{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T11:07:36Z","timestamp":1787742456149,"version":"build-2784847793"},"reference-count":40,"publisher":"BMJ","issue":"3","license":[{"start":{"date-parts":[[2020,8,6]],"date-time":"2020-08-06T00:00:00Z","timestamp":1596672000000},"content-version":"unspecified","delay-in-days":5,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/100000865","name":"Bill and Melinda Gates Foundation","doi-asserted-by":"publisher","award":["OPP1134345"],"award-info":[{"award-number":["OPP1134345"]}],"id":[{"id":"10.13039\/100000865","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Open Qual"],"accepted":{"date-parts":[[2020,6,22]]},"published-print":{"date-parts":[[2020,8]]},"abstract":"<jats:p>The majority of foot amputations are preventable in people with diabetes. Guidelines recommend that people with diabetes should receive a foot examination for risk assessment, at least annually. In an audit at a primary health centre (PHC) in Mumbai, India, no patient with diabetes was offered preventive foot assessment in preceding 12 months. Problem analysis identified a lack of clinic policy, training and equipment for foot assessment. There was no standardised referral pathway for patients identified with foot at risk of diabetes complications. Furthermore, limited data review, high patient volumes and little time available with healthcare providers were important constraints. A quality improvement project was carried out at the PHC from January to September 2017. The project aimed at increasing compliance to standardised foot assessment in patients with diabetes presenting to the PHC from a baseline of 0% to 100% over 6\u2009months. This would help identify patients having a foot at risk of complications due to diabetes. The Quality Standard on foot assessment was adopted from the Ministry of Health and Family Welfare Diabetic Foot Guideline. The electronic medical record (EMR) was standardised, health providers were trained, PHC processes and referral pathways were redesigned. Plan-Do-Study-Act was used to address barriers with weekly data review. 88.2% (848) of patients with diabetes visiting the PHC during the study period received a foot examination. Out of these, 11% (95) were identified to have a foot at risk and referred to a specialist foot centre. 57% of referred patients followed with specialised foot protection services. Training of healthcare providers, standardisation of processes and regular data feedback can improve diabetic foot care. Integrating quality indicators in the EMR helps monitor compliance. The inability to use doctor\u2019s time efficiently was the biggest challenge and sustaining the change will require organisational changes with suitable task shifting.<\/jats:p>","DOI":"10.1136\/bmjoq-2019-000893","type":"journal-article","created":{"date-parts":[[2020,8,7]],"date-time":"2020-08-07T02:04:52Z","timestamp":1596765892000},"page":"e000893","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":13,"title":["Increasing identification of foot at risk of complications in patients with diabetes: a quality improvement project in an urban primary health centre in India"],"prefix":"10.1136","volume":"9","author":[{"given":"Abha","family":"Mehndiratta","sequence":"first","affiliation":[{"name":"Global Health and Development Group, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Satish Chandra","family":"Mishra","sequence":"additional","affiliation":[{"name":"Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, Bhabha Atomic Research Centre Hospital, Mumbai, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Prashant","family":"Bhandarkar","sequence":"additional","affiliation":[{"name":"Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, BARC Hospital, Bhabha Atomic Research Centre Hospital, Mumbai, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kunal","family":"Chhatbar","sequence":"additional","affiliation":[{"name":"Department of Surgery, WHO Collaboration Centre for Research in Surgical Care Delivery in LMIC, BARC Hospital, Bhabha Atomic Research Centre Hospital, Mumbai, India"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Francoise","family":"Cluzeau","sequence":"additional","affiliation":[{"name":"Global