional quality indicators useful for quality monitoring in specialized diabetic foot care. The existing IQED-Foot project has a number of shortcomings that need to be addressed to yield an improved audit methodology with regard to validity, acceptability and usability. In multiple European countries efforts are made to optimize diabetic foot care, notably by improving referral of patients to multidisciplinary DFCs and by creating accreditation programs; however valid and practical quality monitoring tool are still sorely needed. Analyses of IQED-Foot data have shown that DFUs are about 2.5 times more likely to heal in the "best" DFC compared to the "worst" DFC. Large gains in resources and quality-of-life can be expected if quality differences are identified and addressed. The first research question focuses on the three dimensions of care usually used to assess quality of care; two phases are planned. Based on the current definitions the indicators will be refined and their validity checked in phase 1. Structure indicators will be investigated, e.g. pattern and delay of referral, efforts to educate first-line health care professionals and patients, organization of in-hospital care (delay until diagnostic procedure or treatments). Process indicators include delivery of podiatric care, DFU off-loading, revascularization, DFU debridement, orthopedic surgery or composites thereof. DFU healing, major amputation, death and their risk-adjusted counterparts will be the considered outcome indicators. Identification of valid risk-adjustment models for the above outcomes will be the first step in this phase, because the availability of risk-adjusted outcomes is essential to study the correlation with structure and process indicators in phase 2. These analyses will be p