Health and Development Group, Imperial College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Team","family":"PrimaryCareDoctors","sequence":"additional","affiliation":[{"name":"East Deonar Dispensary, Bhabha Atomic Research Centre Hospital, Mumbai, India"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2020,8,6]]},"reference":[{"key":"2025083109313621000_9.3.e000893.1","doi-asserted-by":"publisher","DOI":"10.1186\/1757-1146-7-1"},{"key":"2025083109313621000_9.3.e000893.2","doi-asserted-by":"crossref","first-page":"2","DOI":"10.1002\/dmrr.2694","article-title":"The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus","volume":"32","author":"Bakker","year":"2016","journal-title":"Diabetes Metab Res Rev"},{"key":"2025083109313621000_9.3.e000893.3","unstructured":"IDF diabetes atlas - 2015 Atlas . International diabetes federation, Brussels, Belgium 2015."},{"key":"2025083109313621000_9.3.e000893.4","doi-asserted-by":"crossref","first-page":"816","DOI":"10.1038\/ejcn.2017.40","article-title":"Prevalence of type 2 diabetes and its complications in India and economic costs to the nation","volume":"71","author":"Pradeepa","year":"2017","journal-title":"Eur J Clin Nutr"},{"key":"2025083109313621000_9.3.e000893.5","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(05)66437-9"},{"key":"2025083109313621000_9.3.e000893.6","doi-asserted-by":"publisher","DOI":"10.1001\/archinte.158.2.157"},{"key":"2025083109313621000_9.3.e000893.7","unstructured":"Centers for Disease Control and Prevention . National diabetes statistics report: estimates of diabetes and its burden in the United States. US Dep Heal Hum Serv 2014:2014."},{"key":"2025083109313621000_9.3.e000893.8","doi-asserted-by":"publisher","DOI":"10.1177\/1534734610380025"},{"key":"2025083109313621000_9.3.e000893.9","first-page":"459","volume-title":"Healthy people 2000: National health promotion, disease prevention objectives","volume":"24","year":"1990"},{"key":"2025083109313621000_9.3.e000893.10","unstructured":"Team SD foot . Standard treatment guidelines: The Diabetic Foot - Prevention and management in India 2016. Website Minist Heal Fam welfare, India, 2016. Available: http:\/\/clinicalestablishments.nic.in\/En\/1068-standard-treatment-guidelines.aspx"},{"key":"2025083109313621000_9.3.e000893.11","unstructured":"Team ICG . NICE clinical guideline no 19. diabetic foot problems?: prevention and management. Diabet Foot Probl Prev Manag 2016."},{"key":"2025083109313621000_9.3.e000893.12","doi-asserted-by":"publisher","DOI":"10.1001\/jama.288.7.889"},{"key":"2025083109313621000_9.3.e000893.13","unstructured":"Donaldson MS , Karl D , et al . Vanselow. Editors; Committee on the future of primary care I of medicine. Primary care?: America's health in a new era. National Academy press. Washington DC. Washington, D.C: National Academies Press, 1996: 3\u20136."},{"key":"2025083109313621000_9.3.e000893.14","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.17.9.1050"},{"key":"2025083109313621000_9.3.e000893.15","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-138-3-200302040-00033"},{"key":"2025083109313621000_9.3.e000893.16","doi-asserted-by":"publisher","DOI":"10.1001\/archfami.1995.01850260050014"},{"key":"2025083109313621000_9.3.e000893.17","doi-asserted-by":"crossref","first-page":"311","DOI":"10.1016\/j.endonu.2014.01.007","article-title":"Evaluation of diabetic foot screening in primary care","volume":"61","author":"Alonso-Fern\u00e1ndez","year":"2014","journal-title":"Endocrinol Nutr"},{"key":"2025083109313621000_9.3.e000893.18","doi-asserted-by":"publisher","DOI":"10.1002\/(SICI)1096-9136(199712)14:12<1073::AID-DIA498>3.0.CO;2-9"},{"key":"2025083109313621000_9.3.e000893.19","doi-asserted-by":"crossref","first-page":"173","DOI":"10.4414\/smw.2007.11592","article-title":"Adherence to recommended standards of diabetes care by Swiss primary care physicians","volume":"137","author":"Bovier","year":"2007","journal-title":"Swiss Med Wkly"},{"key":"2025083109313621000_9.3.e000893.20","doi-asserted-by":"publisher","DOI":"10.1136\/ewjm.174.3.175"},{"key":"2025083109313621000_9.3.e000893.21","doi-asserted-by":"publisher","DOI":"10.2105\/AJPH.93.4.635"},{"key":"2025083109313621000_9.3.e000893.22","doi-asserted-by":"publisher","DOI":"10.7326\/0003-4819-135-9-200111060-00012"},{"key":"2025083109313621000_9.3.e000893.23","doi-asserted-by":"publisher","DOI":"10.1016\/j.diabres.2011.02.002"},{"key":"2025083109313621000_9.3.e000893.24","doi-asserted-by":"publisher","DOI":"10.1016\/S0897-1897(05)80062-X"},{"key":"2025083109313621000_9.3.e000893.25","doi-asserted-by":"publisher","DOI":"10.7205\/MILMED.170.3.243"},{"key":"2025083109313621000_9.3.e000893.26","first-page":"1705","article-title":"The effects of clinical practice guidelines on patient outcomes in primary care: a systematic review","volume":"156","author":"Worrall","year":"1997","journal-title":"CMAJ"},{"key":"2025083109313621000_9.3.e000893.27","first-page":"CD000259","article-title":"Audit and feedback: effects on professional practice and health care outcomes","volume":"2","author":"Jamtvedt","year":"2006","journal-title":"Cochrane Database Syst Rev"},{"key":"2025083109313621000_9.3.e000893.28","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.25.11.1946"},{"key":"2025083109313621000_9.3.e000893.29","doi-asserted-by":"publisher","DOI":"10.1136\/bmjqs-2013-001862"},{"key":"2025083109313621000_9.3.e000893.30","doi-asserted-by":"publisher","DOI":"10.2337\/dc10-S062"},{"key":"2025083109313621000_9.3.e000893.31","doi-asserted-by":"crossref","DOI":"10.1371\/journal.pone.0124446","article-title":"Diabetic foot complications and their risk factors from a large retrospective cohort study","volume":"10","author":"Al-Rubeaan","year":"2015","journal-title":"PLoS One"},{"key":"2025083109313621000_9.3.e000893.32","doi-asserted-by":"crossref","unstructured":"Ishikawa K . Introduction to quality control. Chapman-Hall, 1989.","DOI":"10.1007\/978-94-011-7688-0_1"},{"key":"2025083109313621000_9.3.e000893.33","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.j5064"},{"key":"2025083109313621000_9.3.e000893.34","doi-asserted-by":"publisher","DOI":"10.2337\/diacare.15.10.1386"},{"key":"2025083109313621000_9.3.e000893.35","unstructured":"Scottish Diabetes Survey Monitoring Group . Scottish diabetes survey 2014. NHS Scotland, 2014: 1\u201382."},{"key":"2025083109313621000_9.3.e000893.36","first-page":"975","article-title":"Measuring adherence rate to quality indicators for diabetes care identified by primary health care in Bahrain","volume":"35","author":"Al-Ubaidi","year":"2014","journal-title":"Saudi Med J"},{"key":"2025083109313621000_9.3.e000893.37","first-page":"1","article-title":"Audit and feedback: effects on professional practice and healthcare outcomes","volume":"6","author":"Ivers","year":"2012","journal-title":"Cochrane Database Syst Rev"},{"key":"2025083109313621000_9.3.e000893.38","first-page":"50","article-title":"Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town district health services","volume":"50","author":"Mash","year":"2008","journal-title":"South African Family Practice"},{"key":"2025083109313621000_9.3.e000893.39","first-page":"195","article-title":"Barriers to adherence to preventive services reminder letters: the patient's perspective","volume":"36","author":"Ornstein","year":"1993","journal-title":"J Fam Pract"},{"key":"2025083109313621000_9.3.e000893.40","doi-asserted-by":"crossref","DOI":"10.1186\/s12889-018-5763-4","article-title":"Determinants of utilisation rates of preventive health services: evidence from Chile","volume":"18","author":"Rotarou","year":"2018","journal-title":"BMC Public Health"}],"container-title":["BMJ Open Quality"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/bmjoq-2019-000893","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,8,31]],"date-time":"2025-08-31T16:32:01Z","timestamp":1756657921000},"score":1,"resource":{"primary":{"URL":"https:\/\/qir.bmj.com\/lookup\/doi\/10.1136\/bmjoq-2019-000893"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2020,8]]},"references-count":40,"journal-issue":{"issue":"3","published-online":{"date-parts":[[2020,8,6]]},"published-print":{"date-parts":[[2020,8]]}},"alternative-id":["10.1136\/bmjoq-2019-000893"],"URL":"https:\/\/doi.org\/10.1136\/bmjoq-2019-000893","relation":{},"ISSN":["2399-6641"],"issn-type":[{"value":"2399-6641","type":"electronic"}],"subject":[],"published":{"date-parts":[[2020,8]]}}}